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Congestive Heart Disease Flashcards

1
Q

List causes of heart failure

A

Hypertension

Infection/ immune: (viral e.g. HIV, bacterial e.g. sepsis), autoimmune (e.g. lupus, RA)

Genetic: hypertrophic obstructive cardiomyopathy (HOCM)

Heart disease: ischaemic heart disease, MI, atrial fibrillation

Volume overload: renal failure, nephrotic syndrome, hepatic failure

Infiltration: sarcoidosis, amyloidosis, haemochroamtosis

Structural: valvular disease, septal defects

Medications: calcium antagonists, anti-arrythmics, cytotoxic medication, beta-blockers (in the acute phase)

Endocrine disease: hypothyroidism, hyperthyroidism, diabetes, adrenal insufficiency, Cushing’s syndrome

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2
Q

What is high-output cardiac failure?

A

States where demand > normal cardiac output

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3
Q

Name 3 things that can cause high-output cardiac failure?

A
  1. Anaemia
  2. Pregnancy
  3. Sepsis
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4
Q

What symptoms might heart failure present with?

A 
Breathlessness on exertion
Orthopnoea
Paroxysmal Nocturnal Dyspnoea (PND)
Cough (with or without pink frothy sputum)
Fatigue
Reduced appetite
Ankle swelling
Presyncope/ syncope
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5
Q

Within a cardiovascular examination, what are signs of heart failure?

A 
Tachycardia
Hypotension
Pulsus alternans
Displaced apex beat
RV heave
Gallop rhythm (S3)
Murmurs (valvular heart disease)
Peripheral oedema (ankles +/- sacrum)
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6
Q

Within a respiratory examination, what are the signs of heart failure?

A

Tachypnoea
Raised JVP
Stony dullness on percussion
Bibasal end-inspiratory crackles (+/- wheeze)

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7
Q

Within an abdominal examination, what are the signs of heart failure?

A

Ascites

Hepatomegaly

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8
Q

What bedside investigations might you perform when heart failure is suspected?

A

ECG

Urinalysis

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9
Q

What ECG findings might be associated with heart failure?

A

Tachycardia
Atrial fibrillation (due to enlarged atria)
Left-axis deviation (due to left ventricular hypertrophy)
P wave abnormalities (e.g. P.mitrale/ P.pulmonale due to atrial enlargement)
Prolonged PR interval (due to AV block)
Wide QRS complexes (due to ventricular dyssynchrony)

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10
Q

What findings on urinalysis might point you to the cause of the heart failure?

A

Glycosuria (diabetes)

Proteinuria (renal disease)

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11
Q

What blood tests are relevant to heart failure?

A 
FBC 
U&Es
LFTs
Tropnonin
Lipids/ HbA1C
TFTs
Cardiomyopathy screen
N-terminal pro-B-type natriuretic peptide
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12
Q

Why might you do a FBC?

A

Looking for anaemia

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13
Q

Why might you do U&Es?

A

Looking for renal failure, electrolyte abnormalities due to fluid overload (e.g. hyponatraemia)

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14
Q

Why might you do LFTs?

A

Hepatic congestion

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15
Q

Why might you do troponin?

A

If considering recent MI

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16
Q

Why might you do lipids/ HbA1c?

A

Assessing ischaemic risk profile

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17
Q

Why might you do TFTs?

A

Looking for hyper/hypothyroidism

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18
Q

What is included in a cardiomyopathy screen?

A
  1. Serum iron and copper studies
  2. Rheumatoid factor, ANCA/ANA, ENA, dsDNA
  3. Serum ACE
  4. Serum-free light chains
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19
Q

What is the benefit of doing serum iron and copper studies (within cardiomyopathy screen)?

A

To rule out haemochromatosis and Wilson’s disease

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20
Q

What is the benefit of checking rheumatoid factor, ANCA/ANA, ENA, dsDNA (within cardiomyopathy screen)?

A

To rule out autoimmune disease

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21
Q

What is the benefit of checking serum ACE (within cardiomyopathy screen)?

A

To rule out sarcoidosis

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22
Q

What is the benefit of checking serum-free light chains (within cardiomyopathy screen)?

A

To rule out amyloidosis

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23
Q

When should NT-proBNP be measured?

A

In all patients presenting with symptoms and clinical signs of heart failure to inform the type and urgency of further investigations such as echocardiography

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24
Q

What is the course of action if the NT-proBNP level is <400ng/L?

A

Heat failure is unlikely

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25
What is the course of action if the NT-proBNP level is 400-2000ng/L?
Refer routinely for specialist assessment and transthoracic echocardiography within 6 weeks
26
What is the course of action if the NT-proBNP level is >2000ng/L?
Refer urgently for specialist assessment and transthoracic echocardiography within 2 weeks
27
Other than heart failure, what other conditions may the NT-proBNP be raised?
``` Left ventricular hypertrophy Tachycardia Liver cirrhosis Diabetes Acute or chronic renal disease ```
28
What can an echocardiogram calculate?
Ejection fraction
29
What ejection fraction strongly indicates heart failure?
<40%
30
Describe X-ray findings in heart failure
Alveolar oedema (bat-wing opacification) Kerley B lines (interstitial oedema) Cardiomegalogy (CT ratio >50% PA film) Dilated upper lobe vessels Effusions (blunted costophrenic angles)
31
How many classes are there in the NYHA classification system?
4
32
What is NYHA class I?
No symptoms during ordinary physical activity
33
What is NYHA class II?
Slight limitation of physical activity by symptoms
34
What is NYHA class III?
Less than ordinary activity leads to symptoms
35
What is NYHA class IV?
Inability to carry out any activity without symptoms
36
Describe the lifestyle management and other general measures that should be advised to a patient with heart failure
``` Regular exercise Diet (fluid and salt restriction) Smoking cessation Reducing alcohol consumption Yearly flu and pneumococcal vaccination Optimising treatment of o-morbidities Medication review Awareness of depression ```
37
What medical treatment is given first-line to patients with CHF and reduced ejection fraction (=40%)?
1. ACE inhibitors | 2. Beta-blockers
38
What is an example of an ACE inhibitor which might be given for CHF?
Ramipril
39
What is an example of a beta-blocker which might be given for CHF?
Bisoprolol
40
Why are ACE inhibitors given i CHF?
They improve ventricular function and reduce mortality
41
What should be given to patients if they can't tolerate ACE inhibitors?
ARB
42
What should you monitor in a patient taking ACE inhibitors?
U&Es
43
Why are beta-blockers given to patients with CHF?
They decrease HR and oxygen demand
44
What other medication can be given second-line in CHF (in addition to ACE inhibitors and beta-blockers)?
Diuretics (e.g. furosemide)
45
Why are diuretics given sometimes in CHF?
To relieve symptoms of fluid overload (SOB, peripheral oedema)
46
How do diuretics help the symptoms of CHF?
They increase sodium excretion via diuresis so reduce cardiac after-load
47
What should be monitored in patients on diuretics?
U&Es
48
What other medication can be given third-line in CHF (in addition to ACE inhibitors, beta-blockers, and diuretics)?
Aldosterone antagonists (e.g. spironolactone)
49
What should be monitored in patients on spironolactone?
Potassium
50
What medications should be considered if ACEI and ARB intolerant?
Hydralazine and nitrate
51
If symptoms persist despite ACEI/ARB, BB and diuretic/ aldosterone agonist, and the ejection fraction is <35%, what could you do?
Replace ACEI/ARB with sacubitril valsartan
52
If symptoms persist despite ACEI/ARB, BB and diuretic/ aldosterone agonist, and the ejection fraction is <35% with a sinus rhythm heart rate >75, what could you do?
Add ivabradine
53
If symptoms persist despite ACEI/ARB, BB and diuretic/ aldosterone agonist, and the ejection fraction is <35%, what could you add (especially if the patient is of African-Caribbean descent)?
Add hydralazine and nitrate
54
If symptoms persist despite ACEI/ARB, BB and diuretic/ aldosterone agonist, what could be added for heart failure with sinus rhythm?
Digoxin
55
What is cor pulmonale?
Right sided heart failure due to respiratory disease. The respiratory disease causes an increased pressure and resistance in pulmonary arteries which means the right ventricle is unable to effectively pump blood out of the ventricles and into the pulmonary arteries. This results in a back pressure of blood into the systemic venous system.
56
What are causes of cor pulmonale?
``` COPD (most common) PE Interstitial lung fibrosis CF Primary pulmonary hypertension ```
57
How does cor pulmonale present?
SOB (worse on exertion) Peripheral oedema Syncope Chest pain
58
What are signs of cor pulmonale?
``` Hypoxia Cyanosis Raised JVP Ankle/ sacral oedema S3 Murmurs (tricuspid regurgitation) Hepatomegaly (back pressure in hepatic vein) ```
59
What causes left ventricular failure?
The left ventricle is unable to move blood through the heart resulting in back pressure of blood into the left atrium, pulmonary veins and into the lungs. Vessels become engorged with blood (due to an increase in volume and pressure) so fluid leaks causing pulmonary oedema.
60
What can trigger left ventricular failure?
Acute MI Arrhythmia Sepsis Acute valve dysfunction Iatrogenic (e.g. aggressive IV fluids in elderly patient with impaired LV function)
61
How does LV failure present?
Acute SOB Unwell/ fatigue Cough (frothy white/ pink sputum)
62
How might LV failure appear on examination?
Same as CHF but it is important to identify the underlying cause (chest pain (MI), palpitations (arrhythmias), fever (sepsis), murmurs)
63
How is LV failure managed?
STOP IV fluids Sit up patient Oxygen Diuretics (e.g. IV furosemide 40mg stat) Make sure to monitor fluid balance, U&Es and daily body weight
64
What treatment should you consider in severe acute pulmonary oedema?
Morphine (vasodilator) Antiemetics (e.g. IV metoclopramide 10mg) Nitrates (GTN infusion/ spray) NIV/ CPAP
65
What is infective endocarditis?
Infection of the endocardium by bacteria or very rarely, fungus
66
What does infective endocarditis most commonly affect?
Heart valves
67
What bacteria commonly infections the tricuspid valve in IV drug users?
Staph. Aureus
68
What is the most common bacterial cause of infective endocarditis?
Strep. Viridans
69
Does IE usually present acutely or chronically?
It can present acutely or, more commonly, sub-acutely with non-specific symptoms
70
What are risk factors for infective endocarditis?
Aortic or mitral valve disease IV drug use Rheumatic fever Prosthetic valves
71
What are the symptoms of infective endocarditis?
``` Fever with new murmur Petechiae Cardiac/ renal failure Rigors Night sweats ```
72
What are the signs of infective endocarditis?
``` Petechiae (small red/ purple spots) Splinter haemorrhages Janeway lesions (sub-acute presentation) Osler nodes (rare) ```
73
What investigations might you do if you suspect infective endocarditis?
Blood cultures (3 sets at different times at different sites at peak of fever Bloods U&Es Urinalysis ECG Echo
74
What are you looking for in bloods in suspected IE?
Normocytic, normochromic anaemia, low platelet, neutrophilia, high ESR/CRP
75
What are you looking for in urinalysis in suspected IE?
Microscopic haematuria
76
What are you looking for on an echo in suspected IE?
Vegetations
77
What is the name of the criteria for diagnosing IE?
Modified Duke Criteria
78
What are the major criteria in the Modified Duke Criteria?
Positive blood culture (typical organism from two cultures; persistent positive blood cultures taken >12 hours apart; three or more positive cultures taken over >1 hour Endocardial involvement (positive echocardiographic findings of vegetations; new valvular regurgitation)
79
What are the minor criteria in the Modified Duke Criteria?
Predisposing valvular or cardiac abnormality I.V. drug misuse Pyrexia *>/=38 degrees Embolic phenomenon Vasculitic phenomenon Blood cultures suggestive (organism grown but not achieving major criteria Suggestive echocardiographic findings
80
What Modified Duke Criteria would need to be confirmed to diagnosis definite endocarditis?
Two major, or one major and three minor, or five minor
81
What Modified Duke Criteria would need to be confirmed to indicate possible endocarditis?
One major and one minor, or three minor
82
How can chronic heart failure be classified structurally?
Based on left ventricular ejection fraction
83
What two courses of pathology can lead to acute heart failure?
1. Congestion in the pulmonary or systemic circulation | 2. Hypoperfusion of vital organs as cardiac output is reduced
84
How do patients with AHF due to congestion appear?
"Wet"
85
How do patients AHF due to hypoperfusion appear?
"Cold"
86
Do patients only ever appear either congested OR hypoperfused?
No they can be both (wet and cold)

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