Case 9 - Cogestive Cardiac Failure Flashcards
What is the NYHA classification for heart failure?
New York Heart Association classification of heart failure:
Class 1 - no symptoms or limitation
Class 2 - mild symptoms, fatigue in ordinary activity
Class 3 - moderate symptoms, fatigue in less than ordinary activity
Class 4 - severe symptoms, unable to carry any activity without discomfort, symptoms present at rest
What are the guidelines for treatment of heart failure?
1st line - ACE inhibitor and beta blocker
2nd line - add aldosterone antagonist, or hydralazine in combination with nitrate
3rd line - add cardiac resynchronisation therapy or digoxin, can also add ivabradine if the patient has a heart rate >75 and EF <35%
What are the drugs that are shown to improve mortality in patients with heart failure?
ACE inhibitors
Spironolactone
Beta blockers
Hydralazine with nitrates
What is the first line investigation for suspected heart failure?
BNP test (regardless if had MI or not)
- if levels are ‘high’ arrange echo for 2 weeks
- if levels are ‘raised’ arrange echo for 6 weeks
All patients with suspected heart failure should have 12 lead ECG
What are the normal, raised and high levels for BNP?
Normal <100pg/ml
Raised 100-400 pg/ml
High >400pg/ml
Auscultation of the chest in a patient with heart failure, you can often hear what?
A third heart sound
What are the main symptoms of heart failure?
Breathlessness
Reduced exercise tolerance
Oedema
Fatigue
What are the main signs seen in heart failure?
Cyanosis Tachycardia Elevated JVP Displaced apex beat Pulmonary oedema Pitting oedema S3 heart sound (S3 gallop)
What are the signs and symptoms associated with left sided heart failure?
Pulmonary oedema - fluid backs up into lungs
Dyspnoea - extra fluid causes difficulty breathing
Orthopnoea (difficultly breathing when lying flat)
Crackles - bibasel crepitations due to extra fluid in lungs
What are the signs and symptoms of right sided heart failure?
Raised JVP - blood that cannot pump backs up to right side of body
Ascites - fluid backs up to abdominal organs
Pitting oedema - fluid backs up to the legs
What is the CHADS2 score?
Score for stroke risk assessment in AF C - Cardiac heart failure H - hypertension A - Age >75 D - diabetes S - stroke or TIA
What are the management options in acute heart failure?
Oxygen Diuretics Opiates Vasodilators CPAP (continuous positive airway pressure)
What is the Duke’s criteria used to help diagnose?
Infective endocarditis
What are the major criteria regarding dukes criteria?
Two positive blood cultures showing typical organisms consistent with infective endocarditis
Persistent bacteraemia from two blood cultures taken >12 hour apart or three or more positive blood cultures where the pathogen is less specific such as staph.aureus
What are the minor criteria in dukes criteria?
Predisposing heart failure
IV drug use
Fever >38
Vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, janeway lesions, petechiae or purpura
Immunological phenomena: glomerulonephritis, oslers nodes, Roth spots
What is the most common cause of infective endocarditis?
Staphylococcus aureus
What are the risk factors for developing infective endocarditis?
Previous episode of infective endocarditis Previously normal valves Rheumatic valve disease Prosthetic valves Congenital heart defects IVDU
What is orthopnoea?
What commonly causes it?
Breathlessness when lying flat
Symptom of left ventricular failure and/or pulmonary oedema
How can the JVP and carotid pulse be differentiated?
JVP beats twice - is multiphase
JVP is non palpable
JVP can be occluded by lightly pressing against the neck
How do you grade heart murmurs?
Grade 1 - murmur is heard on listening for some time
Grade 2 - faint murmur heard immediately on auscultation
Grade 3 - loud murmur with no palpable thrill
Grade 4 - loud murmur with a palpable thrill
What are the common causes for heart failure?
Ischaemic heart disease Structural causes Congenital heart disease Rate related causes - e.g, AF, heart block Pulmonary causes - e.g, COPD, pulmonary fibrosis Alcohol and drugs Autoimmune disease Pericardial disease
What are the causes of mitral regurgitation?
Rheumatic heart disease
Ischaemic heart disease - associated with papillary muscle rupture
Valvular vegetations - as in patients with endocarditis
Physiological mitral valve regurgitation due to dilated left atrium
Define ejection fraction?
What is a normal ejection fraction?
Ejection fraction is a measurement of how much blood is being pumped out of the heart with each contraction (stroke volume/end diastolic volume)
Normal EF: 50-70%
Why would you not cardiovert someone who has been in AF for longer than 48 hours (unless it was going to be life saving)?
In AF blood flow is turbulent and can cause clots to form, which is significantly more risky if you have been in AF > 48 hours
If normal sinus rhythm is restored this could dislodge clots and cause an embolic stroke
