Case 9 - Congestive Cardiac Failure - Progress Test Flashcards
What are the types of AF?
Paroxysmal - (lasts for less than 7 days and self-resolves. Must have over two episodes)
Persistent - (lasts for over 7 days and doesn’t self-resolve)
Permanatent - (cannot or deemed inappropriate to be cardioverted - treat with rate control and anticoagulation)
When should rhythm control be used over rate control in AF?
Coexistent heart failure
First onset AF
Obvious reversible cause of AF
What is first line rate control management of AF?
Beta blocker or calcium channel blocker (diltiazem)
What is second line rate control management of AF?
2 of:
- beta blocker
- diltiazem
- digoxin
When should cardioversion be used straight away in AF?
AF began less than 48 hours ago.
Heparin should be given prior to cardioversion
How are patients cardioverted?
Electrical cardioversion or
Pharmacological cardioversion with flecainide / amioderane
How long should patients be anticoagulated for before cardioversion in AF of longer than 48 hours in duration?
3 weeks
After a patient with AF of duration > 48 hrs has been cardioverted, how long should they remain on oral anticoagulants?
at least 4 weeks
What factors would favour a rate control strategy in AF?
> 65
History of ischaemic heart disease
What factors would favour a rhythm control strategy in AF?
< 65 Symptomatic First presentation Lone AF or secondary to a corrected cause Congestive heart failure
How is stroke risk calculated in AF?
CHA2DS2-VASc score
determines if a patient should be anticoagulated
What anticoagulation should be given to patients in AF?
Warfarin / NOAC
In acute stroke patients, without haemorrhage, who have AF, when should anticoagulation be started?
2 weeks post stroke
What is the most common causative organism of infective endocarditis?
Staph. aureus
What is the most common causative organism of infective endocarditis if there in an indwelling line?
Staph. epidermidis
What is the most common causative organism of infective endocarditis in the developing world?
Strep. viridans
What are risk factors for developing infective endocarditis?
50% of cases occur in those with normal heart valves (commonly affecting the mitral valve)
Rheumatic fever
Prosthetic heart valve
IVDU (commonly affects the tricuspid valve)
Recent piercings
How are cardiac murmurs graded?
(Levine scale)
1 - very faint 2 - faint 3 - easily audible, no thrill 4 - loud, with trill 5 - very loud, often heard over a wide area, with thrill 6 - heard without a stethoscope
What are common causes of heart failure?
- Coronary heart disease
- Hypertension
- Ischaemic heart disease
- Valvular disease
- Congenital heart disease
- Uncontrolled AF
- Thyrotoxicosis
- Anaemia
- Heart block
- COPD
- Pulmonary fibrosis
- Recurrent PE
- Primary pulmonary hypertension
- Alcohol and chemotherapy
- Chronic pericarditis (TB, lupus, viruses)
- Autoimmune conditions (eg. amyloidosis, sarcoidosis)
- Pregnacy enduced cardiomyopathy
- Acute viral myocarditis
How is heart failure classified?
NYHA class I - no symptoms, no limitations on physical activity
NYHA class II - mild symptoms, slight limitation on physical activity
NYHA class III - moderate symptoms, marked limitation of physical activity
NYHA class IV - severe symptoms, unable to carry out any physical activity without discomfort
What are causes of acute heart failure?
Cardiac ischaemia
Viral myopathy
Toxins
Valve dysfunction
Most common precipitating causes of decomensated heart failure are:
- acute coronary syndrome
- hypertensive crisis
- acute arrhythmia
- valvular disease
How is acute pulmonary oedema managed?
Sit patient upright
Give 100% oxygen unless CO2 retention
Consider small increments of IV diamorphine or morphine if associated chest pain
Give IV furosemide 50mg (or double normal dose if already on oral diuretics)
Repeat diuretics after 30mins to 1 hr - give double 1st dose
If further diuretic required, refer to senior staff
Give IV GTN at 0.5mg/hr and titrate according to BP.
Only give if systolic BP > 90
Consider CPAP or NIV if poor response
Consider IV inotropes or invasive ventilation if not responding
What drugs should be given to manage heart failure?
1st line:
ACE-i + Beta blocker
(start one at a time)
2nd line:
Aldosterone antagonist
3rd line:
(should be started by a specialist)
- Ivabradine (sinus rhythm > 75 bpm + EF < 35%)
- sacubitril-valsartan (EF < 35%, if not responding to ACE-i and beta blocker)
- digoxin (use if coexistent AF)
- hydrazline + nitrate (useful in Afro-Caribbean patients)
- cardiac resynchronisation therapy (indicated if wide QRS)
What vaccines should be offered in heart failure?
Annual influenza vaccine
One off pneumococcal vaccine
What are signs of heart failure?
Pulmonary oedema / pleural effusion Raised JVP Pitting oedema Ascites Tachycardia S3 gallop
What criteria should be used to diagnose infective endocarditis?
Modified Duke criteria
