Chronic Heart Failure Flashcards
What is chronic heart failure?
It is a chronic condition in which the cardiovascular system fails to pump sufficient quantities of blood to meet the physiological demands of the body
Chronic heart failure causes a back flow of blood in which three locations?
Left atrium
Pulmonary veins
Lungs
What are the five causes of chronic heart failure?
Ischaemic Heart Disease
Valvular Heart Disease
Cardiomyopathy
Hypertension
Arrythmias
What is the main cause of chronic heart failure?
Ischaemic heart disease
What valvular heart disease is most commonly associated with chronic heart failure?
Aortic stenosis
What arrhythmia is most commonly associated with chronic heart failure?
Atrial fibrillation
What are the six symptoms of chronic heart failure?
Dyspnoea on Exertion
Cough with White/Pink Sputum
Orthopnoea
Paroxysmal Nocturnal Dyspnoea
Peripheral Oedema
Ascites
What is orthopnea?
It describes shortness of breath experienced when patient’s are lying flat
It is usually relieved by sitting or standing
What is paroxysmal nocturnal dyspnoea?
It describes a severe attack of shortness of breath during the night - which wakes the patient up
What are the six signs of chronic heart failure?
Tachycardia
Tachypnoea
Hypoxemia
3rd Heart Sound
Bilateral Basal Cracks
Increased JVP
What system is used to diagnose chronic heart failure?
Framingham Criteria for Congestive Heart Failure
What ‘Framingham Criteria for Congestive Heart Failure’ score is required to diagnose chronic heart failure?
2 major criteria
OR
1 major criterion and 2 minor criteria
What are the five major criteria of the ‘Framingham Criteria for Congestive Heart Failure’?
PAINS
Paroxysmal Nocturnal Dyspnoea
Acute Pulmonary Oedema
Increased Heart Size/Increased Central Venous Pressure
Neck Vein Dilatation
S3 Gallop
What are the four minor criteria of the ‘Framingham Criteria for Congestive Heart Failure’?
PAIN
Pleural Effusion
Ankle Oedema (Bilateral)
Increased Heart Rate >120bpm
Nocturnal Cough
What three investigations are used to diagnose chronic heart failure?
Blood Tests
Echocardiogram (ECHO)
Chest X-Ray (CXR)
What blood test is used to diagnose chronic heart failure?
N-terminal pro-B-type natriuretic peptide (NT-proBNP)
What is BNP?
It is a hormone that is released from the heart ventricles when the myocardium is stretched beyond normal range
What is the function of BNP?
To relax the smooth muscles in blood vessels, which reduces the systemic vascular resistance and makes it easier for the heart to pump blood
To promote the excretion of water in urine, which reduces circulating volume and improves cardiac function
What is the normal BNP level?
< 100 pg/ml
(29pmol/litre)
What is the normal NTproBNP level?
< 400pg/ml
(47 pmol/litre)
What is an elevated BNP level?
100 – 400 pg/ml
(29 – 116pmol/litre)
What is an elevated NTproBNP level?
400 – 2000/ml
(47 - 236pmol/litre)
How do we manage patients who present with an elevated BNP level?
It is advised that a specialist assessment echocardiogram is arranged within 6 weeks
What is a high BNP level?
> 400 pg/ml
(116pmol/litre)
What is a high NTproBNP level?
> 2000pg/ml
(236 pmol/litre)
What is another cause of elevated NTproBNP levels?
Renal dysfunction, eGFR < 60
How do we manage patients who present with a high BNP level?
It is advised that a specialist assessment echocardiogram is arranged within 2 weeks
How are ECHO scans used to diagnose chronic heart failure?
LV ejection fraction
What is the LV ejection fraction?
This is the percentage of blood in the ventricle that is pumped out with each ventricular contraction
What LV ejection fraction result indicates chronic heart failure?
Reduced
What is the normal LV ejection fraction?
50 - 80%
What LV ejection fraction result indicates mild heart failure?
40 - 50%
What LV ejection fraction result indicates moderate heart failure?
30 - 40%
What LV ejection fraction result indicates severe heart failure?
< 30%
What are the five signs of heart failure on a CXR?
Alveolar Oedema
Kerley B Lines
Cardiomegaly
Dilated Upper Lobe Vessels
Pleural Effusion
What scoring system is used to grade the severity and predict the prognosis of chronic heart failure?
‘New York Heart Association’ classification system
Define NYHA class I in terms of clinical feature severity and exercise tolerance
Clinical Features - There are no clinical features during activity
Exercise Tolerance - No limitation
Define NYHA class II in terms of clinical feature severity and exercise tolerance
Clinical Features - There are mild clinical features during activity
Exercise Tolerance - Mild limitation
Define NYHA class III in terms of clinical feature severity and exercise tolerance
Clinical Features - There are severe clinical features during activity - only comfortable at rest
Exercise Tolerance - Moderate limitation
Define NYHA class IV in terms of clinical feature severity and exercise tolerance
Clinical Features - There are clinical features present at rest
Exercise Tolerance - Severe limitation
In what five ways do we conservatively manage chronic heart failure?
To Receive The Influenza Vaccine Yearly
To Receive A One-Off Pneumococcal Vaccine
To Stop Smoking
To Optimise Treatment of Co-Morbidities
To Exercise Regularly
In what three patient groups do we recommend a booster pneumococcal vaccine every five years?
Those with asplenia
Those with splenic dysfunction
Those with chronic kidney disease
What pneumonic is used to remember pharmacological management of chronic heart failure?
ABAS
ACE Inhibitors
Betablockers
Aldosterone antagonists
Specialist referral
What is the first line treatment option for chronic heart failure?
ACE Inhibitor (or ARB)
AND
Betablocker
Which three ACE inhibitors are usually administered to treat chronic heart failure?
Ramipril
Enalapril
Lisinopril
How do ACE inhibitors manage chronic heart failure?
These drugs prevent the activation of the RAAS system, through inhibition of the angiotensin converting enzyme (ACE)
This reduces the preload and afterload of the heart, thus preserving the LV ejection fraction
This improves clinical features and decreases mortality
In which patient group are ACE inhibitors contraindicated?
Those with valvular heart disease
What is administered when ACE inhibitors are contraindicated or not tolerated? Name a specific drug
ARBs
Candesartan
Which three betablockers are usually administered to treat chronic heart failure?
Bisoprolol
Carvediol
Nebivolol
How do betablockers manage chronic heart failure?
These drugs activate the sympathetic activation, through inhibition of the beta-adrenergic receptors
This reduces the preload and afterload of the heart, thus preserving the LV ejection fraction
This improves clinical features and decreases mortality
What is the second line treatment option for chronic heart failure?
Aldosterone antagonists
Which two aldosterone antagonists are administered to treat chronic heart failure?
Spironolactone
Eplerenone
How do aldosterone antagonists manage chronic heart failure?
These drugs prevent the activation of the RAAS system, through inhibition of the aldosterone receptors
This reduces the preload and afterload of the heart, thus preserving the LV ejection fraction
This improves clinical features and decreases mortality
What effect do both ACE inhibitors and aldosterone antagonists have on potassium levels? How do we manage this?
Increase levels - hyperkalaemia
We monitor potassium levels regularly in patients who are administered both
What are the four third line treatment option of chronic heart failure?
Ivabradine
Sacubitril-Valsartan
Digoxin
Hydralazine + Nitrates
What is the mechanism of action ivabradine?
It is a heart lowering agent, used to reduce the risk of sinus bradycardia
When is ivabradine considered to manage chronic heart failure?
It is a third line management option, in cases where patients have a heart rate > 75
What is a side effect of ivabradine?
Visual disturbances, such as phosphenes and green luminescence
What is sacubitril-valsartan?
It is a combined drug of valsartan, ARB and neprilysin
When is hydralazine and nitrate recommended to manage chronic heart failure?
It is a third line management option, particularly effective in Afro-Carribean patients
Who administers third line treatment options of chronic heart failure?
Specialists
Which medication is contraindicated in individuals with heart failure? Why?
Pioglitazone
It can cause fluid retention
What are the five complications of chronic heart failure?
Stroke
Valvular Heart Disease
Pneumonia
Renal Failure
Ulcerated Cellulitic Legs
What two valvular heart diseases are associated with chronic heart failure?
Mitral Regurgitation
Tricuspid Regurgitation
What is cor pulmonale?
It is defined as right sided heart failure caused by respiratory disease
Describe the pathophysiology of cor pulmonale
In individuals with respiratory disease, pulmonary hypertension can occur, in which there is an increased pressure and resistance in the pulmonary arteries
This results in the right ventricle being unable to effectively pump blood out of the ventricle and into the pulmonary arteries
This ultimately leads to a back pressure of blood in the right atrium, the vena cava and the systemic venous system
What are the five causes of cor pulmonale?
COPD
Pulmonary Embolism
Interstitial Lung Disease
Cystic Fibrosis
Primary Pulmonary Hypertension
What is the main cause of cor pulmonale?
COPD
What are the eight clinical features of cor pulmonale?
Dyspnoea
Peripheral Oedema
Syncope
Chest Pain
Increased JVP
3rd Heart Sound
Tricuspid Regurgitation Murmur
Hepatomegaly
What is the main distinguishing feature of cor pulmonale?
Hepatomegaly
What are the two features of hepatomegaly in cor pulmonale?
It is pulsatile in tricuspid regurgitation
The liver edge is firm, tender and smooth
How do we manage cor pulmonale?
We treat the underlying cause and manage the presenting clinical features
Which drug is contraindicated in individuals with heart failure?
Cyclizine
