Cardiovascular Disease Flashcards by Elaine Brazier

What are the typical symptoms of heart failure?

-Breathlessness
-Fluid retention
-Fatigue
-Lightheadedness/Syncope

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What types of breathlessness can occur when a patient has heart failure?

-Exertional
-Non-exertional
-Orthopnoea
-Paroxysmal nocturnal dyspnoea
-Nocturnal cough

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Where might a patient with heart failure experience/report fluid retention?

-Ankles
-Abdomen

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What risk factors in a patient’s medical history might there be for heart failure?

-Coronary artery disease/previous MI
-HTN
-AF
-DM

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A patient presents with a history of progressively worsening shortness of breath especially when lying flat, and swelling of legs.

What observations would increase suspicion of heart failure?

-Tachycardia
-Tachypnoea
-Hypertension

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A patient presents with a history of progressively worsening shortness of breath especially when lying flat, and swelling of legs.

What examination findings in the chest might indicate heart failure?

-Laterally displaced apex beat
-Heart murmur
-Basal crepitations
-Pleural effusion

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A patient presents with a history of progressively worsening shortness of breath especially when lying flat, and swelling of legs.

What examination findings outside of the chest might indicate heart failure?

-Raised JVP
-Enlarged liver
-Dependant oedema or ascites
-Obesity

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A patient presents with a history of progressively worsening shortness of breath especially when lying flat, and swelling of legs.

How should the likely condition be investigated?

Heart failure

-N-terminal pro-B-type natriuretic peptide
-12 lead ECG
-Other tests as appropriate for any other underlying pathology

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How should NT-pro BNP level be interpretted?

Over 2000 - refer for specialist assessment and echo within 2 weeks

400-2000 - refer for specialist assessment and echo within 6 weeks

Less than 400 - diagnosis of heart failure is less likely

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A patient presents with a history of progressively worsening shortness of breath especially when lying flat, and swelling of legs.

Other than NT-pro BNP and ECG, what tests may be appropriate to determine cause?

-Chest x-ray
-Bloods inc FBC, U&Es, TFTs, LFTs etc
-Urine dip
-Lung function tests

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In which groups of people might NT-pro BNP be reduced?

-Those with BMI >35
-Those on diuretics/ACE-Is/ARBs/beta blockers
-Those of Afro-Caribbean origin

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Other than heart failure, what can increase levels of NT-pro BNP?

-Age over 70
-LVH/MI/tachycardia
-RV overload
-Hypoxia
-Pulmonary HTN
-PE
-CKD
-Sepsis
-COPD
-DM
-Liver cirrhosis

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A patient presents with a history of progressively worsening shortness of breath especially when lying flat, and swelling of legs.

What conditions could explain the breathlessness other than heart failure?

-COPD
-Asthma
-PE
-Lung Cancer
-Anxiety

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A patient presents with a history of progressively worsening shortness of breath especially when lying flat, and swelling of legs.

What conditions could explain the peripheral oedema other than heart failure?

-Prolonged inactivity or venous insufficiency
-Nephrotic syndrome
-Medication
-Hypoalbuminaemia
-Pelvic tumour

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What is heart failure caused by?

Structural and/or functional abnormality that produces raised intracardiac pressure &/or inadequate cardiac output at rest &/or at exercise

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What defines they type of heart failure a patient has?

Ejection fraction

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What level of LVEF (left ventricular ejection fraction) counts as reduced ejection fraction?

<40%

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What level of LVEF (left ventricular ejection fraction) counts as mildly reduced ejection fraction?

41-49%

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What level of LVEF (left ventricular ejection fraction) counts as preserved ejection fraction?

> 50%

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What proportion of patients with heart failure have preserved ejection fraction?

Nearly half

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What system is used to classify the severity of heart failure?

New York Heart Association classification

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What are the categories in NYHA classification for heart failure?

Class I to Class IV

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What is Class I NYHA classification?

No limitation of physical activity

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What is Class II NYHA classification?

Slight limitation of physical activity but comfortable at rest

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What is Class III NYHA classification?

Marked limitation of physical activity but comfortable at rest

What is Class IV NYHA classification?

Unable to carry out any physical activity without discomfort, symptoms can be present at rest

What myocardial diseases can lead to heart failure?

-Coronary artery disease -HTN -Cardiomyopathies

Can valvular heart disease cause heart failure?

Yes

What pericardial disease can cause heart failure?

-Constrictive pericarditis -Pericardial effusion

Can congenital heart disease cause heart failure?

Yes

Can arrythmias cause heart failure?

Yes - AF and other tachyarrythmias can

What high output states can cause heart failure?

-Anaemia -Thyrotoxicosis -Phaemochromocytoma -Sepsis -Liver failure -AV shunt -Paget's disease -Thiamine deficiency

What causes of volume overload can cause heart failure?

-End-stage CKD -Nephrotic syndrome

Can obesity cause heart failure?

Yes

What drugs can cause heart failure?

-Alcohol -Cocaine -NSAIDs -Beta blockers -Calcium channel blockers

What is the average age of first diagnosis of heart failure?

76 years

What sign at time of diagnosis confers better prognosis of newly diagnosed heart failure?

Not requiring hospital admission

What are some of the poor prognostic factors for heart failure?

-Increasing age -Reduced EF -Presence of co-morbidities -Worsening severity of symptoms/signs -Obesity/cachexia -Smoking -Hx of IHD -Presence of complex arrhythmias

Can heart failure cause arrhythmias?

Yes - AF and other ventricular arrhythmias

How common is depression in heart failure?

Common - around 20% of people with heart failure have major depressive order

Can heart failure cause anaemia?

Yes

What proportion of deaths in people with heart failure are due to sudden cardiac death?

30-40%

What can be done during a medication review for a patient with newly diagnosed heart failure?

Stop/reduce any drugs that may contribute to symptoms/worsen heart failure NSAIDs, beta-blockers (in some scenarios), Ca Channel blockers

What should first line medical management of fluid overload symptoms be in a patient with newly diagnosed heart failure?

Prescribe a loop diuretic

What loop diuretics can be prescribed first line for heart failure?

Bumetanide Furosemide Torasemide

How should loop diuretic dose be titrated in heart failure?

According to symptoms

A patient with heart failure is on the maximal dose of oral loop diuretic but has ongoing symptoms. What needs to be done in this situation?

Referral for specialist advice

A patient with newly diagnosed heart failure with LVEF 38% has been prescribed furosemide for symptom control. What else can you prescribe for symptom control and to improve prognosis?

ACE-I and beta-blocker

In what situation is an ACE inhibitor for reduced EF heart failure contraindicated?

-Haemodynamically significant valvular disease unless assessed by specialist -Pt unable to tolerate ACE-I

In what situation is a beta blocker for reduced EF heart failure contra-indicated?

With concurrent Diabetes Mellitus

If a patient with heart failure is unable to tolerate an ACE inhibitor, what can be commenced instead?

Angiotensin-II receptor antagonist

In addition to loop diuretic, ACE-I/ARB, and beta blocker, what can be considered to manage heart failure?

SGLT2 inhibitor e.g. dapagliflozin Aldosterone antagonist e.g. spironalactone

When should an antiplatelet be considered for a patient with HFrEF?

Patients with atherosclerotic arterial disease

What non-cardiac symptoms/conditions need to be screened for in patients with heart failure?

Depression and anxiety

What can be done if a patient is obese or underweight with concurrent heart failure?

Refer for dietetic advice for underweight pts Advice on achieving healthy weight if BMI over 30

When should advance care planning be considered if a patient has been diagnosed with hearth failure?

Should be considered in early stages of the disease The earlier the better, however this is not always practical

How should new medications be started when managing a patient with heart failure?

One at a time, stabilise on one before starting to titrate another

Are aldosterone antagonists or SGLT2 inhibitors recommended by NICE for management of HFrEF?

No however other guidelines suggest they can be considered with specialist input

In mildly reduced ejection fraction heart failure, what medications are recommended by NICE to manage mildly reduced EF heart failure?

1. Loop diuretics 2. ACE-I 3. Beta blocker 4. Aldosterone antagonist 5. Sacubitril valsartan

What is the recommendation regarding Dapagliflozin in management of chronic symptomatic heart failure with preserved or mildly reduced heart failure?

Can be commenced with specialist input

What medications are recommended for managing HFpEF?

Loop diuretics Dapagloflozin with specialist input if optimal diuretics does not improve symptoms

What is regarded as being end-stage heart failure?

If the patient is at high risk of dying within 6-12 months

What indicators are there for end-stage heart failure?

-Frequent hospital admissions -Poor response to treatment -Increasing NYHA score -Cachexia -Low serum albumin -Declining eGFR and BP -Poor QoL &/or functional status

A patient with end stage heart failure is becoming more unwell and it is becoming more difficult to control their symptoms. An ICD had been implanted a few years ago. What needs to be considered at this time?

Deactivation of ICD

What palliative medications could be considered to manage breathlessness in end stage heart failure?

Opiates Benzodiazepine Home oxygen

What palliative medications could be considered to manage chest pain in end stage heart failure?

Morphine Nitrates

A patient with end stage heart failure is newly registered at the practice. What do you need to ensure they have?

Advance care plan RESPECT form Medicine optimisation Anticipatory medicines Psychological support

What symptoms should a GP advise a patient with heart failure to look out for?

Increasing SoB, fatigue, ankle/abdominal swelling, or rapid weight gain

What is a useful measure of oedema when reviewing a patient with heart failure?

Weight

How frequently can you advise a patient with heart failure to weigh themselves to help monitor their fluid renetion?

Daily, weekly, or fortnightly depending on level of risk of deterioration

What dietary advice can be given to a patient with heart failure?

-Reduce salt intake (<5g per day) -Mediterranean diet -Fluid restrict within safe limits

What advice should be given regarding heart failure and driving?

Pts responsibility to inform DVLA of any condition whcih may affect ability to drive and should check with insurer if they are covered Group 2 drivers are disqualified from driving if they are symptomatic but they can be relicensed

How frequently should a patient with stable heart failure be monitored?

At least 6 monthly

Which ARBs are licensed in UK for treatment of heart failure?

Candesartan Losartan Valsartan

What should be checked before commencing an ARB?

Renal function Serum electrolytes inc. potassium BP

What measurements would contraindicate commencing an ARB for heart failure?

Potassium greater than 5 alongside CKD

How soon after commencing and ARB should U&Es and BP be rechecked?

1-2 weeks, earlier if higher risk e.g. pre-existing CKD/more comorbidities/polypharmacy

Once a patient is stabilised on an ARB, how frequently should U&Es be monitored?

Once a month for 3 months, then 6 monthly plus any time they are unwell

What are the sick-day rules for ARBs?

If pt has D&V - Maintain fluid intake, stop ARB for 1-2 days until they recover

What measurement in U&Es can increase due to an ARB?

Creatinine

What level is a non-concerning creatinine rise following commencement of an ARB?

Less than 30%

Up to what level of potassium is acceptable with an ARB?

5.5 mmol/L