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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
What are the 3 types of cardiomyopathies?
Dilated Cardiomyopathy Hypertrophic Cardiomyopathy (hereditary) Restrictive Cardiomyopathy (rare)
26
What are the causes of dilated cardiomyopathy?
–ETOH, pregnancy, systemic disease (SLE), muscular dystrophies –Drug toxicity (chemotherapy – anthracyclines, herceptin) –Myocarditis – Aetiology includes viral (enteroviruses – coxsackie B), HIV
27
What is the main cause of restrictive cardiomyopathy?
Amyloid the main cause in the UK
28
What does pump failure lead to?
Reduced stroke volume and cardiac output
29
Why do compensatory mechanisms kick in at decreased SV + CO?
To maintain arterial pressure and perfusion of vital organs
30
What are the compensatory mechanisms in heart failure?
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
31
32
During compensation, what neurohormonal compounds are released?
Release of Noradrenaline – increases heart rate and myocardial contractility. Causes vasoconstriction Release of ANP/BNP Activation of renin-angiotensin – aldosterone system
33
Complete the diagram on the RENIN, ANGIOTENSION, ALDOSTERONE SYSTEM
34
What is the NP system?
NP - natriuetic peptide Activated by increased ventricular wall stretch
35
Complete the diagram on the NP system
36
How does the NP system cause decreased vasodilatation?
Decreased BP Decreased sympathetic tone Decreased aldosterone levels Natriuresis Diuresis Antifibrotic effects
37
Complete the diagram on activation of the sympathetic nervous system
38
What 3 compensatory mechanisms may succesfully restore cardiac output but worsen heart failure?
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
39
What are the 3 clinical types of heart failure?
Left sided, right sided and biventricular failure Acute and chronic heart failure Compensated and decompensated heart failure
40
What is left sided heart failure?
Blood backs up progressively from the left atrium to the pulmonary circulation
41
What are the causes of left sided heart failure?
Ischaemic heart disease Hypertension Valvular heart disease Myocardial disease
42
What is the effect of left ventricular failure in the lungs?
Pressure in the pulmonary veins is transmitted retrogradely to the capillaries and arteries This leads to pulmonary congestion and oedema Heavy wet lungs
43
What is the effect of left sided ventricular failure in the kidneys?
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
What are the symptoms of left ventricular heart failure in the lungs?
45
What are the symptoms of left sided ventricular heart failure in the brain?
Hypoxic encephalopathy Irritability Loss of attention Restlessness Stupor and coma
46
What causes right sided heart failure?
Usually as a consequence of left sided heart failure (congestive cardiac failure (CCF)) Other causes - * Valvular heart disease * Congenital heart disease
47
What is cor-pulmonale?
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
What causes cor-pulmonale?
Usually as a result of respiratory disease e.g. COPD or pulmonary emboli
49
What are the effects of right sided heart failure on the liver and portal system?
Congestive hepatomegaly Centrilobular necrosis when severe Cardiac cirrhosis
50
What are the effects of right sided heart failure on the spleen?
Congestive splenomegaly
51
What is the effect of right sided heart failure on the abdomen?
Ascites - accumulation of transudate in peritoneal cavity
52
What are the effects of right sided heart failure on subcutaneous tissue?
Peripheral oedema of dependent portions of the body esp. ankle and pretibial oedema Sacral oedema if bedridden
53
What is the effect of right sided heart failure on the pleural and pericardial space?
Effusions
54
Which parts of the body does right sided heart failure have systemic effects on?
Liver and portal system Spleen Abdomen Subcutaneous tissue Pleural and pericardial space
55
What is congestive heart failure?
Biventricular failure
56
What are the causes of congestive heart failure?
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
What are the symptoms of congestive heart failure which are due to excess fluid accumulation?
Dyspnoea Orthopnoea, paroxysmal nocturnal dyspnoea Oedema Hepatic congestion Ascites
58
What are the symptoms of congestive heart failure that are due to reduction of cardiac output?
Fatigue Weakness
59
What are the 4 classes of heart failure?
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
What are the clinical signs of heart failure?
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
What clinical tests are used in heart failure?
CXR ECG Blood investigations Echocardiogram / Cardiac MRI or CT / CT-PET CTCA / Coronary angiography
62
Complete the diagram on the NICE guidelines for chronic heart failure treatment
63
Name 2 loop diuretics
FRUSEMIDE, BUMETANIDE
64
What is LVSD?
Left ventricular systolic dysfunction
65
How do loop diuretics work?
Inhibit Na+ re-absorption from the proximal tubule K+ loss from distal tubule
66
How can loop diuretics be administered?
Can be given iv or orally
67
What dangerous side effects can loop diuretics lead to?
electrolyte abnormalities hypovolaemia and diminished renal perfusion
68
How do mineralocorticoid receptor antagonists work?
Acts on distal tubule Promotes Na+ excretion and K+ re-absorption Reduces hypertrophy and fibrosis
69
Name 2 mineralocorticoid receptor antagonists
EPLERENONE, SPIRONOLACTONE
70
What are the possible side effects of Mineralocorticoid Receptor Antagonists?
Gynaecomastia (esp. Spironolactone) Electrolyte (K+ high) and renal function abnormalities
71
Name some ACE inhibitors used in heart failure
RAMIPRIL, PERINDOPRIL, ENALAPRIL, CAPTOPRIL, LISINOPRIL
72
How do ACE inhibitors work?
Act on activated renin - angiotensin system Block production of angiotensin: * Vasodilatation * BP lowering * Reduce cardiac work
73
How are ACE inhibitors adminstered?
Given orally in small doses with slow titration
74
What are the side effects of ACE inhibitors?
cough, hypotension, renal impairment
75
Name some beta blockers used in heart failure
BISOPROLOL, CARVEDILOL, METOPROLOL
76
How do beta blockers work?
Block the action of adrenaline and noradrenaline on adrenergic beta receptors Slow HR, reduce BP (treat arrhythmias)
77
How are beta blockers administered?
Given orally in small doses with slow titration
78
What are the side effects of beta blockers?
Bronchospasm Claudication
79
How does digoxin work?
Increases myocardial contractility Slows conduction at the AV node (use in AF)
80
How is digoxin excreted?
Excreted by kidney - Toxicity important
81
What is digoxin prescribed to a patient for?
Acute HF especially in AF Chronic HF in selected cases
82
Name 2 ARNIs
SACUBITRIL VALSARTAN
83
What do ARNIs do?
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
What are the side effects of ARNIs?
hypotension, renal impairment
85
What is the mechanism of action for ARNIs?
Dual NEP and RAAS inhibition
86
Name an SA node blockade drug
IVABRADINE
87
How do SA node blockade drugs work?
Blocks the If channel within the SA node Slow HR, no effect on BP
88
How are SA node blockade drugs administered?
Given orally with dose titration
89
What are the side effects of SA node blockade drugs?
Visual aura Bradycardia
90
What other therapies are there for heart failure?
* 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
How does biventricular pacing work?
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
How do pacemakers work?
Standard pacemakers equipped with two wires (or "leads") conduct pacing signals to specific regions of heart.
93
Complete the diagram of the pacemaker leads
94
Complete the diagram of the pacemakers
95

103 Theme 3 - Cardiovascular System (19 decks)

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