Case 9- Heart Failure Flashcards

Question

Heart failure management

Answer 1

NB- loop diuretics (furosemide) initially for Sx control 1st line ACE-I (or ARB), beta blocker (together if reduced LVEF) 2nd line aldosterone receptor antagonist 3rd line ivabradine, hydralazine etc., but if widened QRS complex (LBBB), try cardiac resynchronisation Annual flu vaccine, one off pneumococcal Cardiac rehab Supportive eg. Exercise, diet, sleep etc. NB- patients should have their U&Es monitored closely whilst on diuretics, ACE inhibitors and aldosterone antagonists as all three medications can cause electrolyte disturbances.

Answer 2

ABCDE Alveolar shadowing (batwing appearance) B lines (interstitial oedema) Cardiomegaly Dilated upper lobe veins Effusion (blunted costiohrenic angles)

Answer 3

3 week anticoagulation and echocardiogram has excluded presence of thrombus

Answer 4

A broad complex tachycardia that has the potential to precipitate VF

Answer 5

Eg. Torsades de pointes. Precipitated by prolonged QTc (which can be triggered by macrolide eg, clarithromycin)

Answer 6

Usually. Caused by an MI

Answer 7

Congenital- Jervell-Lange-Nielsen syndrome (deafness, potassium channels), Romano-Ward (no deafness) Drugs- amiodarone, TCA, antipsychotics, chloroquine, terfenadine (antihistamine), sotalol, SSRI (citalopram), erythromycin (&clarith) Other- hypocalcaemia, hypokalaemia, hypomagnesia, acute MI, myocarditis, hypothermia, SAH

Answer 8

Adverse signs- shock, systolic BP <90, myocardial ischaemia, syncope, heart failure, 3 synchronised DC shocks No adverse signs- amiodarone, lidocaine NB- drug therapy fails, use an ICD NB- don’t use verapamil in VT

Answer 9

If adverse signs- 3 synchronised DC shocks Vagal manoeuvres eg. Valsalva, carotid sinus massage IV adenosine- 6mg, 12mg, 12mg (not in asthmatics- use verapamil) Electrical cardio version

Answer 10

Beta blockers Radio frequency ablation

Answer 11

Avoid drugs that precipitate it and strenuous exercise Beta blockers (not sotalol) ICD high risk cases

Answer 12

IV magnesium sulphate

Answer 13

Adverse signs present indicate treatment- shock, systolic BP <90, myocardial ischaemia, syncope, heart failure Atropine (500mcg IV, up to 3mg) Transcutaneous pacing Adrenaline infusion Trans venous pacing

Answer 14

Complete heart block with broad QRS Recent systole Mobitz type II AV block Ventricular pause > 3 seconds

Answer 15

H’s- hypoxia, hypovolameia, electrolyte imbalances (eg. Hyper/hypokalaemia, hypoglycaemia, hypocalcaemia, other metabolic disorders), hypothermia T’s- thrombosis (coronary or pulmonary), tension pneumothorax, tamponade (cardiac), toxins

Answer 16

See picture in gallery

Answer 17

Large proximal cannula (grey)

Answer 18

Asthma COPD Heart failure Heart block Severe hypotension NB- use verapamil instead

Answer 19

Antiarrhythmics eg. Beta blocker, calcium channel blocker, adenosine etc.

Answer 20

Ventricular ectopics that happen after every sinus beat

Answer 21

Bloods- anaemia, electrolyte disturbance, thyroid abnormalities No treatment in healthy individuals

Answer 22

Left ventricle is unable to adequately move blood through the left side of the heart causing a back log into the pulmonary circulation

Answer 23

Iatrogenic (aggressive IV fluids in a frail old person) Sepsis MI Arrhythmias

Answer 24

Rapid onset breathlessness with type 1 respiratory failure (no increase in CO2)

Answer 25

Typical signs and symptoms of heart failure

Answer 26

OBS and clinical exam (hydration status) ECG Bloods- ABG, BNP, FBC, UE, troponin if suspect MI CXR

Answer 27

LVF/HF Tachycardia Sepsis PE Renal impairment COPD

Answer 28

Pour SOD Pour away (stop) the IV fluids Sit up the patient Oxygen Diuretics (IV frusemide 40mg stat) NB- monitor fluid balance and stop beta blockers when pulse below 50, 2/3 heart block, or shock NB- Acute heart failure not responding to treatment - consider CPAP

Answer 29

NIV CPAP Inotropes (noradrenaline) HDU ITU

Answer 30

First time someone is found to have AF

Answer 31

When a patient has 2 or more episodes of AF. If episodes of AF terminate spontaneously

Answer 32

If the arrhythmia is not self-terminating ie. requires flecanide

Answer 33

There is continuous atrial fibrillation which cannot be cardioverted or if attempts to do so are deemed inappropriate

Answer 34

NICE advocate using a rate control strategy except in a number of specific situations such as coexistent heart failure, first onset AF or where there is an obvious reversible cause.

Answer 35

A beta-blocker or a rate-limiting calcium channel blocker (e.g. diltiazem) is used first-line If rate control isn't achieved, any 2 of a beta blocker, diltiazem, and digoxin can be combined

Answer 36

Short duration of symptoms (less than 48 hours) or be anticoagulated for 3 weeks prior to attempting electrical cardioversion.

Answer 37

Those with AF who have not responded to or wish to avoid, antiarrhythmic medication. Anticoagulation should be used 4 weeks before and during the procedure, and if CHADVASC=0, continue for 2 months, or if =1, continue indefinitely

Answer 38

Cardioverted using either: electrical - 'DC cardioversion' pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease Give heparin first either way Following electrical cardioversion patients should be anticoagulated for at least 4 weeks.

Answer 39

Anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus- give heparin and cardiovert immediately Following electrical cardioversion patients should be anticoagulated for at least 4 weeks.

Answer 40

Used to deduce risk of bleed on anticoagulant- falls are not a reason to withhold anticoagulation Haemoglobin <130 g/L for males and < 120 g/L for females, (2 points) Age > 74 years (1 point) Bleeding history (GI bleeding, intracranial bleeding or haemorrhagic stroke) (2 points) Renal impairment (GFR < 60 mL/min/1.73m2) (1 point) Treatment with antiplatelet agents (1 point)

Answer 41

DOACs first line Warfarin second line NB- not aspirin NB- In general, DOACs are used as first-line agents in atrial fibrillation. However, there are some important exceptions e.g. if the patient has moderate or severe mitral stenosis, or if the DOAC was not tolerated (use warfarin)

Answer 42

sinus rhythm > 75/min and a left ventricular fraction < 35%

Answer 43

criteria: left ventricular fraction < 35% is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs should be initiated following ACEi or ARB wash-out period

Answer 44

it is strongly indicated if there is coexistent atrial fibrillation (and sedentary)

Answer 45

indications include a widened QRS (e.g. left bundle branch block) complex on ECG

Answer 46

this may be particularly indicated in Afro-Caribbean patients

Answer 47

Either a) Symptomatic b) Asymptomatic but valvular gradient is greater than 40 and features such as LV systolic dysfunction

Answer 48

when there is life-threatening haemodynamic instability caused by new-onset atrial fibrillation (non-life threatening, then rate/rhythm, control)

Answer 49

Amoxicillin (or vancomycin if penicillin allergic/prosthetic valve) Indications for surgery; severe valvular incompetence aortic abscess (often indicated by a lengthening PR interval) infections resistant to antibiotics/fungal infections cardiac failure refractory to standard medical treatment recurrent emboli after antibiotic therapy

Answer 50

Generally speaking, murmurs heard best in expiration suggest a left valve problem (Expiration, lEft), and murmurs heard best in inspiration suggest a right valve problem (Inspiration, rIght).

Answer 51

This occurs when the cardiac output drops sufficiently to result in renal dysfunction. Whilst it is often thought that in renal dysfunction, nephrotoxic agents need to be withheld and doses of diuretics tapered. In this case, it is the hypervolaemic state that has contributed to reduced cardiac output (shifting the Frank-Starling curve). This means that increased doses of diuretics are required to improve cardiac contractility, improve cardiac output, and thus increase renal perfusion. It would be sensible to start an infusion of furosemide at a reasonably high dose.

Answer 52

Asymptomatic- regular follow up, no surgery Symptomatic -Balloon valvuloplasty for less severe disease -Mitral commissurotomy or replacement for severe disease