Case 9 - Heart Failure Flashcards
What is the continuum from RFs to HF?
RFs Atherosclerotic disease and LVH CAD Myocardial Ischaemia Coronary thrombus MI Arrhythmia and loss of muscle Remodelling Increase in size of ventricles HF Death
What is the epidemiology of HF?
20% of people aged 80+ have HF
How does the Frank-Starling curve explain the pathophysiology of HF?
Frank-Starling curve states that as the volume inside the ventricles increase, the force of contraction of the ventricles will do so too
In heart failure, the ventricles cannot pump as effectively, therefore the volume in the ventricles will decrease
This leads to backlog of the blood
So in RHF - backflow into teh body’s venous system, leading to peripheral oedema and raised JVP
In LHF, backflow into the pulmonary system, leading to pulmonary oedema
Decreased contractility (a shift right) = acidosis and negatively inotropic drugs Increased contractility (a shift left) = calcium and adrenaline
Heart failure shifts the curve to teh right
What are RFs for HF?
Increasing age HTN DM Dyslipidaemia Visceral adiposity Smoking
What are the causes of HF?
HTN Ischaemia - CAD/MI Valvular disease Tachycardias Endocarditis or other infection DM Toxins Genetic Endocrine
What are signs and symptoms of HF?
Orthopnea PND Bibasal crepitations Pitting peripheral oedema Ascites Raised JVP SOBOE or at rest S3 gallop Pulmonary effusion Fatigue Tachycardia Hepatomegaly
How can breathlessness be scored?
Using the NYHA scoring system:
NYHA 1 = No symptoms or limitations on normal activity
NYHA 2 = Breathlessness on normal activity, with only slight limitation
NYHA 3 = Breathlessness on less than normal activity, with marked limitation in activity
NYHA 4 = Breathlessness at rest, severe limitations
How is diagnosis of HF done?
Should have signs and symptoms of HF
Alongside objective evidence of HF e.g. echo finding, S3 gallop etc.
Should look for cause of HF
What is the CHADS-VASC score?
Gives the risk of developing a stroke in a patient with AF
CCF HTN (2)Age 75+ DM (2)Stroke/TIA/VTE previously
Vascular disease
Age 64-74
Sex
Category = female
What investigations could be done for HF?
Echo, ECG, CXR
What would an echo find in HF?
Can measure LVEF - should normally be above 60%, below 45% is impaired EF, above 45% is preserved
May see evidence of valvular disease, previous MI, and can assess chamber size etc.
What would an ECG find in HF?
Won’t see findings of HF itself but may see evidence of previous MI or myocardial ischaemia etc.
Seeing LBBB guides therapy
LVH indicates HTN or other disease process
What would a CXR find in HF?
Alveolar oedema - batwing appearance
B - Kerley B lines - horizontal white lines at the periphery of the lung fields
Cardiomegaly (more than 50% of transthoracic diameter)
Dilated upper lobe vessels
Effusion
What are the treatments for HF?
For preserved LVEF:
Diuretics
Treat co-morbidities
For impaired LVEF: Diuretics ACE-i Beta blockers Aldosterone receptor antagonists ICD/CRT
How do ACE-i help?
First line alongside beta blockers
They help to control blood pressure and therefore reduce the strain on the heart by reducing salt and water retention
Inhibit LV remodelling, vasoconstriction and increase venous capacity
How do beta blockers help?
First line
Reduce heart rate and reduce the contractility of the heart, reducing the strain it is under
Only certain types are licensed for use in HF - not atenolol
How do aldosterone receptor antagonists help?
Help to get rid of the excess fluid in the body e.g. ascites by encouraging excretion of water
Use in severe LV dysfunction e.g. 35% or NYHA 2
What devices can be used in HF?
ICD - Intracardiac defibrillator
CRT - cardiac resynchronisation therapy - 2 ventricular leads and an atrial lead
15% of HF have desynchrony
How do you diagnose and treat acute HF?
Should perform:
- ECG
- CXR
- FBC, U and Es, TFTs, glucose, haematinics
- In those with new presentation of HF, BNP
For those with high BNP > echo
IV diuretics
Monitor urine output, renal function and weight
Continue beta blockers (except if HR<50, A-V block or in shock)
ACE-i and aldosterone antagonists in reduced LVEF
What is AF?
When the signal through atria unsynchronised, leading to a discharge of electrical activity, and improper contraction of the atria
Different R-R intervals and no distinct P waves
Increasing prevalence with increasing age
What are the RFs for AF?
Older Alcohol excess Hormonal abnormalities Inflammation Atrial enlargement
How do you manage AF?
Rate control - beta blockers. These are used in everyone to ensure normal heart rate is maintained
Can also use calcium channel blockers
Digoxin only used in sedentary
Rhythm control - should only be used in those who have had AF for less than 48 hours, or for those who have been stabilised on rate control
The use of rhythm control can increase the risk of emboli dislodging and causing a stroke
Can use drugs like amiodarone or CRT
Preventing strokes - e.g. warfarin, apixaban
Anti-coagulants given to decrease the LT risk of strokes from emboli
What is infective endocarditis?
Infection of the inner layer of the heart
Can present as an acute rapidly progressing infection or as a sub-acute chronic infection with high grade fever
What are the differentials for endocarditis?
Chronic infection Reumatological Neurological Autoimmune Malignancy
What are the signs of endocarditis?
Oslers nodes - red nodules on distal digits
Roth spots - retinal haemorrhages
Petechiae - red patches on skin
Janeway lesions - red nodules on palms and soles
Splinter haemorrhages - vertical lines under the nail beds suggestive of mucocutaneous bleeding
How do you diagnose endocarditis?
Modified Duke Criteria
Need major and minor criteria
Major - signs of valvular vegetations/oscillating mass/abscess on echo, positive blood cultures x2, evidence of endocardial involvement
Minor - fever, any of the classic signs of endocarditis, positive cultures, echo findings
How do you manage endocarditis?
Broad spectrum abx
Consider for valvular replacement surgery when stable, in uncontrolled infection or if high risk of emboli
