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Cardio and Resp diseases > Congestive heart failure > Flashcards

Congestive heart failure Flashcards

1
Q

What is atherosclerosis?

A
  • The process of progressive thickening and hardening of the walls of medium and large-sized arteries as a result of cholesterol deposition

Main pathological condition that causes ischaemic heart disease

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2
Q

How can atherosclerosis cause a heart attack?

A
  • atheroma/plaque narrows lumen
  • patients experience angina
  • atheroma is very thrombogenic
  • if blood comes into contact thrombus/clots can form which can completely occlude the artery
  • it will cause heart attack/acute myocardial infarction
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3
Q

What are non-modifiable Cardiovascular Disease Risk Factors?

A
  • Age
  • Male sex
  • Family History
  • Low Birth weight
  • Premature Birth
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4
Q

What are modifiable Cardiovascular Disease Risk Factors?

A
  • Hypertension
  • Smoking
  • Diabetes mellitus
  • Hypercholesterolemia
  • Obesity
  • Physical inactivity
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5
Q

Define heart failure?

A
  • “A complex of symptoms—shortness of breath, fatigue, and congestion
  • Due to an impairment of the heart’s ability to (contract) empty* or (relax) fill* properly,
  • leading to inadequate perfusion of tissues during exertion (causes forwards symptoms), and retention of fluid (causes backward symptoms)”
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6
Q

What are some causes of heart failure?

A 
• Decreased contractility, can be due to
o Coronary heart dis.
o Cardiomyopathies: Viral myocarditis 
o Drug: ß-adrenergic blockers
o Arrhythmias

• Increased Afterload
o Hypertension
o Valvular disease
o HOCM (hypertrophic obstructive cardiomyopathy)

• Increased Output
o Anaemia
o Hyperthyroidism
o AV shunts

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7
Q

What is Acute Decompensation?

A

Means the patient had been treated, symptoms resolved but there’s a reappearance of symptoms

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8
Q

What can cause acute decompensation?

A
  • Discontinuation of treatment
  • ACS (new event)
  • Arrhythmias (AF)
  • Infection
  • Anaemia
  • Pulmonary Embolism
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9
Q

How does the New York Heart Association (NYHA) classify heart failure?

A

Class I
• No limitation of physical activity
• Ordinary physical activity does not cause SOB (dyspnoea) or fatigue

Class II
• Slight limitation of physical activity
• Ordinary physical activity result in dyspnoea or fatigue

Class III
• Marked limitation of physical activity
• Less than ordinary physical activity result in dyspnoea or fatigue

Class IV
• Inability to carry out any physical activity without discomfort
• Symptoms are present at rest

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10
Q

How is heart failure diagnosed?

A
  1. NT-proBNP (ANP derivative) – measured in the urine, if <400 ng/L then HF is unlikely
  2. ECHO cardiogram (ultrasound of heart): can show HFrEF (heart failure with reduced ejection fraction) or HFpEF (heart failure with preserved ejection fraction)
  3. Cardiac MRI (CMR)
  4. Other tests: ECG, CXR, U&Es, ABGs, D-dimer
  5. Look for cause(s) of decompensation: Troponin for ACS, ECG for Arrhythmias, etc..
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11
Q

What is ejection fraction?

A
  • Ejection fraction (EF) is a percentage of how much blood the left ventricle pumps out with each contraction.
  • EF of 60% means that 60% of the total amount of blood in the left ventricle is pushed out with each heartbeat – 50% is normal
  • EF also called Fractional shortening
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12
Q

What are the types of HF

A

• Failure of filling of blood:
o Aka Diastolic HF in the past
o HFp EF (Heart failure with preserved ejection fraction >50%)
o HFpEF patients are older, female, hypertension, obesity, anemia, and AF

• Failure of ejection of blood:
o Systolic HF
o HFr EF (Heart failure with reduced ejection fraction ≤40%)

• HFmrEF (mid-range ejection fraction) – in between normal of 50 and abnormal of 40 (41-49%), now name changed to mildly reduced ejection fraction

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13
Q

Aims of heart failure treatment?

A
  1. Removal of the underlying or precipitating causes
  2. Improving survival & reducing mortality
  3. Relief of symptoms (& Improvement in quality of life)
  4. Prevention of re-admissions to hospital, recurrent ischaemic events, and further deterioration in left ventricular function
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14
Q

Ways of treating HF by removal of precipitating causes?

A
  • Treatment of hypertension
  • Correction of valvular lesions
  • Treat anaemia, thyrotoxicosis, fluid overload, increased dietary salt intake
  • Improve compliance with treatment
  • Drugs: beta-blockers, salt-retaining drugs (NSAIDs, steroids) – can cause/worsen heart failure
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15
Q

What drugs may be used to treat heart failure?

A
  • ACE inhibitors
  • Beta Blockers
  • Angiotensin receptor antagonists (ARBs)
  • Aldosterone antagonists
  • Hydralazine/nitrate
  • Diuretics
  • Digoxin
  • Sacubitril-Valsartan (ARNI)
  • SGLT2 inhibitors
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16
Q

How do beta blockers and renin inhibitors work?

A

Prevent ANG I production - interferes with the RAAS system

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17
Q

How do ACE inhibitors work?

A

Prevent ANG II production - interferes with the RAAS system

  • Reduce angiotensin II levels thus induce arteriolar vasodilatation
  • Reduce systemic vascular resistance
  • Reduce norepinephrine release
  • Decrease sympathetic activity
  • Decrease aldosterone secretion
  • Suppress vasopressin release
  • Increase bradykinin levels
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18
Q

How do Angiotensin receptor antagonists/blockers (ARBs) work?

A

Prevent ANG II from binding to its receptor - no vasoconstriction or aldosterone
• Block angiotensin II type 1 receptors

19
Q

Name a study for ACE inhibitors and say what it showed?

A

Acute Infarction Ramipril Efficacy (AIRE):

  • Effect of Ramipril on mortality and morbidity of survivors of acute MI with HF
  • 2006 patients, EF ≤ 35% post-MI
  • Follow-up average 15 months
  • Overall mortality significantly reduced 27%
  • Development of severe heart failure reduced by 23%
20
Q

Other uses for ACEi?

A
  • Hypertension
  • Post-Myocardial Infarction (LVD)
  • Diabetic nephropathy
  • Diabetic retinopathy
21
Q

Side effects for ACEi?

A
  • First dose may cause hypotension
  • Cough
  • Angioedema – most dangerous, swelling of lips and tongue
  • Rash
  • Neuropathy
  • Deterioration of renal function (in RAS)
22
Q

Contraindications for ACEi

A
  • Pregnancy & breast feeding
  • Renal artery stenosis (bilateral, single k)
• Caution with patients that have: 
o Peripheral vascular disease
o Low BP
o High dose diuretic, hypovolaemia
o Age >70 ys
o Creatinine >150µmol/L
o +NSAIDs
23
Q

Alternatives if ACEi are contraindicated or untolerated?

A
  • Other vasodilators: Angiotensin Receptor Blockers e.g. Candesartan, Losartan
  • Hydrallazine & Nitrates
  • Angiotensin receptor-neprilysin inhibitor (ARNI )
24
Q

What study showed ARBs were effective?

A

ELITE study: (Evaluation of Losartan In The Elderly)
• 722 patients with CHF (congestive heart failure)
• Designed to study effects of losartan on renal function (vs captopril)
• All cause mortality was 46% lower

25
Q

How do beta-blockers reduce chances of HF?

A
  • Reduce sympatho-adrenergic activity
  • Reduce afterload
  • Decrease myocardial oxygen demand – important for patients that have angina
  • Reduce ventricular remodelling
  • Reduce renin release
  • Coronary and peripheral vasodilatation
  • Negative inotropic effect/direct weaking affect on the myocardium – can make HF worse,
26
Q

What study shows that beta-blockers are effective for treating HF

A 
MERIT-HF:
• 39991 patients in USA & Europe
• NYHA II- III
• Metoprolol-XL 12.5mg up to 200mg od
• Total mortality: Decreased by 34%
• CV mortality: Decreased by 38%
• Sudden death: Decreased by 41%

Benefit not clear in class I or class IV

27
Q

Side effects of beta blockers?

A
  • Fatigue
  • Sleep disturbances
  • Bradycardia
  • Hypotension
  • Heart failure (start low doses, slowly increase)
  • Conduction disorders
  • Bronchospasm
  • GI disturbances
28
Q

Cautions & Contraindications for beta blockers?

A
  • Asthma, COPD – can be made worse
  • Uncontrolled heart failure
  • Severe bradycardia
  • Hypotension or shock
  • Pheochromocytoma (unless with a-blocker)
  • Peripheral vascular disease
29
Q

What is a diuretic used for HF?

A

Spironolactone

30
Q

How does Spironolactone work?

A
  • Acts through its active metabolite, canrenone

* Blocks aldosterone receptors on the distal convoluted tubule

31
Q

What study shows spironolactone was effective?

A

RALES (Randomised Aldactone Evaluation Study)
• 1663 patients, severe heart failure (NYHA IV) (LVEF<35%)
• Rx ACEi + Loop diuretic ± Digoxin
• Spironolactone 25mg - 50mg od
• Total mortality : 30% reduction p<0.001
• Cardiac mortality : 31% reduction
• Hospitalization: 35% reduction

32
Q

What are the side effects of spironolactone?

A

o Gynaecomastia in males (painful) – doesn’t reverse
o Testicular atrophy
o Menstrual irregularities
o Hyperkalaemia (esp. renal impairment

33
Q

What aldosterone blocking agent is also used for HF?

A

Epleronone:

• Eplerenone produces less painful gynaecomastia than spironolactone

34
Q

What study proves epleronone as effective?

A

EPHESUS study:
• 13% reduction in mortality from cardiovascular causes or hospitalization
• 21% reduction in sudden death
• Can cause hyperkalaemia and renal dysfunction

35
Q

What does digoxin do?

A
  • Inhibits Na+-K+ ATPase pump, inactivating Na+-Ca2+ exchanger, increasing Ca 2+
  • Increases force of contraction

• Other effects
o Decrease in AV conduction
o Increase in vagal activity
o Decrease in heart rate

36
Q

What are the uses of digoxin?

A
  • Slowing ventricular rate in rapid AF (atrial fibrillation)

* Treatment of heart failure in patients who remain symptomatic despite optimal doses of diuretics and ACE inhibitors

37
Q

Side effects of digoxin

A

o Nausea, vomiting, arrhythmias, confusion

o Toxicity enhanced by hypokalaemia

38
Q

What trials show digoxin efficacy?

A
  • Digoxin has no effect on mortality (DIG trial)
  • Clinical effects are not dramatic
  • Withdrawal of digoxin may cause clinical deterioration in 1/4 of patients stable on digoxin and diuretic ±ACEi (RADIANCE and PROVED trials)
39
Q

What do diuretics do in treating HF?

A
  • Only relieve symptoms
  • Relieve circulatory congestion and pulmonary and peripheral oedema
  • Reduce atrial and ventricular diastolic pressure
  • Do not improve LV dysfunction
  • Little impact on mortality
40
Q

What are the side effects of Diuretics?

A 
• Metabolic effects:
o Hypokalaemia (low K)  (arrhythmias) – most dangerous
o Hyperglycaemia (high glucose)  (diabetes)
o Hyperuricaemia (high uric acid) (gout)

• Social disruption
o Frequency, urgency, incontinence

41
Q

How are Hydralazine & Nitrate used for heart failure?

A
  • Hydralazine in combination with nitrate (especially if the patient is of African or Caribbean origin and moderate to severe heart failure [NYHA class III–IV]
  • V-HeFT (Vasodilator-Heart Failure Trial) - 43% reduction in mortality
  • A-HeFT (African American-Heart Failure Trial)
42
Q

What are Non-Drug Therapy of Heart Failure?

A
  • Cardiac-Resynchronization Therapy (RCT)

- Surgery

43
Q

How does Cardiac-Resynchronization Therapy (RCT) work?

A
  • Using atrial-synchronized bi-ventricular pacing – different pacing wires in ventricles to make the heart work as one unit
  • Indicated for patients with severe symptoms and intra-ventricular conduction delays i.e. QRS ≥120 msec
  • Leads to dys-synchronous LV contraction, impaired emptying, MR
  • Can reduce symptoms, improve functional capacity, reduce hospitalizations and increase survival
44
Q

How does surgery work?

A
  • Ventricular Assist Devices – a pump put into the left ventricle and aorta
  • Cardiac Transplantation
  • Xeno Cardiac transplantation (genetically modified pig heart) 7th January 2022

Cardio and Resp diseases (29 decks)

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