Cardiovascular system

Question 1

Heart failure - LEARN

• Risk factors
• Main symptoms
• Main findings on clinical exam for diagnosis
• What to look for on clinical examination

Answer 1

Risk factors
Hypertension
MI
Valvular heart disease
AF
Alcohol
Inherited cardiomyopathy

Main symptoms

• SOB, on exertion, orthopnea, paroxymal noctornal dyspnoea
• leg swelling
• fatigue

Signs (to diagnose - elevated JVP, laterally displaced apex beat, 3rd heart sound)

Other
BP (HTN)
Pulse rate and rhythm (Tachycardia, irregular pulse (AF risk)
Peripheral pulses (?)
Palpation - laterally displaced apical beat
Auscultation - Murmur (risk factor), 3rd heart sound
Elevated JVP (Rsided HF)
Sacral + pedal Oedema (Rsideded HF)
Pulmonary rales - that do not clear with coughing

Question 2

Heart Failure - LEARN

• Investigations
• What can bnp tell us?
• what level of bnp to rule out HF
• when to use an echogram

Answer 2

Investigations
Bloods - FBC, C, U+E, albumin, BNP, TFTs
Iron studies (ferritin, TIBC, transferrin saturation) -look for haemochromatosis and iron deficiency
ECG - ischemia, prev MI, arrhythmias
Chest Xray -alternative cause, cardiomegaly
Echogram - (test if bnp high, and signs suggest HF), - Can estimate systolic function, look for heart valves

BNP
Hormones released from myocardium in response to stress, particularly stretch and results in an increase in sodium secretion
We measure it to rule out heart failure
BNP-32 (<30) and NT-proBNP (<35) both used - if they are less than 35 then can rule out heart failure

Question 3

Heart Failure - LEARN
General - LEARN

Differential diagnosis - SOB

Answer 3

Cardiac causes

• MI/ACS
• Heart failure - orthopnea, paroxymal noctornal dyspnea
• Arrhythmia
• Valvular disease

Respiratory

• Asthma
• COPD
• Pneumothroax
• PE
• Pneumonia
• interstitial lung disease

Other

• Obesity
• anxiety
• anaemia
• hyperthyroidism

Question 4

Heart Failure - LEARN
General management of Heart failure

Side effects of medication

Answer 4

1. Attend to other risk factors and CVS risk factors
2. Stop other medications that could be contributing (NSAIDs, corticosteroids, tricyclic antidepressants)
3. ACE + beta blocker + diuretic
4. Spironolactone + digoxin
   Hydralazine + nitrate
5. Lifestyle modification
6. Manage exacerbations (daily weights, swelling)

-if EF <40 - cardiology assessment and poorer prognosis

Things to check in medication

• K level
• renal function

Question 5

Heart failure - EXTRA - read

What drugs decrease mortality in HF

Answer 5

The following drugs have all been shown to reduce mortality in patients with left ventricular failure:
ACE-inhibitors
Beta-blockers
Angiotensin receptor blockers
Aldosterone antagonists
Hydralazine and nitrates

Question 6

Heart failure - EXTRA -read

Drugs to know

Answer 6

Furosemida, bumetanide –> loop diuretics

Digoxin –> Improve symtpoms due to inotropic properties, good when have AF

Hydralazinez (vasodilator) + nitrate –>

Ivabradine

Lorsatan –> AT2 receptor antagonist