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Cardiovascular > CCF (inc pulmonary oedema) > Flashcards

CCF (inc pulmonary oedema) Flashcards

1
Q

What is heart failure?

A

Clinical syndrome resulting from almost any cardiac disorder that impairs ability of ventricle to fill with or eject blood.
i.e. CO less than body needs.

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2
Q

What is forward heart failure?

A

Heart unable to maintain adequate CO to meet demand, or can only do so by elevating filling pressure.

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3
Q

What is backward heart failure?

A

Heart unable to accommodate venous return resulting in elevated filling pressure and vascular congestion (systemic or pulmonary).

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4
Q

Signs and symptoms of low CO LHF?

A
  • Fatigue
  • Syncope
  • Systemic hypotension
  • Cool extremities
  • Slow capillary refill
  • Peripheral cyanosis
  • Pulsus alternans
  • Mitral regurgitation
  • S3
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5
Q

Signs and symptoms of backward (venous congestion) LHF?

A
  • Dyspnoea, orthopnoea, PND
  • Cough
  • Crackles
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6
Q

Signs and symptoms of forward RHF?

A
  • LHF symptoms if RHF leads to LV underfilling
  • Tricuspid regurgitation
  • S3 (rhs)
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7
Q

Signs and symptoms of backward RHF?

A
  • Peripheral oedema
  • Pulsatile liver (if TR)
  • Hepatosplenomegaly
  • elevated JVP w/ abdominal jugular reflex and Kussmaul’s sign
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8
Q

Outline the pathophysiology of heart failure.

A

Compensatory vascular and cardiac changes to maintain CO. As HF progressives, mechanisms overhwelmed: peripheral vasoconstriction and Na+ retention due to RAAS activation (decompensation).

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9
Q

What is the systemic response in heart failure?

A

SNS activation. Systemic response to ineffective circulating volume:

  • RAAS activation (retain H20 and Na)
  • increased HR and contractility
  • increased afterload
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10
Q

What is systolic dysfunction?

A

Impaired myocardial contractile function -> decreased LVEF and SV -> decreased CO.

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11
Q

Signs systolic dysfunction?

A
  • Displaced apex beat
  • S3
  • increased heart size on CXR
  • Decreased LVEF
  • LV dilation
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12
Q

Causes LV systolic dysfunction?

A
  • Ischaemic: e.g. CAD, MI

- Non-ischaemic: HTN, DM, alcohol/toxins, myocarditis, dilated cardiomyopathy.

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13
Q

What is heart failure with preserved ejection fraction also known as?

A

Diastolic dysfunction!

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14
Q

What is the difference b/w systolic dysfunction and HFPEF?

A

Up to 50% HF pts have normal systolic fxn i.e. preserved ejection fraction; heart failure caused by impaired diastolic filling.

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15
Q

Pathophysiology of HFPEF?

A

Impaired diastolic filling -> increased LV filling pressures -> upstream venous congestion (pulmonary, systemic).

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16
Q

Signs HFPEF?

A
  • Apex beat sustained
  • S4
  • Normal heart size on CXR
  • HTN
  • LVH on ECG/Echo
  • Normal LVEF
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17
Q

Causes of decreased compliance in HFPEF?

A

-Transient: ischaemia
-Permanent:
>severe hypertrophy (HTN, AS, HCM)
>restrictive cardiomyopathy (e.g. amyloid)
>MI

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18
Q

Describe NYHA heart failure classification.

A

i: ordinary physical activity does not cause symptoms.
ii: comfortable at rest, ordinary activity causes symptoms
iii: limitation of ordinary activity, less than ordinary physical activity causes symptoms
iv: inability to carry out any physical activity without discomfort; symptoms may be present at rest.

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19
Q

What is high output heart failure?

A

Demand for increased CO; often exacerbates existing HF of decompensates pt w/ other cardiac pathology

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20
Q

Ddx high output heart failure?

A
  • Anemia
  • Thyrotoxicosis
  • Thiamine deficiency
  • A-V fistula / L>R shunting
  • Paget’s disease
  • Renal Disease
  • Hepatic disease
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21
Q

Precipitants of heart failure?

A

HEART FAILED

  • HTN
  • Endocrine (phaechromocytoma / hyperaldosteronism)
  • Anemia
  • RHD / other valvular disease
  • Thyrotoxicosis
  • Failure to take Rx
  • Arrhythmia
  • Infection / ischaemia / infarction
  • Lung (PE / pneumonia / COPD)
  • Endocarditis / environment
  • Dietary (e.g. FR non compliance)
22
Q

Blood Ix heart failure?

A
  • FBE
  • UEC
  • CMP
  • fasting BSL
  • HbA1C
  • Lipids
  • LFTs
  • TSH
  • Iron studies
  • BNP
23
Q

ECG features to look for in heart failure?

A
  • Chamber enlargement
  • Arrhythmia
  • Ischaemia / infarction
24
Q

CXR features to look for in heart failure?

A

HERB-B

  • Heart enlargement
  • Effusion (pleural)
  • Re-distribution (alveolar oedema)
  • B Lines (Kerley B lines)
  • Bronchiolar-alveolar cuffing
25
Q

Echo features in heart failure?

A
  • LVEF
  • Cardiac dimensions
  • Wall motion abnormalities
  • Valvular disease
  • Pericardial effusion
26
Q

What is the acute treatment of heart failure?

A

Treat precipitants! +

  • L) Lasix: frusemide 40 - 500mg IV
  • M) Morphine: 2-4mg IV
  • N) Nitroglycerin: topical / IV/ SL
  • O) Oxygen: in hypoxemic patients
  • P) Position/positive airway pressure (CPAP/BiPAP)
27
Q

Why is morphine given in acute treatment heart failure?

A

Decreases anxiety and preload.

28
Q

Conservative measures for symptomatic management of HF?

A

Oxygen in hospital, bed rest, elevate head of bed.

29
Q

Lifestyle measures for conservative management of heart failure?

A
  • Diet / exercise
  • Smoking cessation
  • DM control
  • Decrease EtOH
  • Patient education
  • FR and Na restriction
30
Q

Pharmacological management of heart failure?

A

1) Vasodilators (ACEi / ARB)
2) B-blocker
3) Diuretics
4) Aldosterone antagonist
5) Inotropes
6) Antiarrhythmics
7) Anticoagulants

31
Q

In which pts should ACEi be instituted?

A
  • All symptomatic pts class II-IV

- Asymptomatic pts LVEF

32
Q

When should ARB be instituted?

A
  • Second line to ACEi if not tolerated; adjunct to ACEi if B-blockers not tolerated
  • Consider in acute renal failure until creatinine stabilises
33
Q

Which pts should receive B-blocker therapy?

A

-Class I - III with LVEF

34
Q

Which pts should receive spironolactone?

A

Class IIIb and IV CHF already on ACEi and loop diuretic.

35
Q

Indications for inotropes in heart failure?

A
  • Patient in sinus rhythm and symptomatic on ACEi,

- or CHF + AF

36
Q

When should biventricular pacemaker be considered?

A
  • QRS>130msec

- LVEF

37
Q

What are the pathophysiological changes in heart failure?

A
  • Ventricular dilation
  • Myocyte hypertrophy
  • Increased collagen synthesis
  • Increased ANP secretion
  • Na+ and water retention
  • SNS activation
  • Peripheral vasoconstriction
38
Q

What is after load?

A

Outflow Resistance (afterload): load the heart pumps against = pulmonary/systemic resistance + physical characteristics of vessel walls + volume of blood ejected.

39
Q

Effect of neurohormonal activation in HF?

A
  • SNS activated by baroreceptors early in HF, provides inotropic support to maintain CO.
  • Chronic SNS ==> increases neurhormonal activation + myocyte apoptosis —> B-receptor downregulation.
40
Q

What are the major Framingham criteria for HF? (dx = 1 major, 2 minor)

A

Major (SAWPANIC)
◦S3 heart sound present (‘gallop’ sound)
◦Acute pulmonary oedema (left side of heart is unable to clear fluid from lungs)
◦Weight loss of more than 4.5kg in 5 days when treated (patients lose retained fluids)
◦Paroxysmal nocturnal dyspnoea
◦Abdominojugular reflux (JVP waveform rises when pressure applied over liver area)
◦Neck vein distended (i.e. JVP elevated at rest)
◦Increased cardiac shadow on X-ray (cardiomegaly: heart occupies more than ≈50% of chest diameter)
◦Crackles heard in lungs

41
Q

What are the minor Framingham criteria for HF?

A

MINOR (HEARTV)

  • Hepatomegaly
  • Effusion, pleural
  • Ankle oedema bilaterally
  • exeRtional dyspnoea
  • Tachycardia
  • Vital capacity decreased by 1/3 max value
42
Q

What are Starling Forces across capillaries?

A

Fluid leaks in/out according to balance of forces (hydrostatic, oncotic).
Tends out at arterial; in at venous.

43
Q

In relation to Starling Forces at Capillaries, alteration at which end causes pulmonary oedema?

A

Fluid tends out at arterial; in at venous.

Increases in VENOUS pressure causes fluid to leak out and oedema.

44
Q

What are the causes of oedema?

A
  • Increased venous pressure e.g. HF
  • Decreased osmotic pressure e.g. plasma protein loss (hep/ren failure)
  • Blockage of lymphatics e.g. cancer
  • Increased capillary permeability e.g. infection
45
Q

Alterations in pressure in which vessels cause oedema?

A

VENOUS not arterial.

46
Q

What is indicated by elevated JVP?

A

High RA pressure (therefore high RVED pressure).

Generally also thus high LA (&LVED) pressure.

47
Q

Causes of pure RHF?

A
  • PAH: Cor pulmonale e.g. COPD / CF; PE
  • Right structural disease: pul or tricuspid valves; R ventricular cardiomyopathy
  • Pericardial disease
48
Q

What are the 4 key components of pt diagnosis of HF?

A

1) Is it HF?
2) What is underlying cause?
3) Precipitating cause of this episode?
4) What other problems? (i.e. CV/ Renal / hepatic)

49
Q

Principles of HF treatment?

A
  • Reduce venous pressure
  • Block RAAS
  • Blocks SNS (B blocker)
  • Treat underlying and precipitating causes
50
Q

Which B-blocker should be used in patients with asthma?

A

Metoprolol: B1 selective therefore better for asthma / COPD patients.

Cardiovascular (22 decks)

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