Case 9- Heart Failure Flashcards
Investigations for suspected heart failure
ECG (axis deviation/ point to cause)
PFT- exclude respiratory cause
Bloods- FBC, UE, LFT (lack of perfusion) NT-pro-BNP
CXR
TOE
Drugs contraindicated in heart failure
NSAIDS
Non dihydropiridines Calcium channel blockers (amlodipine may be used cautiously in controlled heart failure)
Pioglitazone
Moxonidine
Sydenham chorea
Involuntary, irregular, nonrepetitive movements of the limbs, neck, head, face sometimes confined to one side (hemichorea)
Erythema marginatum
Expanding pink rash with a well defined out er border and central clearing. Trunk and limbs affected, face is spared. Painless and non pruritic
Organisms causing IE
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
Causes of CHF
Cardiac- CAD, valvular disease eg. AS, HOCM, uncontrolled AF, HTN
Pulmonary- COPD, pulmonary fibrosis
Drugs- fluoruracil and cisplatin
Autoimmune- amyloidosis, sarcoidosis
Symptoms of CCF (what patient may complain about)
Reduced perfusion- fatigue, exercise intolerance
Pulmonary congestion- orthopnoea, PND, white or pink sputum, cardiac wheeze, nocturnal cough
Systemic congestion- peripheral oedema, weight gain
Signs of CCF (what I look for in an exam)
Reduced perfusion- cyanosis, tachypnoea, tachycardia
Pulmonary congestion- fine basal crepes (oedema), pleural effusion, S3 heart sound
Systemic congestion- raised JVP, peripheral oedema, hepatomegaly, ascites
Rheumatic fever Sx
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
Rheumatic fever investigations
Throat cultures
Jones criteria calculation
Bloods- ESR, CRP, WBC, blood cultures, rapid antigen test for group A streptococci
ECG
CXR
TOE
Sx of IE
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))
AF aetiology
CAD, HTN, hyperthyroidism, alcohol abuse, infections/sepsis
Investigations for palpitations, possible AF
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
IE Investigations
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
Valvular disease investigations
ECG- any hypertrophy?
Bloods- TFT, FBC (anaemia), NT-pro-BNP
CXR- calcification of aortic valve
Echo- TOE
CHA2DS2VASC
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.
HASBLED
OLD/ REDUNDANT scoring system for establishing patients risk of major bleeding whilst on anticoagulation
Pill in the pocket approach
Flecanide for paroxysmal AF (avoid in atrial flutter)
Treatment for bradycardia/AV nodal block
Stable- observe
Unstable- atropine (6 doses), then noradrenaline, then a defibrillator/ pacing etc.
Aortic stenosis
SAD- syncope, angina, dyspnoea
NB- nitrates contraindicated
Aortic regurgitation (chronic)
Palpitations, symptoms of LHS heart failure (lung symptoms), exertional dyspnoea, angina, fatigability, syncope
Mitral stenosis
Dyspnoea (PND), orthopnoea, haemoptysis, AF, then RHF Sx (generally LHS first)
Mitral regurgitation (chronic)
Dyspnoea, palpitations, LHS heart failure Sx (lung symptoms)
Valvular pathologies
4 under most pressure in LHS often cause LHS Sx of heart failure first (lungs)
Heart failure management
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.
Heart failure CXR findings
ABCDE
Alveolar shadowing (batwing appearance)
B lines (interstitial oedema)
Cardiomegaly
Dilated upper lobe veins
Effusion (blunted costiohrenic angles)
Cardio version
3 week anticoagulation and echocardiogram has excluded presence of thrombus
What is VT
A broad complex tachycardia that has the potential to precipitate VF
Polymorphic VT
Eg. Torsades de pointes. Precipitated by prolonged QTc (which can be triggered by macrolide eg, clarithromycin)
Monomorphic VT
Usually. Caused by an MI
Causes of a prolonged QTc
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
Management of VT
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
Acute management of SVT
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
Prevention of SVT episodes
Beta blockers
Radio frequency ablation
Management of a prolonged QTc
Avoid drugs that precipitate it and strenuous exercise
Beta blockers (not sotalol)
ICD high risk cases
Management of Torsades de pointes
IV magnesium sulphate
Management of peri arrest bradycardia
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
Risks for asystole
Complete heart block with broad QRS
Recent systole
Mobitz type II AV block
Ventricular pause > 3 seconds
Reversible causes of cardiac arrest
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
Adult advanced life support management
See picture in gallery
Administering adenosine
Large proximal cannula (grey)
Contraindications to adenosine
Asthma
COPD
Heart failure
Heart block
Severe hypotension
NB- use verapamil instead
Medications contraindicated in people with WPW and AF
Antiarrhythmics eg. Beta blocker, calcium channel blocker, adenosine etc.
What is bigeminy
Ventricular ectopics that happen after every sinus beat
Management of bigeminy
Bloods- anaemia, electrolyte disturbance, thyroid abnormalities
No treatment in healthy individuals
Treatment for stable bradycardias
Observe
What is acute LVF
Left ventricle is unable to adequately move blood through the left side of the heart causing a back log into the pulmonary circulation
Causes of acute LVF
Iatrogenic (aggressive IV fluids in a frail old person)
Sepsis
MI
Arrhythmias
Typical presentation of acute LVF
Rapid onset breathlessness with type 1 respiratory failure (no increase in CO2)
Signs and symptoms of acute LVF
Typical signs and symptoms of heart failure
Investigations for acute LVF
OBS and clinical exam (hydration status)
ECG
Bloods- ABG, BNP, FBC, UE, troponin if suspect MI
CXR
Causes of a raised BNP
LVF/HF
Tachycardia
Sepsis
PE
Renal impairment
COPD
Management of acute LVF
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
Options to consider in severe acute pulmonary oedema or cardiogenic shock
NIV CPAP
Inotropes (noradrenaline)
HDU ITU
How many blood cultures to take in suspected IE
3
First detected episode of AF
First time someone is found to have AF
Paroxysmal AF
When a patient has 2 or more episodes of AF. If episodes of AF terminate spontaneously
Persistent AF
If the arrhythmia is not self-terminating ie. requires flecanide
Permanent AF
There is continuous atrial fibrillation which cannot be cardioverted or if attempts to do so are deemed inappropriate
Rate control vs rhythm control
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.
Criteria for rate control management
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
Criteria for rhythm control management
Short duration of symptoms (less than 48 hours) or be anticoagulated for 3 weeks prior to attempting electrical cardioversion.
Catheter ablation for AF
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
Rhythm control in AF- cardioversion within 48 hours
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.
Cardioversion after 48 hours
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.
ORBIT scoring system
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)
Anticoagulants in AF
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)
Ivabradine
sinus rhythm > 75/min and a left ventricular fraction < 35%
sacubitril-valsartan
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
Digoxin
it is strongly indicated if there is coexistent atrial fibrillation (and sedentary)
Cardiac resynchronisation therapy
indications include a widened QRS (e.g. left bundle branch block) complex on ECG
Hydralazine + nitrate
this may be particularly indicated in Afro-Caribbean patients
Aortic stenosis surgical management criteria
Either
a) Symptomatic
b) Asymptomatic but valvular gradient is greater than 40 and features such as LV systolic dysfunction
What can give a falsely low Nt-proBNP
ACE-i
When is DC cardioversion recommended for AF
when there is life-threatening haemodynamic instability caused by new-onset atrial fibrillation (non-life threatening, then rate/rhythm, control)
Management of IE
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
Murmurs- inspiration and expiration
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).
Cardiorenal syndrome
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.
Mitral stenosis management
Asymptomatic- regular follow up, no surgery
Symptomatic
-Balloon valvuloplasty for less severe disease
-Mitral commissurotomy or replacement for severe disease
