Cardiology - Heart Failure and CM Flashcards
What is heart failure
A syndrome characterised by fatigue, breathlessness and fluid retention
Caused by impaired cardiac function leading to circulatory insufficiency
What does dx of heart failure rely on
Clinical judgement based on several factors e..g symptoms and signs, severity, underlying cardiac abnormality, co-morbidities
Classification of heart failure based on LVEF
HF w/ reduced LVEF (HFrEF) - <40%
HF w/ mid-range LVEF (HFmrEF) - 40-49%
HF w/ preserved LVEF (HFpEF) - >50%
LVEF
LV ejection fraction
Calculating Ejection fraction
End diastolic volume - end systolic volume / end-diastolic volume
How can we measure EF
Echo
MRI
Myocardial perfusion scan
What is a lower ejection fraction associated with
Higher risk of mortality
What is a lower ejection fraction associated with
Higher risk of mortality
What does EF look at
How much blood is pumped out of the heart vs the volume in ventricles before
Normal EF
55%
What are causes of systolic heart failure
IHD
DCM
Myocarditis
Causes of diastolic heart failure
HCM/ HOCM
Restrictive CM
Cardiac tamponade
Main causes of high-output cardiac failure
Anaemia and pregnancy
Pathophysiology of heart failure
Initial event causing myocardial damage –> increase in wall stress –> activates multiple neuroendocrine systems causing further damage to myocardium
Epidemiology of heart failure
CAD is leading cause of HF in UK
Incidence increases w/ age - age at first px is 76 yrs, M > F
Prognosis of HF
Usually poor - 3yrs survival from dx, 40% die within 1 yr
Presentation of HF
SOB Fatigue Orthopnoea PND Swollen ankles Palpitations
NYHA clinical classification of HF
Class I - no limitations on activity
Class II - symptoms brought on by ordinary physical activity (mild HF)
Class III - Marked limitation of physical activity (moderate HF)
Class IV - pts have symptoms at rest (severe HF)
Ix in HF
Standard bloods Other bloods Urinalysis BNP & N-terminal pro BNP ECG Echo CXR Cardiac imaging
Standard bloods for HF ix
FBC
Renal function
Extra bloods for HF ix
LFT
TFT
Glucose
Cholesterol
Urinalysis for HF ix
Looking for protein and glucose
What happens if BNP is normal in suspected HF
Normal BNP generally rules out HF
When does BNP increase
In ventricular stretch/ LVEDP (preload)
CXR in a/c HF
Cardiomegaly - cardiothoracic ratio > 0.5
Pulmonary oedema
Bilateral blunting of costophrenic angles
Mx of a/c pulmonary oedema
Oxygen
Diuretics
Nitrates
Morphine
Weight pt daily and take daily U&Es
Key imaging method for pts w/ suspected heart failure
Echo
Provides info on structure and function of cardiac chambers, valves and pericardium
When can you not do an echo
If the ‘window’ is poor
What do stress echos look for
Reversible ischaemia
What does a cardiac MR provide info about
Extent of fibrosis and perfusion abnormalities
When is a cardiac MR particularly useful
When echo images are poor due to obesity or COPD
What is usually required for cardiac MR
Specialist referral
Ddx of HF
Chest diseases Venous insufficiency in LL Drug-induced ankle swelling/ fluid retention Angina Hypoalumineamia Intrinsic renal/ hepatic failure Severe thyroid disease Bilateral renal artery stenosis
General measures for managing HF
Pt education Wt control Reducing salt and fluid Smoking cessation Mx of co-morbidities
Poor prognostic factors in HF
Low EF (<30%) - most important Low systolic BP Coronary disease Raised creatine/ eGFR Hyponatremia DM Anaemia Arrhythmia AF
Aims of therapy in HF
Improve life expectancy
Improve QoL
Aims of treatment of a/c HF
Improve haemodynamic & symptomatic profile
Prevent myocardial & renal damage
A/c HF mx
PODMAN
Positioning - sit up (high Fowler's position) Oxygen Diuretics (loop) Morphine Antiemetics Nitrates (IV)
May also give IV dobutamine and non-invasive ventilation (CPAP, BiPAP)
Diuretics therapy for HF
Rapid relief of congestive symptoms and fluid retention w/ loop diuretics e.g. furosemide, bumetanide
May be titrated according to need after adding new meds
Which HF symptoms do loop diuretics improve
Breathlessness
Exercise performance
Drugs for c/c HFrEF
ACEi/ ARB
BB - reduce HR
Aldosterone receptor blockers (spironolactone, eplerenone)
Sacubitril/ valsartan
When would you use sacubitril/valsartan in c/c HF
Replaces ACEi/ ARB when EF <35%
Other potential treatments for c/c HF
Ivabradine (similar to BB)
Digoxin (esp w/ AF)
Amiodarone (pts w/ arrhythmias)
Anticoags
Why does ACE cough develop
ACE inactivates bradykinin
ACE inhibition therefore leads to increase in bradykinin levels —> cough and angiodema
Mx of pts w/ HF due to LV systolic dysfunction
ACEi (titrated up to correct dose)
Treatment should be initiated before BB introduced
MOA of sacubutril/ valsartan
Neprilysin inhibits naturietic peptides and sacubutril is a neprilysin inhibitor (prevents breakdown)
Also inhibits angiotensin pathway
Treating HF and AF
Anticoag - consider for those w/ hx of thromboembolism, LV aneurysm or intracellular cardiac thrombus
Amiodarone - effective against most ventricular arrhythmias
Side effects of amiodarone
Thyroid dysfunction
Pulmonary fibrosis
Liver damage
Neuropathy
Surgery and devices for c/c HF
Coronary revascularisation Transplantation LVAD CRT - biventricular pacing Ablation for AF ICD Valve repairs if indicated
LVAD
LV Assist Device
Revascularisation for HF
PCI/ CABG may relieve ischaemic symptoms and improve mortality in heart failure pts w/ multi-vessel disease and stable angina
CRT for HF
~30% of HF pts have dyssynchronous ventricular contraction (LBBB)
When should CRT be considered in HF pts
LVSD (EF < 35%) on medical therapy and a QRS duration > 120msec
Heart transplant for HF
Limited availability of donor organs
Few UK centres
c/c immunotherapy required
Mechanical support for HF pts
Implanted mechanical pumps can provide circulatory support for short/medium term
When should mechanical support be considered for HF pts
Specialists consider this in pts w/ severe refractory symptoms, or refractory symptoms or refractory cardiogenic shock
What is HFpEF associated with
Older age and HTN/ LV hypertrophy, obesity, DM
Mutation seen in Marfan syndrome
FBN1 gene –> less functional fibrillin-1 produced
Inheritance pattern for Marfan syndrome
Autosomal dominant
Mutations seen in Long QT syndrome
KCNQ1, KCNH2 and SCN5A genes
Inheritance pattern for long QT syndrome
Autosomal dominant
Fabry disease
Results from build up of fat, globotriaosylceramide
What mutations cause Fabry disease
GLA –> absence of alpha-galactosidase A –> globotriaosylceramide isn’t broken down
Inheritance pattern of Fabry disease
X-linked
Mutations causing familiaal hypercholesterolaemia
Mutations in APO8, LDLR, LDLRAP1 or PCSK9
Most common cause of familial hypercholesterolaemia
Changes in LDLR –> less LDL receptors made –> less LDLs removed from blood stream
Inheritance pattern of familial hypercholesteolaemia
Autosomal dominant pattern
Genetic variation affecting mx of pts w/ CVD
Some pts treated w/ statins have bad ADRs e.g. myopathy associated w/ simva and a variant of gene SLCO1B1
Some pts treated w/ clopi don’t benefit as variants of cytochrome P450 can alter conversion of inactive prodrug to its active metabolite
Cardiomyopathy
Disorder in which heart muscle is structurally and functionally abnormal (in absence of other heart condns severe enough to cause the heart muscle abnormality)
Commonest types of cardiomyopathies
Hypertrophic
Dilated
Arrhythmogenic
What type of impairment is seen in HCM
Diastolic
What type of impairment is seen in DCM
Systolic
Commonest CM
HCM
HCM
Unexplained LV hypertrophy - Pattern is usually asymmetric septal hypertrophy
Most common inherited cardiac disease (autosomal dominant)
Commonest cause of sudden death in young (<35yrs) and in athletes
What % of HCM pts have Fhx
50%
Usual px of HCM
HCM can px at any age - birth to >90
Most cases are asymtpmatic
What % of HCM pts have an obstructive form
25%
What is HCM a disease of
Sarcomere
Mutated peptides incorporated into sarcomere –> impaired contractile function –> increased myocyte stress –> compensatory hypertrophy and increased fibrosis
Which proteins in the sarcomere are affected by HCM
Myosin binding protein c
B myosin heavy chain
Hypertrophy vs hyperplasia
Hypertrophy is increase in muscle cell SIZE
Hyperplasia is increase inn cell no.
Examination findings in HCM
May be normal
Double apical impulse
S4
Features of systolic outflow obstruction
Features of systolic outflow obstruction
Jerky pulse
Systolic murmur - obstruction –> murmur at LSE (dynamic - changes depending on preload and afterload), MI
Jerky pulse
Brisk carotid upstroke which suddenly stops
ECG in HCM
Typically, v abnormal showing LVH w/ strain pattern
Imaging tests of choice in suspected HCM
Echo or MRI
Mx of HCM
General measure Treat symptoms Manage AF risk Assess risk of sudden death Family screening
General measures for HCM
Avoid competitive sports
Reassure pt w/out high-risk features
Overall prognosis is good
Treating symptoms of HCM
BB (or verapamil)
- Decreased HR –> increased diastolic filling time
- Decreased force of contraction —> decreased myocardial oxygen demand
Myomectomy (or septal ablation) if still symptomatic
Myomectomy
Surgeon removes small amount of thickened septal wall to widen outflow tracts from LV to aorta
Family screening for HCM
Screen by ECG and echo (and genetic testing if mutation known)
What is DCM characterised by
Enlargement of one or both ventricles w/ impaired contractile function
What does DCM commonly cause
Systolic HF
Pathophysiology of DCM
Myocyte injury –> decreased contractility –> decreased SV
This leads to increased ventricular filling pressure, LV dilatation, decreased CO
Types of DCM
Idiopathic Familial Infl Toxic Metabolic Tachycardia induced Neuromuscular
Infl DCM
Infectious - post viral
Non-infectious - CTD, peripartum mypoathy, sarcoidosis
When does peripartum myopathy occur
Between 6th to 9th month of pregnancy
Toxic DCM
Alcohol - may be reversible by stoping alcohol intake
Chemotherapy
Metabolic DCM
Caused by hypothyroidism
Tachycardia-induced DCM
May recover fully w/ treatment of arrhythmia
Neuromuscular DCM
Muscular or myotonic dystrophy
Px of DCM
Usually presents w/ signs of CCF
What should you ask a DCM pt when they px
Fhx
Alcohol
Exposure to chemotherapeutic drugs
Ix for DCM
Bloods ECG CXR Echo/ MRI Angiography
Bloods for DCM
U&E’s
Ca
P
TFTs
ECG for DCM
No spp features
Finding incl non-spp ST/T wave changes, conduction defects (incl BBB)
CXR findings for DCM
Cardiomegaly
Eco/ MRI findings for DCM
Enlargement of all 4 chambers w/ decreased systolic function
Angiography for DCM
To exclude IHD
Arrhythmogenic CM
An inherited heart muscle disorder characterised by replacement of RV myocardium by fibrofatty tissue
What is arrhythmogenic CM a disease of
Desmosome
Px of arrhythmogenic CM
Presents in young-middle age
May be asymptomatic or present w/ palpitation, syncope or SCD
SCD
Sudden cardiac death
CCF
Congestive cardiac failure
ECG for arrythmogenic CM
Usually abnormal, showing T wave inversion nd localised prolongation of QRS interval in R precordial leads (V1 - V3)
Typical arrhythmia seen in arrhythmogenic CM
LBBB morphology VT
Dx of arrhythmogenic CM
Combi of ECG, imaging, Fhx, biopsy
ICD for arrhythmogenic CM pts
Pts who have survived cardiac aresst
Pts who’ve had haemodynamically unstable ventricular arrhythmias
Pts who have severe cardiac impairment
What do desmosomes do
Bind muscle cells together
Restrictive CM
Rare
Due to myocardial fibrosis or infiltration (usually amyloid)
Poor prognosis
Pathophsyiology of restrictive CM
Rigid myocardium leads to increased diastolic ventricular pressure –> venous congestion
As well as decreased ventricular filling –> decreased CO
Myocarditis
Infl of heart muscle
Which groups can the causes of myocarditis be divided into
Infection
Immune mediated
Toxic
Infection as a cause of myocarditis
Viral (commonest) - coxsackie (enterovirus), adenovirus, others e.g. Chaga disease
What is the commonest infection causing myocarditis worldwide
Trypanosoma cruzi
Endemic in Central and South America
Immune-mediated myocarditis
Incl giant cell myocarditis, sarcoidosis
Toxic causes of myocarditis
Drugs (anthracycline)
Alcohol
Radiation
Which drugs can induce swelling
CCB
Which drugs can induce fluid retention
NSAIDs
Px of myocarditis
Classically presents w/ febrile illness w/ resp/ GI symptoms followed by any cardiac symptoms (fatigue, SOB, chest pain, palpitations, HF)
Spectrum of disease for myocarditis
Asymptomatic to cardiogenic shock
Cardiogenic shock
Life-threatening condn where heart suddenly cannot pump blood to meet body’s needs
Px of myocarditis on young pts vs older pts
A/c flulike px is commoner in younger pts
Older pts are more likely to px w/ DCM and HF
Ix for myocarditis
Bloods
ECG
Imaging
Endomycoardial biopsy
Blood results for myocarditis
Increased troponin
ECG changes in myocarditis
Non-spp ST/ T wave changes
May mimic MI
Arrhythmias
Imaging of choice for myocarditis
CMR
Endomyocardial biopsy
Gold standard test for myocarditis
Not performed as is invasive and hit & miss
Generally reserved for sickest pts
Layers of pericardium
Parietal pericardium
Visceral pericardium
Functions of pericardium
Anchors heart to thorax
Barrier to infection
Limits a/c dilatation of heart
Is the pericardium essential
No
Congenital absence or surgical removal aren’t associated w/ adverse effects
What can go wrong w/ the pericardium
Infl (pericarditsi) Fluid accumulation (effusion --> tamponade) Fibrosis (constriction)
How can the causes of a/c pericarditis be split up
Infectious
Non-infectious
Infectious causes of a/c pericarditis
Idiopathic/ viral - Coxsackie B, influenza, mumps, rubella (80% of cases) Other infections (bacterial, TB, fungal)