Cardiovascular Flashcards
What is Cardiac Failure?
The failure of the heart to maintain the cardiac output required to meet the body’s demands
LHF + RHF = Congestive Heart Failure
What does it mean by ‘Output States’ in relation to Cardiac Failure?
Low Output State = heart fails to pump in response to normal exertion
High Output State = cardiac output is normal but there are higher metabolic needs such as pregnancy, anaemia, hyperthyroidism
What are the ways in which Cardiac Failure can be classified?
- By EF
- By time
- By LHF or RHF
What are the parameters for classifying Cardiac Failure by EF?
- Patients with reduced LVEF (< 35-40%) have HF-rEF
This is due to systolic dysfunction (impaired myocardial contraction) - Patients with normal (preserved) LVEF have HF-pEF
This is due to diastolic dysfunction (impaired filling during diastole)
LVEF measured using echocardiography
Causes of Systolic and Diastolic dysfunction for Heart Failure
SD
- Ischaemic Heart Disease
- Dilated CMO
- Myocarditis
- Arrhythmias
DD
- Hypertrophic Obstructive CMO
- Restrictive CMO
- Cardiac Tamponade
- Constrictive Pericarditis
What are the parameters for classifying Cardiac Failure by time?
Acute or Chronic
- Acute typically refers to an acute exacerbation of chronic
- Most urgent symptoms are often due to LV failure resulting in pulmonary oedema
What are the parameters for classifying Cardiac Failure by LHF and RHF?
HF-rEF and HF-pEF typically develop left-sided heart failure. This may be due to increased left ventricular afterload (e.g. arterial hypertension or aortic stenosis) or increased left ventricular preload (e.g. aortic regurgitation resulting in backflow to the left ventricle).
Right-sided heart failure is caused by either increased right ventricular afterload (e.g. pulmonary hypertension) or increased right ventricular preload (e.g. tricuspid regurgitation).
History and Examination for LHF
Respiratory symptoms
- Increased heart and respiratory rate
- Arrhythmia
- Dyspnoea
- Nocturnal cough (may have pink frothy sputum)
- Fatigue
History and Examination of RHF
Swelling symptoms
- Swelling
- Fatigue
- Raised JVP
- Reduced exercise tolerance
- Anorexia
- Nausea
- Nocturia
- Ascites
Clinical Diagnosis for Cardiac Failure by Framingham Criteria
2+ majors or 1 major and 2 minors from:
Investigations for Cardiac Failure
CHRONIC
-NT-proBNP (nice)
- 2000ng/litre, urgent referral for transthoracic echo in 2/52
- 400-2000ng/litre, same as above but in 6/52
ACUTE
- BNP > 100ng/litre
- NT-proBNP > 300ng/litre
- Perform transthoracic Doppler 2D echocardiography to establish the presence or absence of cardiac abnormalities
- ECG
- Bloods - FBCs, U&Es, LFTs, TFTs, BNP
- Chest X-Ray
- Transthoracic Echocardiography
- Coupled with Doppler
- Can calculate EF (normal 50-70%)
Findings for Cardiac Failure on X-Ray
- Alveolar Oedema
- Cardiomegaly
- B-lines (Kerley)
- Dilated upper lobe vessels and upper lobe
- Effusion
Management of Cardiac Failure if Acute
ABCDE approach
- Sit patient upright
- Give oxygen (target 94-98%)
- GTN infusion if concomitant myocardial ischaemia, severe hypertension or left-sided regurgitation
- Can cause hypotension
- IV furosemide for pulmonary oedema
- CPAP if not responding to treatment and in respiratory failure.
- Inotropic agents such as dobutamine should be considered with severe left ventricular dysfunction and cardiogenic shock (hypotensive).
- Stop beta-blockers if HR < 50, second or third degree heart block, or shock
Management of Cardiac Failure if Chronic
- Treat underlying cause
- Treat exacerbating factors
- Lifestyle modifications
- Drugs
- ACE inhibitor - give to all patients with LV dysfunction (reduced EF) and beta-blocker - reduce O2 demand on heart
- Aldosterone agonist
- Spironolactone, eplerenone
- Monitor potassium to avoid hyperkalaemia
- SGLT-2 inhibitors for reduced ejection fraction
- Ivabradine if sinus rhythm > 75/min and EF < 35%
- Sacubitril-valsartan if EF < 35% and symptomatic on ACEi’s or ARBs (initiate after wash-out period)
- Digoxin if coexistent atrial fibrillation
- Consider hydralazine and nitrates in Afro-Caribbean patients
- Cardiac resynchronisation therapy if widened QRS
- Annual influenza vaccine
- One-off pneumococcal vaccine
What are complications of Cardiac Failure?
- Respiratory complications
- Renal failure
- Acute exacerbations
What is Deep Vein Thrombosis?
Deep vein thrombosis (DVT) is a significant medical condition characterised by the formation of a thrombus within the deep venous system, typically in the lower extremities.
What do patients with DVT usually present with?
- Pain + tenderness + swelling in affected leg
- Warmth + redness in affected leg
- Shortness of breath and chest pain (suggestive of PE)
What scoring system is carried out for suspected DVT?
Well’s Score
Investigations for DVT
If scores from Well’s Score:
- Is >2 : Ultrasound of affected leg, D-dimer if negative
- Is <2 OR US can’t be carried out in 4 hours : D-dimer, give DOAC in meantime
- If +ve D-dimer, stop DOAC and do US in a week
Management for DVT
The management of DVT involves the following steps:
- Apixaban or rivaroxaban
- If unsuitable, severe renal impairment or antiphospholipid syndrome then low molecular weight heparin followed by vitamin K antagonist (warfarin)
- 3 months for provoked VTE
- 6 months for unprovoked VTE
- Compression stockings: These help to prevent swelling and improve blood flow in the affected leg.
- Elevation of the affected leg: This helps to reduce swelling and improve blood flow.
- Thrombectomy: This is a surgical procedure to remove the blood clot in the affected vein
