Cardiovascular 3 Flashcards
In the chronic management of heart failure with a reduced ejection fraction, what are the two first line medications?
ACE inhibitor PLUS a Beta Blocker
In the chronic management of heart failure with a reduced ejection fraction, if an ACE inhibitor is contraindicated or not tolerated, what other medication can be combined with the Beta Blocker?
Angiotensin Receptor Blocker (ARB)
In the chronic management of heart failure with a reduced ejection fraction, if ACE/ARB + Beta Blocker aren’t tolerated, what is the next first line option?
Hydralazine + Nitrates
What class of diuretics are used to treat fluid overload in heart failure? What other class may be used in addition to these?
Loop Diuretics, e.g. Furosemide. Although you can add in Thiazide-like diuretics if overload is severe
In the chronic management of heart failure with a reduced ejection fraction, what is the MOA of Ivabradine?
Reduces heart rate by inhibiting SA node current and does not reduced contractility.
According to NICE guidance, what are the (3) prescribing considerations for Ivabradine?
NYHA Class II-IV + Systolic dysfunction + LVEF <35%
Must be in sinus rhythm with HR >75 BPM
Stable on standard therapy for at least 4 weeks
In the chronic management of heart failure with a reduced ejection fraction, what is the MOA of Sacubritril Valsartan (brand name Entresto)?
Sacubritril inhibits enzyme that breaks down ANP, BNP and Bradykinin. Increased levels of ANP and BNP stimulate sodium and water excretion, promote myocardial relaxation and stimulates vasodilation.
Valsartan is an ARB which is blocking the effect of Angiotensin II.
In the chronic management of heart failure with a reduced ejection fraction, what is the MOA of Hydralazine + Nitrates?
Hydralazine = Arterial vasodilator Nitrates = Venous vasodilator
decreasing TPR, and thus afterload, and decreasing venous return and thus preload
In the chronic management of heart failure with a reduced ejection fraction, what is the MOA of Digoxen?
Na/K ATPase pump inhibitor. Increases force of contraction, but slows heart rate.
In the ACUTE management of heart failure, what should be administered?
Oxygen (if required) + IV Furosemide
In the ACUTE management of heart failure, according to NICE what (3) medications are NOT recommended for routine administration?
Opioids, Nitrates, Inotropes/Vasopressors
Common side effects of loop diuretics, e.g. Furosemide
Dehydration, Hypotension, AKI, Electrolyte Imbalances, Hearing loss/tinnitus (same co-transporter regulates endolymph in ear)
What medications have the potential to worsen heart failure?
Steroids, NSAIDs, CCBs, Metformin/Poiglitazone.
Name the atrioventricular vavles:
Mitral and Tricuspid valves
Name the semilunar valves
Aortic and Pulmonary valves
How many leaflets/cusps does each valve have?
Mitral has 2 leaflets (bicuspid), Pulmonary, Tricuspid and Aortic valves have 3 leaflets.
What is the name of the structure that connects the atrioventricular valves (mitral and tricuspid) to the papillary muscles on the inner wall of the ventricles?
Chordae Tendineae
What (6) conditions can cause heart valves to become insufficient/Regurgitate?
Congenital Abnormalities - Prolapse or Bicuspid Aortic valve.
Inflammation - Rheumatic fever
Infective causes - Infective endocarditis
Ischaemic Events - Increase likelihood of traumatic rupture of chordae tendineae
Hypertrophy and Dilation
What is meant by valvular stenosis?
Stiffened, thickened or hardened cusps/leaflets,
causing faster and more turbulent flow of blood.
What is meant by valvular regurgitation?
Loose, floppy cusps/leaflets, Increased stagnation of blood. Valve remains open throughout cycle
causing constant drip flow and
backflow of blood.
(7) Common causes of heart failure
CAD, previous MI
HTN
AF
Valvular Heart Disease
Excess Alcohol
Infection
Cardiomyopathy of unknown cause
What is another name for systolic heart failure?
Heart failure due to reduced ejection
fraction (HFrEF)
What is Systolic Heart Failure/HFrEF due to?
Due to
left ventricular systolic dysfunction.
In Systolic Heart Failure/HFrEF, what is the ejection fraction?
<40%
What is another name for diastolic heart failure?
Heart failure with preserved ejection
fraction (HFpEF)
In Diastolic Heart Failure/HFpEF, what is the ejection fraction?
> 50%. Although this may decline over time.
What is the main pathophysiology/mechanisms behind Diastolic Heart Failure/HFpEF?
Delayed relaxation of the left ventricle and as a result, impaired left ventricle filling. The ventricular myocardium becomes thickened, increasing the stiffness.
Define the Frank-Starling Mechanism
Defines the normal relationship between the length and tension of the myocardium. The greater the stretch on the myocardium before systole (preload), the stronger the ventricular contraction.
What will the Frank-Starling Curve look life in heart failure?
In HF, the Frank–Starling curve is moved
down (flattened) because more venous
return and filling pressure is required to
increase contractility and stroke volume.
Presenting symptoms of Left Sided Heart Failure?
SOB, Cough, Wheeze, Blood in sputum, Fatigue, Waking up being breathless at night (PND)
Findings of Left Sided Heart Failure on examination?
Increased RR
Tachycardia
Rales/crackles in lung bases (pulmonary oedema)
Cool extremities at rest
Cyanosis
Laterally displaced apex beat (LV Hypertrophy)
Gallop Rhythm
Findings of Right Sided Heart Failure on examination?
Peripheral Oedema, Sacral Oedema, Raised JVP, Parasternal Heave, Ascites, Hepatosplenomegaly, Jaundice
Name of the blood test used when suspecting heart failure?
B-Type Natriuretic Peptide (BNP) (Levels go up when heart failure develops)
What is B-Type Natriuretic Peptide (BNP)?
A hormone produced by the heart in response
to changes in pressure inside the heart. Levels goes up when heart failure develops
What BNP level(s) should a patient have in order to be referred to have transthoracic echocardiography?
Between 400 and
2,000 pg/L
Describe where each valve is located when doing a cardiovascular examination
Aortic = 2nd ICS, right sternal edge Pulmonary = 2 ICS, left sternal edge Tricuspid = 4th ICS, left sternal edge Mitral = 5th ICS, MCL
