Case 9 - Congestive Heart Failure Flashcards
What is the HAS BLED score?
Assess 1-year risk of major bleeding in patients taking anticoagulants with atrial fibrillation.
What is stroke volume?
The volume of blood pumped by LV in single heartbeat.
What is ejection fraction?
% of blood pumped by LV in each contraction.
What is afterload?
The force against which the ventricles contract.
What is preload?
How much the heart muscle stretched before systole.
What are the causes of LVHF?
- Arrhythmia: AF
- Rate related: AF, thyrotoxicosis, anaemia
- Valvular disease: MR, AS, AS
- HTN
- MI
- Congenital defects: VSD, ASD
What is BNP?
Ventricular myocyte released in response to ventricular stretching.
What are the signs and symptoms of LV HF?
- Dyspnoea
- Orthopnoea
- Pulmonary odeama
- Bilateral basila rales
- Paroxysmal nocturnal dyspnoea
- Nocturnal cough (pink frothy sputum)
- Cardiac asthma (wheeze)
- Cardiomegaly
- Cool peripheries
- Nocturia
- Fatigue
- S3 gallop
- Tachycardia
What is the NYHA classification of HF?
I - no limitation/sx with normal physical activity
II - slight limitations/sx of normal physical activity
III - marked sx with less than normal physical activity e.g. getting dressed
IV - sx at rest, can’t really do any physical activity
How to diagnose HF?
- BNP >100 ng/L or NT-pro BNP >300 ng/L
- FBC: anaemia/vitamin B12 deficiency
What signs of HF are present on ECG?
- Signs of LV hypertrophy
- Increased QRS
- Arrhythmias (AF)
What signs of HF are present on chest X-ray?
ABCDE -
- Alveolar oedema: ‘bat-wing’ shadowing
- Kerley B lines: leading out towards lung borders
- Cardiomegaly: heart >50% of thorax
- Dilated upper lobe veins
- Pleural effusions: blunted costophrenic angles)
What is systolic heart failure?
Inability of the ventricle to contract properly with ejection fraction <40%
What is diastolic heart failure?
Inability of the ventricle to relax and fill normally causing increased filling pressures but ejection fraction >50%.
What can be seen on an echocardiogram for HF?
- Transthoracic echo
- Used to see ejection fraction
- Can differentiate between systolic and diastolic HF
What is congestive heart failure?
LV HF and RV HF
What are the causes of RV HF?
- Left HF
- COPD
- Pulmonary hypertension - due to arterioles constricting
- Tricuspid regurgitation
- Atrial septal defect
What are he signs and symptoms of RV HF?
- Peripheral pitting oedema: upto sacrum, thighs
- RaisedJVP with hepatojugular reflex
- Hepatosplenomegaly
- Ascites
- RV heave: due to pulmonary hypertension
How conservatively treat HF?
- Salt restriction
- Fluid restriction
- Weight loss + exercise
- Alcohol and smoking cessation
What drugs improve mortality and are used in HF with EF not preserved?
- ACEi/ARBs
- Beta blockers
- Spironolactone (ldosterone antagonist)
What drugs are used for symptomatic relief in HF and EF preserved HF?
- Diuretics
- Digoxin
What can be fitted in patients with electrical desynchrony?
- Implantable cardiac defibrillators (ICD)
- In patients with EF <35%
What is acute decompensated HF?
What causes Acute decomp HF?
- Exacerbation of HF
- Pneumonia, anaemia, volume overload, noncompliance, MI, myocarditis, AF
How to treat acute decompensated heart failure?
LMNOP -
- Lasix: IV Furosemide
- Morphine
- Nitrates
- Oxygen 100%
- Sitting position
What are the different risk factors for AF?
- HTN, DM, age, obesity
- CAD, valvular heart disease.
- COPD, PE, hyperthyroidism
What are the symptoms of AF?
- Most asymptomatic
- Palpitations
- Dizziness
- Fatigue
- Dyspnoea
- Syncope
What ECG changes are present for AF?
- Irregularly irregular rhythm
- Narrow QRS
- Absent P waves
- Increased rate
How to treat paroxysmal AF?
- 24 hr ambulatory
- Flecainide
What are rate control drugs for AF stating with the most effective?
1st - Beta blockers (propranolol)
2nd - CCB (verapamil)
3rd - Digoxin
What are rhythm control drugs for AF starting with the most effective?
1st - Cardioversion
2nd - Flecainide
3rd - Amiodarone
What drug is given to reduce risk of secondary thromboembolism?
- DOAC
- Warfarin
Which 2 scores can you use to assess risk/benefit of starting anticoagulation in AF?
- CHADS-VASc
- HAS-BLED
What is CHADS-VASc score used for?
What are the results?
- Assess stroke risk in patients with AF
- Offer anti-coagulation for score ≥2 (>1 for men)
How to treat acute AF?
- Make haemodynamically stable
- Emergency cardioversion: IV amiodarone
- Stable and AF started <48 hours ago: rate or rhythm control (rhythm more preferred)
- Stable and AF started >48 hours ago: RATE control
If AF has been present for >48 hours or an unknown duration, how long would you ideally anticoagulate before cardioversion?
3 weeks
What is pericarditis?
Inflammation of the pericardium that is most commonly caused by infection
- What are the causes of pericarditis?
- Who is more likely to get it?
- Most commonly viral (Coxsackie)
- Autoimmune (SLE/RA)
- Post MI (Dresselers syndrome)
- Trauma/surgery
- Uraemia
- TB
- Mainly young people get it
What are the symptoms of pericarditis?
- Low grade, intermittent fever
- Tachypnoea, dyspnoea, cough
- Pleuritic chest pain – sharp, pleuritic, improves on sitting and leaning forward
- Ongoing for a few days to weeks
- Pericardial friction rub
What are the ECG/troponin changes for pericarditis?
- PR depression in every lead
- ST elevation (saddle shaped) in all leads (depression in aVR + V1)
- Elevated troponin rise
How to treat pericarditis?
- Often self-limiting and resolves in 2-6 weeks
- Treat underlying cause
- NSAIDs
- Restrict physical activity
What is infective endocarditis?
Infectious (bacterial) inflammation of the endocardium that affects the heart valves
What should be considered if new murmur and fever of unknown origin develops?
Infective endocarditis
What are the risk factors for infective endocarditis?
- Dental procedures
- Surgery
- Distant primary infections
- Non-sterile injections
- Prosthetic valves
- IVDU
- Male
What are the symptoms of infective endocarditis?
- Fever and chills
- Tachycardia
- General malaise
- Weakness
- Night sweats
- Weight loss
- Dyspnoea
- Cough
- Pleuritic chest pain
- Arthralgia (joint pain)
- Myalgia (muscle pain)
- Headache
What signs are seen in infective endocarditis due to bacteria?
FROM JANE
- Fever
- Roths spots
- Oslers nodes
- Murmur
- Janeway lesions
- Anaemia
- Nail bed haemorrhage
- Emboli
What is used to diagnose infective endocarditis?
Modified Duke Criteria:
- 2 major
- 1 major and 3 minor criteria
- 5 minor criteria
How to treat infective endocarditis?
- Empirical IV Abx
- Staphylococcus: flucloxacillin and rifampicin
- Streptococcus: benzlypenicillin, gentamicin
What is Duke criteria?
Major: - Blood culture +ve from 2 sep sites - Echo: valvular problems Minor: - >38 degrees - Underlying heart disease or IVDU - Immunological phenomena (Oslers nodes)
What is the investigation for infective endocarditis?
- Blood culture from 2 sep sites
- Echo: valvular problems
What are the symptoms of myocarditis?
- Viral syndrome -
- Chest pain
- Acute decompensated congestive heart failure
- What the 2 different ways infective endocarditis presents?
- Which bacteria is more likely to present that way?
- Acute: Staphylococcus aureus
- Subacute: Streptococcus Viridans
Who is more likely to get infective endocarditis due to staphylococcus aureus (more common cause)?
- Prosthetic valves after 2 months
- Patients with no PMH
- IVDUs who present acutely
Who is more likely to get infective endocarditis due to streptococcus viridans?
- Prosthetic heart valves
- Poor dental health
- After a dental procedure
Which valve is more likely to be affected in infective endocarditis?
Tricuspid
