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Cardio/Resp > Congestive Heart Failure > Flashcards

Congestive Heart Failure Flashcards

1
Q

Define Atherosclerosis

A

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

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2
Q

Non- Modifiable CVD risk factors (5)

A

Age
Male sex
Family History
Low Birth weight
Premature Birth

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3
Q

Modifiable CVD risk factors (6)

A

Hypertension
Smoking
Diabetes mellitus
Hypercholesterolemia
Obesity
Physical inactivity

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4
Q

CVD continuum (8)

A

Risk factors/ diabetes/ Hypertension

Ather + LVH

MI

Remodelling

Ventriuclar Dilation

Congestive Haert Failure

End-stage Heart disease

Death

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5
Q

Definition of Heart Failure (3)

A

“A complex of symptoms—shortness of breath, fatigue, and congestion

Due to an impairment of the heart’s ability to empty* or fill* properly, (systolic or diastolic)

= leading to inadequate perfusion of tissues during exertion, and retention of fluid”

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6
Q

Heart Failure facts (4)

A

 Affects 1-2% of population

 10% among persons ≥ 70 years

 Prognosis 25-40% mortality ~ 5 years(similar to cancer)

 Prognosis worse if (1yr ~ worse than cancer)
– severe symptoms
– high dose of diuretics
– low BP
– low sodium

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7
Q

Causes of Heart Failure (3)

A

Decreased contractility:
- Coronary heart dis.
- Cardiomyopathies
Viral myocarditis (Covid)
Infiltrations

  • Drugs
    ß-adrenergic blockers
    Verapamil
    Doxorubicin
  • Arrhythmias

Increased Afterload:
- Hypertension
- Valvular disease
- HOCM

Increased Output:
- Anaemia
- Hyperthyroidism
- AV shunts

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8
Q

Acute Decompensation (6)

A

One or more events
1. Discontinuation of treatment
2. ACS (new event)
3. Arrhythmias (AF)
4. Infection
5. Anaemia
6. Pulmonary Embolism

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9
Q

New York Heart
Association (NYHA) - 4 classes (4)

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

Diagnosis of HF - 5 steps (5)

A
  1. (BNP) or NT-proBNP:
    if <400 ng/L HF is unlikely if <400 ng/L HF is unlikely
  2. ECHO: HF, rEF or HF, pEF
  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

Ejection Fraction (3)

A

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.

EF also called Fractional shortening

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12
Q

Types of HF (2)

A

Failure of filling of blood:
– Diastolic HF
– HF (Heart failure with preserved ejection fraction >50%)
- HFpEF patients are older, female, hypertension, obesity, anaemia, and AF

Failure of ejection of blood:
–– Systolic HF
–– HFHF
(Heart failure with reduced ejection fraction ≤40%)

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13
Q

Aims of Treatment (4)

A
  1. Removal of the underlying or
    precipitating causes
  2. Improving survival & reducing mortality
  3. Relief of symptoms (& Improvement in quality of life)(& 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

Removal of precipitating causes (5)

A

 Treatment of hypertension

 Correction of valvular lesions

 Anaemia, thyrotoxicosis, fluid
overload, increased dietary salt intake

 Poor compliance with treatment

 Drugs: beta-blockers, salt- retaining drugs (NSAIDs, steroids)

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15
Q

Standard Drug Therapy
(1st , 2nd + 3rd line) (9)

A

1st:
- ACE inhibitors / ARNI
- Beta Blockers

2nd:
- Angiotensin receptor antagonists (ARBs)
- Aldosterone antagonists
- Hydralazine/nitrate

3rd:
- Diuretics
- Digoxin
- Sacubitril-Valsartan (ARNI)
- SGLT2 inhibitors

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16
Q

RAAS + which drug is used where (4)

A

1) Angiotensin (+ renin)
- beta blockers + renin inhib

2) = angiotensin I (+ACE Chymase)
- ACE inhib

3) = Angiotensin II
- ARBs

4) Aldosterone + Vasoconstriction

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17
Q

ACE Inhibitors (4)

A
  • Indicated in all patients with heart failure (EF<40)
    (unless contraindicated)

e.g.’s
–– Captopril
–– Enalapril
–– Lisinopril
–– Perindopril
–– Ramipril
–– Trandolapril

  • Documented survival benefit
  • Several large controlled trials
    –– CONSENSUS
    –– SOLVD
    –– SAVE
    –– AIRE
    –– TRACE
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18
Q

How do ACE inhib work? (8)

A

Reduce angiotensin II levels

 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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19
Q

Acute Infarction Ramipril
Efficacy (AIRE) (5)

A

 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%

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20
Q

ACEi: other uses (6)

A

 Heart failure
 Hypertension
 Post-Myocardial Infarction (LVD)
 Diabetic nephropathy
 Diabetic retinopathy

21
Q

ACEi: side effects (6)

A

First dose hypotension
Cough
Angioedema
Rash
Deterioration of renal function (in RAS)

22
Q

ACEi: Contraindications (3)

A
  • Pregnancy(or risk of pregnancy)
  • Renal artery stenosis (bilateral, single k)R

Caution: Peripheral vascular disease
–– Low BP
–– High dose diuretic, hypovolaemia
–– Age >70 ys
–– Creatinine >150μmol/L
–– +NSAIDs

23
Q

What if ACEi are
contraindicated or untolerated? (3)

A

Other vasodilators
–– Angiotensin Receptor Blockers e.g. Candesartan, Losartan

–– Hydrallazine & Nitrates

– Angiotensin receptor-neprilysin inhibitor
(ARNI )

24
Q

Angiotensin Receptor
Blockers (ARBs) (4)

A
  • Block angiotensin II type 1 receptors

Examples:
–– Losartan
–– Candesartan
–– Irbesartan
–– Valsartan
–– Eprosartan

25
Q

ELITE study - ARBs (4)

A

 Evaluation of Losartan In The Elderly

 722 patients with CHF

 Designed to study effects of losartan
on renal function (vs
captopril)

 All cause mortality was 46% lowe

26
Q

Sacubitril-Valsartan
(Entresto)- ARNI (6)

A

 Angiotensin receptor-neprilysin inhibitor
(ARNI)

 Moderate to severe heart failure [NYHA
class II–IV]

 LV ejection fraction of ≤35%

 Already on a stable dose of ACEi or ARBs

 PARADIGM-HF Trial

43% reduction in mortality

27
Q

PARADIGM-HF (8)

A

P-rospective comparison of A-ngiotensin II

R-eceptor blocker neprilysin inhibitor

with A-ngiotensin-converting enzyme
inhibitor to D-etermine

I-mpact on Global

M-ortality and morbidity in heart failure

28
Q

Beta-Blockers (7)

A

 Reduce sympatho-adrenergic activity

 Reduce afterload

 Decrease myocardial oxygen demand

 Reduce ventricular remodelling

 Reduce renin release

 Coronary and peripheral vasodilatation

 Negative inotropic effect

29
Q

Evidence Based Medicine
Beta-Blockers (4)

A

only 3 used for HF

Beta-blockers reduce mortality in mild
-to-moderate CHF, reduce hospitalization, improve symptoms

Benefit not clear in class I or class IV

Reduction in mortality may not be a
class effect (metoprolol vs atenolol)

30
Q

MERIT-HF - BB (6)

A

 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%

31
Q

Beta-Blockers: Side
effects (8)

A

 Fatigue
 Sleep disturbances
 Bradycardia
 Hypotension
 Heart failure
(start low, go slow)
 Conduction disorders
 Bronchospasm
 GI disturbances

32
Q

BB: Cautions &
Contraindications (7)

A

 Asthma, COAD
 Uncontrolled heart failure
 Severe bradycardia
 Hypotension or shock
 AV block (2AV block (2nd& 3rddegrees), SSS
 Pheochromocytoma (unless with alphablocker)
 Peripheral vascular disease

33
Q

Spironolactone- including side effects (3)

A

 Blocks aldosterone receptors on the distal
convoluted tubule

 RALES study

 Side effects:
– Gynaecomastia (painful)
– Testicular atrophy
– Menstrual irregularities
– Hyperkalaemia
(esp. renal impairment)

34
Q

RALES
Randomised Aldactone Evaluation Study (6)

A

 1663 patients, severe heart failure (NYHA1663 patients, severe heart failure (NYHA
IV) (LVEF<35%)

 Rx ACEi + Loop diuretic ± Digoxin
 Spironolactone 25mg - 50mg od
 Total mortality :Total mortality : 30% p<0.001reduction
 Cardiac mortality 31% reduction
 Hospitalization:35% reductionr

35
Q

Epleronone - including study ( 4)

A

 Eplerenone produces less painful gynaecomastia
than spironolactone

EPHESUS study:
 13% reduction in mortality from cardiovascular
causes or hospitalization

 21% reduction in sudden death

 Can cause hyperkalaemia and renal dysfunction

 Eplerenone produces less painful gynaecomastia
than spironolactone
EPHESUS study:
 13% reduction in mortality from cardiovascular
causes or hospitalization
 21% reduction in sudden death
 Can cause hyperkalaemia and renal dysfunction

36
Q

Digoxin (3)

A

Inhibits Na+-K+ ATPase pump, inactivating Na+-
Ca2+ exchanger, increasing Ca2+

 Increases force of contraction

 Other effects
–– dec. AV conduction
–– inc. vagal activity
–– dec. heart rate

37
Q

Digoxin: uses + side effects (4)

A

 Slowing ventricular rate in rapid AF
 Treatment of heart failure in patients who
remain symptomatic despite optimal doses
of diuretics and ACEi

Side effects:
–– Nausea, vomiting, arrhythmias, confusion
–– Toxicity enhanced by hypokalaemia#

38
Q

Evidence Based Medicine Digoxin (4)

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 (digoxin and diuretic ±ACEi (RADIANCERADIANCE and PROVED trials)
  • Reduces hospitalization rates
39
Q

Diuretics (7)

A

 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**

Frusemide
 Other loop diuretics e.g. bumetanide
 Metolazone

40
Q

Diuretics: side effects (2)

A

 Metabolic effects:
–– Hypokalaemia (low K)
= (arrhythmias)
–– Hyperglycaemia (high glucose)= (diabetes)
–– Hyperuricaemia (high uric acid)= (gout)

 Social disruption
–– Frequency, urgency, incontinence

41
Q

Hydralazine & Nitrate (4)

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

Sodium-GLucose co-
Transporter-2 inhibitors (4)

A

 SGLT2 inhibitors or gliflozins

 Indicated in Type 2 Diabetes mellitus

 Inhibit reabsorption of glucose in the kidney and lower blood sugar

Examples:
Dapagliflozin, Empagliflozin, Canagliflozin,
Ertugliflozin, Sotugliflozin

42
Q

Non-Drug Therapy
of Heart Failure (2)

A

Cardiac-Resynchronization
Therapy (RCT)

surgery

43
Q

Cardiac-Resynchronization
Therapy (RCT) (4)

A

 Using atrial-synchronized bi-ventricular pacing

 Indicated for patients with severe symptoms and intra-ventricular conduction delays i.e. QRS ≥120 msec

 Leads to dys-synchronous LV contraction, contraction,
impaired emptying, MR

 Can reduce symptoms, improve functional capacity, reduce hospitalizations and increase survival

44
Q

Surgery (3)

A

 Ventricular Assist Devices

 Cardiac Transplantation

 Xeno Cardiac
transplantation
(genetically modified
pig heart) 7th January 2022

45
Q

SUMMARY 1 (Diuretics, ACEi, Digoxin) (3)

A

 Diuretics alone alleviate symptoms but do not but do not
improve heart function or mortality

 ACEiA improve LV dysfunction, CV mortality and total mortality but do not appear to protect against sudden death

 Digoxinimprove symptoms, reduces
hospitalization rates but no positive effect
on survival

46
Q

SUMMARY 2 (BB, Spironolactone) (2)

A

 Beta-blockers reduce mortality in mild-to-reduce mortality in CHF, reduce hospitalization,
improve symptoms
–– Benefit not clear in class I or class IV
–– Reduction in mortality may not be a class effect
(metoprolol vs atenolol)

 Spironolactone reduce CV and total
mortality and hospitalization

47
Q

SUMMARY 3 (ARNI, Gliflozins) (2)

A

 ARNI reduce mortality in HFrEF, reduce hospitalization, improve symptoms

Gliflozins (Dapagliflozin and Empagliflozin)
reduce CV mortality and hospitalization in
HFrEF and HFpEF

Cardio/Resp (34 decks)

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