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103 Theme 3 - Cardiovascular System > Heart failure > Flashcards

Heart failure Flashcards

1
Q

What is the definition of heart failure?

A

A state that develops when the heart fails to maintain an adequate cardiac output to meet the demands of the body

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2
Q

What does heart failure result from?

A

Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (systolic HF) or fill with blood (diastolic HF)

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3
Q

What is the equation for cardiac output?

A
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4
Q

What is the normal value for cardiac output?

A

At rest, cardiac output is typically 70mls/kg/min

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5
Q

How does an increased heart rate increase cardiac output?

A

Heart contracts in systole and relaxes in diastole. Ventricular filling occurs in diastole

Excessively high HR results in a decrease in the amount of time allowed for the ventricles to fill in diastole which causes SV and, thus CO to fall

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6
Q

What 3 things make up stroke volume?

A

Contractility: the intrinsic ability of the myocardium to contract

Preload: the volume of blood or stretching of cardiomyocytes at the end of diastole prior to the next contraction

Afterload: the resistance/end load against which the ventricle contracts to eject blood

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7
Q

What is preload?

A

The volume of blood or stretching of cardiomyocytes at the end of diastole prior to the next contraction

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8
Q

What is preload affected by?

A

Is affected by venous blood pressure and the rate of venous return to the heart

This, in turn, is affected by venous tone and volume of circulating blood

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9
Q

What increases and decreases preload?

A

Preload increases with increasing blood volume and vasoconstriction

Preload decreases with blood volume loss and vasodilatation

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10
Q

What is Frank-Starling Law?

A

Describes the relationship between Preload and Cardiac Output

States that….

  • An increase in volume of blood filling the heart stretches the heart muscle fibres causing greater contractile forces which, in turn, increases the stroke volume
  • Is true only up to a certain point… at some stage the fibres become over-stretched and the force of contraction is reduced
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11
Q

According to Frank-Starlings Law, what will happen if there is a increased preload?

A
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12
Q

What is afterload?

A

The resistance/end load against which the ventricle contracts to eject blood

It is the pressure in the aorta/pulmonary artery that the left/right ventricular muscle must overcome to eject blood

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13
Q

Does preload or afterload increase when the pressure increases in the pulmonary artery/aorta?

A

Afterload

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14
Q

What increases and decreases afterload?

A

Afterload increase with hypertension and vasoconstriction

Afterload decreases with vasodilatation

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15
Q

What happens to cardiac output when afterload increases?

A

As the afterload increases, cardiac output decreases

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16
Q

What is low output heart failure?

A

Systolic heart failure

Diastolic heart failure

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17
Q

What is high output heart failure?

A

Occurs in the context of other medical conditions which increase demands on cardiac output, causing a clinical picture of heart failure

The heart itself is functioning normally but cannot keep up with the unusually high demand for blood to one or more organs in the body

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18
Q

Name some causes of high output heart failure

A

thyrotoxicosis, profound anaemia, pregnancy, pagets disease, acromegaly, sepsis

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19
Q

What is systolic heart failure?

A

Progressive deterioration myocardial contractile function

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20
Q

What is diastolic heart failure?

A

Inability of the heart chamber to relax, expand and fill sufficiently during diastole to accommodate an adequate blood volume

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21
Q

What are the 3 types of systolic heart failure?

A

Ischaemic injury

Volume overload

Pressure overload

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22
Q

What are the 4 types of diastolic heart failure?

A
  • Significant left ventricular hypertrophy (LVH) e.g HCM
  • Infiltrative disorders
  • Constrictive pericarditis
  • Restrictive cardiomyopathy
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23
Q

What are the 5 causes of heart failure?

A

Coronary Heart Disease

Hypertensive Heart Disease

Valvular Heart Disease

Myocardial Disease/ Cardiomyopathies

Congenital Heart Disease

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24
Q

What is the definition of cardiomyopathies?

A

Diffuse disease of the heart muscle leading to functional impairment

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25
Q

What are the 3 types of cardiomyopathies?

A

Dilated Cardiomyopathy

Hypertrophic Cardiomyopathy (hereditary)

Restrictive Cardiomyopathy (rare)

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26
Q

What are the causes of dilated cardiomyopathy?

A

–ETOH, pregnancy, systemic disease (SLE), muscular dystrophies

–Drug toxicity (chemotherapy – anthracyclines, herceptin)

–Myocarditis – Aetiology includes viral (enteroviruses – coxsackie B), HIV

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27
Q

What is the main cause of restrictive cardiomyopathy?

A

Amyloid the main cause in the UK

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28
Q

What does pump failure lead to?

A

Reduced stroke volume and cardiac output

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29
Q

Why do compensatory mechanisms kick in at decreased SV + CO?

A

To maintain arterial pressure and perfusion of vital organs

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30
Q

What are the compensatory mechanisms in heart failure?

A

The Frank Starling mechanism: vasoconstriction, increased venous return to the heart, increased preload, heart muscle fibres stretch, enhanced contractility

Myocardial structural change: Augmented muscle mass (hypertrophy) with or without cardiac chamber dilatation

Activation of neurohormonal system

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31
Q
A
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32
Q

During compensation, what neurohormonal compounds are released?

A

Release of Noradrenaline – increases heart rate and myocardial contractility. Causes vasoconstriction

Release of ANP/BNP

Activation of renin-angiotensin – aldosterone system

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33
Q

Complete the diagram on the RENIN, ANGIOTENSION, ALDOSTERONE SYSTEM

A
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34
Q

What is the NP system?

A

NP - natriuetic peptide

Activated by increased ventricular wall stretch

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35
Q

Complete the diagram on the NP system

A
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36
Q

How does the NP system cause decreased vasodilatation?

A

Decreased BP

Decreased sympathetic tone

Decreased aldosterone levels

Natriuresis

Diuresis

Antifibrotic effects

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37
Q

Complete the diagram on activation of the sympathetic nervous system

A
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38
Q

What 3 compensatory mechanisms may succesfully restore cardiac output but worsen heart failure?

A

Vasoconstriction: ↑resistance against which heart has to pump (i.e.↑afterload), and may therefore ↓ CO

Na and water retention: ↑fluid volume, which ↑ preload. If too much “stretch” → ↓ contractile strength and CO

Excessive tachycardia → ↓diastolic filling time → ↓ventricular filling → ↓SV and CO

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39
Q

What are the 3 clinical types of heart failure?

A

Left sided, right sided and biventricular failure

Acute and chronic heart failure

Compensated and decompensated heart failure

40
Q

What is left sided heart failure?

A

Blood backs up progressively from the left atrium to the pulmonary circulation

41
Q

What are the causes of left sided heart failure?

A

Ischaemic heart disease

Hypertension

Valvular heart disease

Myocardial disease

42
Q

What is the effect of left ventricular failure in the lungs?

A

Pressure in the pulmonary veins is transmitted retrogradely to the capillaries and arteries

This leads to pulmonary congestion and oedema

Heavy wet lungs

43
Q

What is the effect of left sided ventricular failure in the kidneys?

A

Decreased cardiac output

Reduction in renal perfusion

Activation of renin - angiotensin – aldosterone system

Retention of salt and water with consequent expansion of interstitial fluid and blood volumes

44
Q

What are the symptoms of left ventricular heart failure in the lungs?

A
45
Q

What are the symptoms of left sided ventricular heart failure in the brain?

A

Hypoxic encephalopathy

Irritability

Loss of attention

Restlessness

Stupor and coma

46
Q

What causes right sided heart failure?

A

Usually as a consequence of left sided heart failure (congestive cardiac failure (CCF))

Other causes -

  • Valvular heart disease
  • Congenital heart disease
47
Q

What is cor-pulmonale?

A

Right sided HF due to significant pulmonary hypertension due to increased resistance within the pulmonary circulation

Usually as a result of respiratory disease e.g. COPD or pulmonary emboli

48
Q

What causes cor-pulmonale?

A

Usually as a result of respiratory disease e.g. COPD or pulmonary emboli

49
Q

What are the effects of right sided heart failure on the liver and portal system?

A

Congestive hepatomegaly

Centrilobular necrosis when severe

Cardiac cirrhosis

50
Q

What are the effects of right sided heart failure on the spleen?

A

Congestive splenomegaly

51
Q

What is the effect of right sided heart failure on the abdomen?

A

Ascites - accumulation of transudate in peritoneal cavity

52
Q

What are the effects of right sided heart failure on subcutaneous tissue?

A

Peripheral oedema of dependent portions of the body esp. ankle and pretibial oedema

Sacral oedema if bedridden

53
Q

What is the effect of right sided heart failure on the pleural and pericardial space?

A

Effusions

54
Q

Which parts of the body does right sided heart failure have systemic effects on?

A

Liver and portal system

Spleen

Abdomen

Subcutaneous tissue

Pleural and pericardial space

55
Q

What is congestive heart failure?

A

Biventricular failure

56
Q

What are the causes of congestive heart failure?

A

Either due to the same pathological process on each side of the heart

OR

A consequence of left heart failure leading to volume overload of the pulmonary circulation and eventually the right ventricle causing right ventricular failure

57
Q

What are the symptoms of congestive heart failure which are due to excess fluid accumulation?

A

Dyspnoea

Orthopnoea, paroxysmal nocturnal dyspnoea

Oedema

Hepatic congestion

Ascites

58
Q

What are the symptoms of congestive heart failure that are due to reduction of cardiac output?

A

Fatigue

Weakness

59
Q

What are the 4 classes of heart failure?

A

Class I: No limitation of physical activity

Class II: Slight limitation of ordinary activity

Class III: Marked limitation, even during less-than-ordinary activity

Class IV: Severe limitation with symptoms at rest

60
Q

What are the clinical signs of heart failure?

A

Cool, pale, cyanotic extremities

Tachycardia

Elevated JVP

Third heart sound (S3) – gallop rhythm

Displaced apex (LV enlargement)

Crackles or decreased breath sounds at bases on chest auscultation

Peripheral oedema

Ascites

Hepatomegaly

61
Q

What clinical tests are used in heart failure?

A

CXR

ECG

Blood investigations

Echocardiogram / Cardiac MRI or CT / CT-PET

CTCA / Coronary angiography

62
Q

Complete the diagram on the NICE guidelines for chronic heart failure treatment

A
63
Q

Name 2 loop diuretics

A

FRUSEMIDE, BUMETANIDE

64
Q

What is LVSD?

A

Left ventricular systolic dysfunction

65
Q

How do loop diuretics work?

A

Inhibit Na+ re-absorption from the proximal tubule

K+ loss from distal tubule

66
Q

How can loop diuretics be administered?

A

Can be given iv or orally

67
Q

What dangerous side effects can loop diuretics lead to?

A

electrolyte abnormalities

hypovolaemia and diminished renal perfusion

68
Q

How do mineralocorticoid receptor antagonists work?

A

Acts on distal tubule

Promotes Na+ excretion and K+ re-absorption

Reduces hypertrophy and fibrosis

69
Q

Name 2 mineralocorticoid receptor antagonists

A

EPLERENONE, SPIRONOLACTONE

70
Q

What are the possible side effects of Mineralocorticoid Receptor Antagonists?

A

Gynaecomastia (esp. Spironolactone)

Electrolyte (K+ high) and renal function abnormalities

71
Q

Name some ACE inhibitors used in heart failure

A

RAMIPRIL, PERINDOPRIL, ENALAPRIL, CAPTOPRIL, LISINOPRIL

72
Q

How do ACE inhibitors work?

A

Act on activated renin - angiotensin system

Block production of angiotensin:

  • Vasodilatation
  • BP lowering
  • Reduce cardiac work
73
Q

How are ACE inhibitors adminstered?

A

Given orally in small doses with slow titration

74
Q

What are the side effects of ACE inhibitors?

A

cough, hypotension, renal impairment

75
Q

Name some beta blockers used in heart failure

A

BISOPROLOL, CARVEDILOL, METOPROLOL

76
Q

How do beta blockers work?

A

Block the action of adrenaline and noradrenaline on adrenergic beta receptors

Slow HR, reduce BP

(treat arrhythmias)

77
Q

How are beta blockers administered?

A

Given orally in small doses with slow titration

78
Q

What are the side effects of beta blockers?

A

Bronchospasm

Claudication

79
Q

How does digoxin work?

A

Increases myocardial contractility

Slows conduction at the AV node (use in AF)

80
Q

How is digoxin excreted?

A

Excreted by kidney - Toxicity important

81
Q

What is digoxin prescribed to a patient for?

A

Acute HF especially in AF

Chronic HF in selected cases

82
Q

Name 2 ARNIs

A

SACUBITRIL

VALSARTAN

83
Q

What do ARNIs do?

A

Acts on activated renin - angiotensin system

Also blocks breakdown of ANP/BNP

Block production of angiotensin:

  • Vasodilatation, BP lowering, reduce cardiac work

Promote natriuresis

  • Sodium excretion, vasodilatation, reduce hypertrophy and fibrosis
84
Q

What are the side effects of ARNIs?

A

hypotension, renal impairment

85
Q

What is the mechanism of action for ARNIs?

A

Dual NEP and RAAS inhibition

86
Q

Name an SA node blockade drug

A

IVABRADINE

87
Q

How do SA node blockade drugs work?

A

Blocks the If channel within the SA node

Slow HR, no effect on BP

88
Q

How are SA node blockade drugs administered?

A

Given orally with dose titration

89
Q

What are the side effects of SA node blockade drugs?

A

Visual aura

Bradycardia

90
Q

What other therapies are there for heart failure?

A
  • Cardiac Resynchronisation Therapy (CRT)
  • Implantable Cardioverter Defibrillator (ICD)
  • Dialysis & Ultrafiltration
  • Ventricular Assist Device (LVAD/RVAD)
  • Intra-aortic balloon pump
  • Cardiac transplantation
  • (Stem cell therapy)
91
Q

How does biventricular pacing work?

A

Biventricular pacemakers have an additional third lead designed to conduct signals directly into the left ventricle. Combination of all three leads promote synchronised pumping of ventricles, increasing efficiency of each beat and pumping more blood on the whole.

92
Q

How do pacemakers work?

A

Standard pacemakers equipped with two wires (or “leads”) conduct pacing signals to specific regions of heart.

93
Q

Complete the diagram of the pacemaker leads

A
94
Q

Complete the diagram of the pacemakers

A
95
Q
A

103 Theme 3 - Cardiovascular System (19 decks)

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