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Year 3 OSCE > Case 9- Heart Failure > Flashcards

Case 9- Heart Failure Flashcards

1
Q

Investigations for suspected heart failure

A

ECG (axis deviation/ point to cause)
PFT- exclude respiratory cause
Bloods- FBC, UE, LFT (lack of perfusion) NT-pro-BNP
CXR
TOE

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2
Q

Drugs contraindicated in heart failure

A

NSAIDS
Non dihydropiridines Calcium channel blockers (amlodipine may be used cautiously in controlled heart failure)
Pioglitazone
Moxonidine

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3
Q

Sydenham chorea

A

Involuntary, irregular, nonrepetitive movements of the limbs, neck, head, face sometimes confined to one side (hemichorea)

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4
Q

Erythema marginatum

A

Expanding pink rash with a well defined out er border and central clearing. Trunk and limbs affected, face is spared. Painless and non pruritic

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5
Q

Organisms causing IE

A

Strep viridians/sanguinis (dental hygiene), staph aureus (IVDU), staph epidermidis (if <2 months who had valvular heart surgery), strep bovis (CRC) enterococci, coxiella burnetti (previous ABX use), HÁČEK

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6
Q

Causes of CHF

A

Cardiac- CAD, valvular disease eg. AS, HOCM, uncontrolled AF, HTN

Pulmonary- COPD, pulmonary fibrosis

Drugs- fluoruracil and cisplatin

Autoimmune- amyloidosis, sarcoidosis

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7
Q

Symptoms of CCF (what patient may complain about)

A

Reduced perfusion- fatigue, exercise intolerance

Pulmonary congestion- orthopnoea, PND, white or pink sputum, cardiac wheeze, nocturnal cough

Systemic congestion- peripheral oedema, weight gain

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8
Q

Signs of CCF (what I look for in an exam)

A

Reduced perfusion- cyanosis, tachypnoea, tachycardia

Pulmonary congestion- fine basal crepes (oedema), pleural effusion, S3 heart sound

Systemic congestion- raised JVP, peripheral oedema, hepatomegaly, ascites

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9
Q

Rheumatic fever Sx

A

Constitutional Sx, migratory polyarthritis, pancarditis (endo, myo, pericarditis), valvular lesions, syndeham chorea, erythema marginatum

NB- rheumatic heart disease occurs many years later. In a valve station, ask if they had rheumatic fever as a child

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10
Q

Rheumatic fever investigations

A

Throat cultures
Jones criteria calculation
Bloods- ESR, CRP, WBC, blood cultures, rapid antigen test for group A streptococci
ECG
CXR
TOE

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11
Q

Sx of IE

A

Constitutional Sx eg. tachycardia, general malaise, weakness, night sweats, weight loss. Dyspnoea, cough, pleuritic chest pain, arthralgia, myalgia, finger clubbing, cardiac murmur, peripheral stigmata (Roth, Osler (immunologic- also SLE, gonorrhoea, typhoid and haemolysis) Jane way (vascular), splinter haemorrhages (conjunctiva or fingernails), abdominal pain or stroke (emboli))

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12
Q

AF aetiology

A

CAD, HTN, hyperthyroidism, alcohol abuse, infections/sepsis

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13
Q

Investigations for palpitations, possible AF

A

Bloods- troponin?, NT proBNP, FBC (anaemia, infection), TSH (thyrotoxicosis), UE (electrolyte disturbance), toxicology (cocaine)

ECG- irregularly irregular RR intervals, P waves indiscernible, tachycardia, narrow QRS complex

TOE- rule out underlying structural disease

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14
Q

IE Investigations

A

ECG
Bloods- 3 separate cultures (preferably different sites), WCC, ESR, CRP
CXR (emboli may travel to lungs and cause cavities)
TOE or TTE (latter is quicker and less invasive)
CT- look for emboli

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15
Q

Valvular disease investigations

A

ECG- any hypertrophy?
Bloods- TFT, FBC (anaemia), NT-pro-BNP
CXR- calcification of aortic valve
Echo- TOE

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16
Q

CHA2DS2VASC

A

Whether someone with AF needs anticoagulation or not

CHF
HTN
Age (65-74:1, 75+:2)
DM
(Previous) Stroke/TIA/thromboembolism (2)
Vascular disease
Sex (female:1)

0- no
1 (female)- no
1 (male)- consider
2- yes

NB- anyone with a history of AF, not just current persistent AF (ie. Those with asymptomatic PAF or first onset)

NB- ensure a transthoracic echocardiogram has been done to exclude valvular heart disease (esp. people who score 0), which in combination with AF is an absolute indication for anticoagulation.

NB- certain people with AF will score 0: they wont need anticoagulation (although they may still have rate control eg. beta blocker if tachycardia is present, and they will definitely need an echocardiogram to exclude structural heart disease (which add AF requires anticoagulation)

NB- If valvular heart disease is present alongside AF, this indicates anticoagulation as it increases the risk of stroke.

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17
Q

HASBLED

A

OLD/ REDUNDANT scoring system for establishing patients risk of major bleeding whilst on anticoagulation

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18
Q

Pill in the pocket approach

A

Flecanide for paroxysmal AF (avoid in atrial flutter)

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19
Q

Treatment for bradycardia/AV nodal block

A

Stable- observe

Unstable- atropine (6 doses), then noradrenaline, then a defibrillator/ pacing etc.

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20
Q

Aortic stenosis

A

SAD- syncope, angina, dyspnoea

NB- nitrates contraindicated

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21
Q

Aortic regurgitation (chronic)

A

Palpitations, symptoms of LHS heart failure (lung symptoms), exertional dyspnoea, angina, fatigability, syncope

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22
Q

Mitral stenosis

A

Dyspnoea (PND), orthopnoea, haemoptysis, AF, then RHF Sx (generally LHS first)

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23
Q

Mitral regurgitation (chronic)

A

Dyspnoea, palpitations, LHS heart failure Sx (lung symptoms)

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24
Q

Valvular pathologies

A

4 under most pressure in LHS often cause LHS Sx of heart failure first (lungs)

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25
Q

Heart failure management

A

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.

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26
Q

Heart failure CXR findings

A

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

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27
Q

Cardio version

A

3 week anticoagulation and echocardiogram has excluded presence of thrombus

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28
Q

What is VT

A

A broad complex tachycardia that has the potential to precipitate VF

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29
Q

Polymorphic VT

A

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

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30
Q

Monomorphic VT

A

Usually. Caused by an MI

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31
Q

Causes of a prolonged QTc

A

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

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32
Q

Management of VT

A

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

33
Q

Acute management of SVT

A

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

34
Q

Prevention of SVT episodes

A

Beta blockers
Radio frequency ablation

35
Q

Management of a prolonged QTc

A

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

36
Q

Management of Torsades de pointes

A

IV magnesium sulphate

37
Q

Management of peri arrest bradycardia

A

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

38
Q

Risks for asystole

A

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

39
Q

Reversible causes of cardiac arrest

A

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

40
Q

Adult advanced life support management

A

See picture in gallery

41
Q

Administering adenosine

A

Large proximal cannula (grey)

42
Q

Contraindications to adenosine

A

Asthma
COPD
Heart failure
Heart block
Severe hypotension

NB- use verapamil instead

43
Q

Medications contraindicated in people with WPW and AF

A

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

44
Q

What is bigeminy

A

Ventricular ectopics that happen after every sinus beat

45
Q

Management of bigeminy

A

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

46
Q

Treatment for stable bradycardias

A

Observe

47
Q

What is acute LVF

A

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

48
Q

Causes of acute LVF

A

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

49
Q

Typical presentation of acute LVF

A

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

50
Q

Signs and symptoms of acute LVF

A

Typical signs and symptoms of heart failure

51
Q

Investigations for acute LVF

A

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

52
Q

Causes of a raised BNP

A

LVF/HF
Tachycardia
Sepsis
PE
Renal impairment
COPD

53
Q

Management of acute LVF

A

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

54
Q

Options to consider in severe acute pulmonary oedema or cardiogenic shock

A

NIV CPAP
Inotropes (noradrenaline)
HDU ITU

55
Q

How many blood cultures to take in suspected IE

A

3

56
Q

First detected episode of AF

A

First time someone is found to have AF

57
Q

Paroxysmal AF

A

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

58
Q

Persistent AF

A

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

59
Q

Permanent AF

A

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

60
Q

Rate control vs rhythm control

A

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.

61
Q

Criteria for rate control management

A

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

62
Q

Criteria for rhythm control management

A

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

63
Q

Catheter ablation for AF

A

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

64
Q

Rhythm control in AF- cardioversion within 48 hours

A

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.

65
Q

Cardioversion after 48 hours

A

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.

66
Q

ORBIT scoring system

A

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)

67
Q

Anticoagulants in AF

A

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)

68
Q

Ivabradine

A

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

69
Q

sacubitril-valsartan

A

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

70
Q

Digoxin

A

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

71
Q

Cardiac resynchronisation therapy

A

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

72
Q

Hydralazine + nitrate

A

this may be particularly indicated in Afro-Caribbean patients

73
Q

Aortic stenosis surgical management criteria

A

Either

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

74
Q

What can give a falsely low Nt-proBNP

A

ACE-i

75
Q

When is DC cardioversion recommended for AF

A

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

76
Q

Management of IE

A

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

77
Q

Murmurs- inspiration and expiration

A

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).

78
Q

Cardiorenal syndrome

A

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.

79
Q

Mitral stenosis management

A

Asymptomatic- regular follow up, no surgery

Symptomatic
-Balloon valvuloplasty for less severe disease
-Mitral commissurotomy or replacement for severe disease

Year 3 OSCE (61 decks)

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