Cardiology (Heart failure) Flashcards
classification of heart failure
- Timeline
- Ejection fraction
- Systole/diastole
- Site of heart involved
- Symptoms
HF by timeline
Acute (decompensated):
- Sudden worsening of signs and symptoms of heart failure
- Can be due to decompensation of chronic heart failure due to intercurrent illness (e.g. myocardial infarction, arrhythmia, infection, severe hypertension, or drugs) or high-output heart failure (discussed below)
Chronic heart failure:
- Long-term and controlled by managing symptoms
define LVEF
left ventricular ejection fraction : the percentage of blood pumped out during a single contraction
left ventricular ejection fraction (LVEF, the percentage of blood pumped out during a single contraction):
LVEF <40%: heart failure with reduced ejection fraction (HFrEF)
LVEF >50% but has symptoms of heart failure/raised levels of natriuretic peptides:** heart failure with preserved ejection fraction (HFpEF)**
left sided heart failure
Oxygenated blood from the lungs enters the left side of the heart and is pumped to the rest of the body.
Left-sided heart failure leads to a back up of blood in the lungs leading to pulmonary oedema characterised by:
- Tachypnoea
- Dyspnoea
- Bilateral basal crackles
- Orthopnoea – shortness of breath when lying down
- Paroxysmal nocturnal dyspnoea – waking up short of breath at night, usually improved by sleeping upright
- Laterally displaced apex beat – due to enlargement of the left ventricle
- Additional heart sounds – S3 and S4
right sided heart failure
Deoxygenated blood from the body enters the right side of the heart to be pumped to the lungs. Right-sided heart failure is often caused by pulmonary diseases (such as pulmonary stenosis or pulmonary hypertension), leading to increased work on the right ventricle, hypertrophy, and subsequent right heart failure.
This leads to the accumulation of fluid in the systemic circulation characterised by:
- Peripheral oedema (usually ankle/sacral oedema)
- Raised jugular venous pressure
- Hepatomegaly with or without splenomegaly
- Due to liver congestion
- This can lead to impaired liver function, jaundice, and coagulopathy due to impaired clotting factor synthesis
how can left sided HF lead to right sided HF
Failure of one side of the heart can lead to the failure of the other. Left-sided heart failure can lead to pulmonary congestion, which puts more strain on the right side of the heart, which can lead to right-sided heart failure.
The New York Heart Association (NYHA) classification of heart failure
Based on the severity of symptoms and limitation of physical activity:
Class I: asymptomatic
- Ordinary physical activity does not cause breathlessness, fatigue, or palpitations
Class II: mild symptoms with moderate exertion
- Comfortable at rest
- Ordinary physical activity does cause breathlessness, fatigue, or palpitations
Class III: symptoms with minimal activity
- Comfortable at rest
- Less than ordinary physical activity does cause breathlessness, fatigue, or palpitations
Class IV: symptoms at rest
- Unable to carry out any physical activity without symptoms
- Discomfort worsens with physical activity
High-output heart failure
High-output heart failure describes when an intact heart cannot pump enough blood to meet the demands of the body. This can occur in scenarios where the metabolic rate of the body increases such as:
- Anaemia
- Sepsis
- Hyperthyroidism
- Paget’s disease of bone
- Multiple myeloma
- Arteriovenous malformation
- Vitamin B1 (thiamine) deficiency
Left-sided heart failure suymptoms –
Due to pulmonary congestion:
- Tachypnoea
- Dyspnoea
- Bilateral basal crackles
- Orthopnoea – shortness of breath when lying down
- Paroxysmal nocturnal dyspnoea – waking up short of breath at night, usually improved by sleeping upright
- Laterally displaced apex beat – due to enlargement of the left ventricle
- Additional heart sounds – S3 and S4
Right-sided heart failure presentation–
due to systemic congestion
- Peripheral oedema (usually ankle/sacral oedema)
- Raised jugular venous pressure
- Hepatomegaly with or without splenomegaly
- Due to liver congestion
- This can lead to impaired liver function, jaundice, and coagulopathy due to impaired clotting factor synthesis
Biventricular failure (congestive) presentation
failure of one side of the heart can lead to failure of the over:
- An overlap of the above signs and symptoms may be seen
- Pleural effusions may occur – this can still happen in unilateral heart failure
define acute heart failure
Acute heart failure is either new-onset heart failure in people without a history of cardiac dysfunction, or an acute decompensation (worsening) of chronic heart failure.
Acute heart failure should be suspected in any patient with a sudden onset of:
- breathlessness
- ankle swelling, fatigue
- reduced exercise tolerance
acute heart failure symptoms are caused by
During acute heart failure, patients have volume overload with pulmonary and/or systemic oedema (congestion). This gives rise to the signs and symptoms seen.
causes of acute heart failure
- Acute coronary syndrome
- Hypertensive emergencies
- Arrhythmia
- Chest trauma
- Pulmonary embolism
- Infection e.g. myocarditis
- Cardiac tamponade
- Myocarditis
- Causes of high-output heart failure (e.g. anaemia, sepsis, thyrotoxicosis)
Risk Factors for acute HF
- History of heart failure
- History of cardiovascular disease
- Hypertension
- Older age
- Diabetes mellitus
- Family history of cardiovascular disease
- Family history of cardiomyopathy
- Excess alcohol consumption
- Smoking
- History of arrhythmia
- History of sarcoidosis or haemochromatosis
- History of chemotherapy
- Some drugs NSAIDs, corticosteroids, rate-limiting calcium channel blockers (diltiazem or verapamil)
- Valvular heart disease
*
investigations for acute heart failure
ECG
- may show arrhythmia or changes in wave morphology/duration
Chest x-ray
- pulmonary congestion
- pulmonary oedema
- pleural effusion
- cardiomegaly
Blood tests
- NT-proBNP blood test: Elevated
- Troponin: May be elevated
- Full blood count: May identify anaemia or leukocytosis suggesting infection
- Urea and electrolytes (U&Es)
- Liver function tests (LFTs): To screen for liver pathology which can worsen heart failure or to screen for liver pathology due to heart failure
- Thyroid function tests (TFTs): To screen for hypo- or hyperthyroidism
- C-reactive protein: Non-specific marker of inflammation, may be elevated
- D-dimer: If pulmonary embolism suspected
Echocardiography
This assesses the systolic and diastolic function of the ventricles
acute heart failure management: haemodynamically stable
stop b-blockers if HR <50, heart block or cardiogenic shock
- Treat underlying cause
- Sit the patient up
- IV loop diuretic if there are signs and symptoms of congestion e.g. furosemide
- If loop diuretic is insufficient and there are still signs and symptoms of congestion, consider an aldosterone antagonist e.g. spironolactone or eplerenone
- Oxygen only if saturations are <90%
- Consider CPAP if respiratory failure occurs (severe dyspnoea with or without acidaemia)
- Consider invasive ventilation if respiratory failure occurs or there is reduced consciousness/physical exhaustion
acute heart failure management: haemodynamically unstable
- Identify and treat the underlying cause
- Request critical care
- Vasoactive drugs – given in a specialist setting:
1) Inotropes (e.g. dobutamine): - If there is severe left ventricular dysfunction with potentially reversible cardiogenic shock
2) Vasopressors (e.g. noradrenaline): - Generally used if there is an insufficient response to inotropes and evidence of end-organ hypoperfusion
- Oxygen only if saturations are <90%
- Consider CPAP if respiratory failure occurs (severe dyspnoea with or without acidaemia)
- Consider invasive ventilation if respiratory failure occurs or there is reduced consciousness/physical exhaustion
measures patients should take to prevent recurrence of acute heart failure
- Restricting fluid and salt intake
- Reducing alcohol intake
- Continuing medication as prescribed
- Regularly checking weight
how is chronic heart failure classified
Left ventricular ejection fraction (LVEF) *This is the amount of blood in the left ventricle that is pumped out with each heartbeat. The LVEF is measured using echocardiography. *
Heart failure with reduced ejection fraction (HFrEF):
- Ejection fraction <40%
- Patients usually have systolic dysfunction – impaired ventricular contraction during systole
Heart failure with preserved ejection fraction (HFpEF):
- Ejection fraction >40%
- Patients usually have diastolic dysfunction – impaired ventricular filling during diastole
most common causes of chronic heart failure
- coronary heart disease
- hypertension
- valvular disease
- cardiomyopathies
risk factors for chronic heart failure
Risk Factors
- Previous cardiovascular disease
- Previous myocardial infarction
- Hypertension
- Diabetes mellitus
- Increasing age
- Male
- Family history
- Arrhythmia e.g. atrial fibrillation
- Obesity
- Valvular heart disease
- Sleep apnoea
- Hypo- and hyperthyroidism
- Anaemia
- Connective tissue disorders
- Same risk factors for acute heart failure
investigations for chronic heart failure
N-terminal pro-B-type natriuretic peptide (NT-proBNP)
- a key initial test
- Elevated
- If >2000ng/L (high) – referral for specialist assessment and echocardiography within 2 weeks
- If 400-200ng/L (raised) – referral for specialist assessment and echocardiography within 6 weeks
Full blood count (FBC):
- May identify anaemia, which can worsen heart failure
Urea and electrolytes (U&Es):
- May show hyponatraemia – heart failure can lead to increased water retention and dilution of serum sodium
ECG – may show:
- Ventricular hypertrophy
- Conduction abnormalities
- Abnormal QRS duration
Chest x-ray – may show:
- Pulmonary oedema – Kerley B lines
- Cardiomegaly
- Pleural effusions
Transthoracic echocardiogram:
Identifies systolic or diastolic ventricular dysfunction
management of chronic heart failure
First line
- ACEi + beta-blocker (add b blocker once ACEi established)
Second line
- aldosterone antagonist e.g. spironolactone/eplerenone
Additional treatment
- Loop diuretic e.g. furosemide for symptomatic relief (do not improve survival but reduce symptoms of fluid overload)
- SGLT-2 inhibitors
Third line: initiated by a specialist
- If Afro-Caribbean: Hydralazine and isosorbide dinitrate
- If heart rate >75bpm and ejection fraction <35%: Ivabradine
- If reduced LVEF, especially for those with atrial fibrillation: Digoxin
- If LVEF <35% and ACEi/ARB ineffective: Sacubitril-valsartan after ACEi/ARB washout period completed
general recomendations for all heart failure patients
- Annual influenza vaccination
- One-off pneumococcal vaccination
Patients should:
- Regularly monitor their weight – assesses fluid overload
- Restrict salt and fluid intake
- Stop smoking
- Limit alcohol intake
- Have a balanced and healthy diet
- Control blood pressure and diabetes
- Exercise regularly and as much as tolerated
Complications of HF
- Pleural effusion
- Acute heart failure
- Acute kidney injury
- Chronic kidney disease
- Anaemia (dilutional)
- Cardiac arrest
Acute kidney injury secondary to HF
This could be due to poor perfusion due to heart failure itself or as a side effect of the medications e.g. ACE inhibitors, aldosterone antagonists etc.
Chronic kidney disease secondary to HF
Patients may develop a “cardiorenal syndrome” in which the dysfunction of the heart may lead to dysfunction of the kidneys and vice versa.
This is a difficult scenario as medications for heart failure often negatively impact the kidneys
what is cor pulmonale
the dysfunction of the right ventricle secondary to respiratory disease. This is due to the right ventricle working harder against pulmonary hypertension causing backflow of blood into the right atrium, the vena cava, and the systemic venous system.
Pulmonary hypertension may be due to:
Chronic hypercapnia and respiratory acidosis leading to pulmonary vasoconstriction
Damage to the lung parenchyma itself e.g. pulmonary fibrosis/COPD
Increased blood viscosity due to the lung disease e.g. secondary polycythaemia
risk factors for cor pulmonale
Risk Factors
- COPD
- Smoking
- Pulmonary embolism
- Interstitial lung disease
- Primary pulmonary hypertension
- Obstructive sleep apnea
presentation of cor pulmonale
SoB
Other symptoms:
- Worsening tachypnoea
- Peripheral oedema
- Shortness of breath on exertion
- Syncope
- Chest pain
- Haemoptysis
- Hepatic congestion – this is a late-stage feature which has:
- Anorexia
- Jaundice
- Right-upper quadrant abdominal discomfort
management of cor pulmonale
Management involves treating the underlying cause as well as possibly using long-term oxygen therapy.
stage 1 hypertension
Clinic blood pressure ≥140/90mmHg
Ambulatory/home blood pressure ≥135/85mmHg
stage 2 hypertension
clinic blood pressure of >160/100 mmHg
A/HBPM average blood pressure of >150/95 mmHg or higher.
stage 3 hypertension
clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.
malignant hypertension
severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve)
Referral for same-day specialist assessment should be arranged for hypertensives with:
- A clinic blood pressure of 180/120 mmHg and higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension) or life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
- Suspected phaeochromocytoma, for example labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis.
types of hypertension
Primary (essential) - no identifiable cause
Secondary
secondary hypertension causes
Renal disease – most common cause of secondary hypertension
- Examples are renovascular disease e.g. renal artery stenosis due to atherosclerosis or fibromuscular dysplasia
Endocrine disease:
- Cushing’s syndrome
- Hyperaldosteronism
- Hyperthyroidism/hypothyroidism
- Phaeochromocytoma
- Acromegaly
- Hyperparathyroidism
Obstructive sleep apnoea
Pre-eclampsia and pregnancy-induced hypertension
Some drugs/toxins:
- Alcohol
- Cocaine
- Amphetamines
- Antidepressants e.g. venlafaxine
- Combined oral contraceptive pill
- Glucocorticoids
Risk Factors for hypertension
- Increasing age
- Sex – more common in men if <65, but higher in women between 65-74 years
- Ethnicity – Black African/Hispanic people are at higher risk
- Family history
- Social deprivation
- Smoking
- Excess alcohol
- Excess dietary salt
- Obesity
- Low exercise
- Anxiety and emotional stress
complications of hypertension
- coronary artery disease
- Stroke
- HF
- Hypertensive retinopathy
- PAD
- Aortic dissection
- Malignant hypertension
Assessment blood pressure
- Blood pressure measurement on two or more occasions with the average recorded
- Blood pressure should be measured in both arms. A difference in the arms may suggest aortic dissection
if between 140/90mmHg and 180/120mmHg then offer
ambulatory/home blood pressure monitoring (ABPM/HBPM)
Hypertension is diagnosed and staged if the two following criteria are met:
- Clinic blood pressure of ≥140/90mmHg and
- ABPM/HBPM ≥135/85mmHg
Investigations for end-organ damage
ECGs:
- May show left ventricular hypertrophy or signs of myocardial ischaemia
- A normal result does not rule out coronary artery disease
Urine dipstick:
- May show signs of renal disease e.g. haematuria/proteinuria
Urea and electrolytes (U&Es):
- To check for renal disease which may cause or be a cause of hypertension
Thyroid function tests(TFTs):
- Indicated if there are signs of hypo-/hypothyroidism
Lipid panel:
- To check for dyslipidaemia
HbA1c:
- To check for diabetes mellitus
which hypertensives are offered antihypertensives
1) Have stage 2 hypertension
2) Under 80 years of age with stage 1 hypertension that have:
* Type 2 diabetes
* Chronic kidney disease
* End-organ damage
* QRISK score ≥10%
first line antihypertensives for <55 or Type 2 diabetes
ACEi e.g. Ramipril or ARB e.g. Candesartan
switch to ARB is ACEi not tolerated
Angiotensin-converting enzyme inhibitors (ACEi):
Examples: ramipril, lisinopril, enalapril
Mode of action: inhibits the conversion of angiotensin I to angiotensin II
Common side effects:
- Dry cough
- Postural hypotension
- Acute kidney injury, especially in renal artery stenosis
- Angioedema
- Hyperkalaemia
Cautions:
- Avoid in pregnancy
- Renal function must be checked 2 weeks after starting as renal function may decline in people with renovascular disease e.g. renal artery stenosis
Angiotensin II receptor blockers (ARB):
Examples: candesartan, valsartan
Mode of action: blocks the angiotensin II receptor and prevents its action
Common side effects:
* Hyperkalaemia
Cautions:
* Avoid in pregnancy
* Do not combine with ACEi
first line for:
- >55 years and no type 2 diabetes
- Afro-caribbean and no type 2 diabetes
calcium channel blocker
Calcium channel blockers (CCBs):
Examples: amlodipine, felodipine, nifedipine
Mode of action: block voltage-gated calcium channels and relax vascular smooth muscle and decrease the force of heart contractions
Common side effects:
* Ankle swelling
* Headache
* Dizziness
* Bradycardia
* Flushing
second line anti hypertensives
A+C e.g. ACEi or ARB + CCB
or
A+ D
ACEi or ARB + Thiazide like diuretic
Thiazide-like diuretics:
Examples: indapamide, chlortalidone
Mode of action: inhibit sodium absorption at the start of the distal convoluted tubule
Common side effects:
* Hyponatraemia
* Hypokalaemia
* Hypercalcaemia
* Hyperuricaemia
* Dehydration
Cautions:
* Can worsen diabetes, gout, and systemic lupus erythematosus
* Can cause erectile dysfunction in men
third line
A + C + D
fourth line
DEPENDS ON SERUM POTASSIUM
- If K+ >4.5 - add alpha/beta blocker
- ## If K+ <4.5 - add low-dose spironolactone
alpha blockers
Examples: doxazocin and terazosin
Mode of action: inhibit post-synaptic alpha1-adrenergic receptors leading to vasodilation of the blood vessels
Common side effects:
* Dizziness
* Drowsiness
* Orthostatic hypotension
beta blockers
Examples: carvedilol, metoprolol, bisoprolol
Mode of action: block beta-adrenergic receptors and lead to vasodilation and reduced heart contraction strength
Common side effects:
* Diabetes
* Impotence
* Bradycardia
* Fatigue
* Cold hands and feet
* Worsening psoriasis
Cautions:
* Contraindicated in asthma
* Contraindicated in 3rd-degree heart blocks
Aldosterone antagonists:
Examples: spironolactone, eplerenone
Mode of action: bind to aldosterone receptors and reduces sodium absorption and promotes water excretion
Common side effects:
* Hyperkalaemia
* Spironolactone – gynaecomastia
Cautions:
* Contraindicated in hyperkalaemia or Addison’s disease
treatment targets for HTN
types of hypertensive crisis
Malignant hypertension
Hypertensive urgency
Malignant (accelerated) hypertension:
Hypertensive urgency:
Severe hypertension without end-organ damage
RF for hypertensive emergecy
- Inadequately treated hypertension
- Renal artery stenosis
- Chronic kidney disease
- Renal transplant
- Hyperaldosteronism
- Cushing’s syndrome
- Acromegaly
- Hyperparathyroidism
- Hyper-/hypothyroidism
- Phaeochromocytoma
- Pregnancy
- Older age
- Afro-Caribbean ethnicity
- Male sex
Presentation of hypertensive emergency
Blood pressure >180/120mmHg
Neurological symptoms:
* Vision changes
* Headaches
* Dizziness
* Seizures
* Weakness
* Gait problems
Cardiorespiratory symptoms:
* Chest pain
* Shortness of breath
* Palpitations
* Orthopnoea
* Paroxysmal nocturnal dyspnoea
* Oedema
* New murmurs
* S3
* Jugular venous distention
Oliguria
Fundoscopy signs:
* Retinal haemorrhages
* Retinal exudates
* Papilloedema
* Enlarged retinal veins
examination for patients with hypertensive crisis
Blood pressure measurement from both arms and repeated after 5 minutes
- If there’s a >20mmHg difference between the arms, aortic dissection may need to be considered
Fundoscopy which may show:
- Papilloedema
- Retinal haemorrhages
- Retinal exudates
Cardiorespiratory examination
Neurological examination
Investigations for patients with hypertensive crisis
Urea and electrolytes (U&Es)
- May show acute kidney injury
Urinalysis and microscopy:
- May show red cells and protein
ECG: - May show myocardial infarction
Chest x-ray:
- May show pulmonary oedema, or a widened mediastinum that may suggest aortic dissection
malignant hypertensive same -day referral
- Papilloedema/retinal haemorrhages
- New-onset confusion
- Chest pains
- Signs of heart failure
- Signs of AKI
- Suspected phaeochromocytoma
general management of hypertensive emergency
1st line: IV labetalol
2nd line: IV nicardipine
3rd line: IV fenoldopam
orthostatic hypertension definition
a drop in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.
causes of orthostatic hypertension
Normal ageing
Deconditioning due to prolonged bed rest
Hypovolaemia:
- Dehydration
- Excess diuretic use
- Vasodilators
Drugs:
- Beta-blockers
- Sildenafil
- Tricyclic antidepressants
- MAO inhibitors
- Alpha blockers
- Levodopa and dopamine agonists
Neurological:
- Parkinson’s disease
- Alcoholic neuropathy
- Guillain-Barré syndrome
- Neurosyphilis
- Multiple system atrophy
Cardiovascular:
- Aortic stenosis
- Arrhythmia
- Myocardial infarction
- Heart failure
- Constrictive pericarditis
- Cardiac tamponade
Haematological:
- Anaemia
Endocrine: - Diabetes mellitus
- Primary hypoaldosteronism (Addison’s disease)
- Phaeochromocytoma
cause of fainting with orthostatic hypotension
The symptoms are a result of inadequate cerebral perfusion due to the blood pressure being too low as the body responds too slowly. They may experience:
- Blurred vision
- Light-headedness
- Nausea
- Weakness
- Syncope or loss of consciousness
Patients may have aggravating factors:
- Early morning – due to not drinking water overnight
- Hot environments – due to vasodilation
- Post-prandial – due to diversion of blood to the gut
- During or after exercise – due to the diversion of blood to muscles
*
conservative management of orthostatic hypotension
prescription reveiw
increase water
salt ingestion
if conservative management of orthostatic hypotension fails
fludrocortisone
