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Phase 2CARDIORESP > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

Define heart failure

A

Pathophysiological process in which the heart as a pump is unable to meet the metabolic requirements of the tissues for oxygen and substrates despite the venous return to the heart being either normal or increased.

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2
Q

What are the 3 compensatory mechanisms of Heart Failure?

A

-Increased preload -Increased heart rate -Increased systemic resistance

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3
Q

What does the Frank Starling mechanism state?

A

The stroke volume of the LV will increase in proportion to the amount of blood in the left ventricle ie increased venous return/preload will cause an increased in myocardial stretching–> increase in stroke volume (due to myocyte stretch causing a more forceful systolic contraction

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4
Q

The Starling curve represents the relationship between which two cardiac parameters?

A

preload

cardiac output

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5
Q

The Starling curve shows that the force of contraction is proportional to what?

A

The preload or the initial length of the cardiac muscle fiber

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6
Q

What happens when the Starling Curve can no longer compensate in heart failure?

A

increased preload–> Increase in myocardial stretching–> increase in stroke volume–> increase in cardiac output

THEN; reaches a PLATEAU—> DECOMPENSATION—> reduction in stroke volume–> causing interstitial oedema

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7
Q

How does chronic activation make decompensated HF worse?

A
  • VASOCONSRICTION: further exacerbates heart failure by increasing afterload
  • Myocardial apoptosis
  • Increased intravascular volume–>release of ANP and BNP
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8
Q

What effect do the compesnatory mechanisms have?

A

increased prelaod, afterload and heart rate+ prioritisation of blood flow to vital organs

  • this increases cardiac work–> cellular hypertrophy and myocardial demand ischaemia
  • causing cellular necrosis and apoptosis–> worsening cardiac function and increased reliance on compensatory mechanisms
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9
Q

Classify systolic and diastolic heart failure in terms of ejection fraction

A
  • Systolic HF; REDUCED EF ie heart cannot pump
  • Diastolic HF; PRESERVED EF ie heart cannot fill
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10
Q

WHY can’t the heart fill in diastolic HF?

A

Walls are stiff and thick

  • less compliance of the heart
  • cannot get a good volume into the left ventricle because the EDV is restricted therefore SV is also affected

the stiff ventricles fill with less blood than normal

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11
Q

Give some common causes of HF

A
  • IHD
  • HTN
  • inherited or acquired cardiomyopathies

eg Inherited Hypertrophic cardiomyopathy, Restricted cardiomyopathy, Dilated cardiomyopathy

DM

Valve disease

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12
Q

Name 2 rare drugs which can cause HF

A
  • Biologics; monoclonal antibodies
  • ANTHRACYCLINES; cancer drugs used for breast cancer and haematological malignancies
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13
Q

Name some causes of LHF

A

Pump failure:

  • Heart muscle disease; IHD, cardiac muscle myopathy
  • Restricted filling; pericarditis, tamponade

Excessive preload:

  • mtiral regurgitation

Chronic excessive afterload:

  • atrial stenosis
  • hypertension
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14
Q

Name some causes of RHF ?

A
  • INTRINSICE; RV infarciton
  • Volume overload; pulmonary and trsicuspid regurgitation, SHUNTS; VSD and ASD
  • increased afterload; Left HF, PE, chronic lung disease
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15
Q

Give 4 symptoms of LHF

A
  • SOBOE
  • Orthopnoea
  • Paroxysmal Nocturnal Dyspnoea
  • Nocturnal cough with or without pink frothy sputum
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16
Q

Give 6 signs of left heart failure

A
  • Tachycardia
  • Tachypnoea
  • Cardiomegaly
  • Third heart sound ie S3
  • Pulmonary crackles
  • Pleural effusion
17
Q

Give 5 syptoms of RHF

A
  1. Swollen ankles
  2. Dyspnoea
  3. Fatigue
  4. Anorexia
  5. Nausea/loss of appetite
18
Q

Give 4 signs of RHF

A
  1. Pitting oedema
  2. Hepatomegaly
  3. Ascites
  4. Raised JVP+ jugular venous distension
19
Q

How is Dyspnoea with HF classified?

A

NYHA-New York Heart Association

Class I:Heart disease present but no undue dyspnoea/NO LIMITATION ON PHSYICAL ACTIVITY

Class II: Comfortable at rest but dyspnoea with ordinary activities

Class III: Less than ordinary activity causes dyspnoea, limiting lifestyle; marked limitation on physical activity

Class IV: Dyspnoea present at rest

20
Q

How does an ECG help in diagnosis of HF?

A

Helps to identify causes of AHF and ischaemia

  • can get ventricular tachycardia, arrythmias, AF, LVH
  • Patthological Q waves indicate previous MI
  • Do a Hb level; checking for anaemia, FBC
    *
21
Q

Describe the pharmacological actions of BNP:

a) Haemodynamic
b) Neurohormonal
c) Cardiac
d) Renal

A

Haemodynamic: balanced vasodilation on veins, arteries and coronary arteries

Neurohormonal:

  • decreased aldosterone
  • decreased endothelin
  • decreased norepinephrine

Renal: increased diuresis and increased natriuresis

Cardiac:

  • anti-fibrotic
  • anti-remodeling
  • iusiotropic
22
Q

What are the 3 main investigations always done to investigate heart failure?

A
  1. ECG
  2. ECHO
  3. BNP
23
Q

What is your diagnosis if BNP and ECG are normal?

A

if both of these are normal, HF is unlikely. no need to do any more cardiac tests

24
Q

What other investigations would you carry out for suspected HF?

A

Bloods - FBC, U&E, BNP, TFT, LFT, cholesterol, glucose, eGFR

CXR

Echo

ECG

25
Q

Describe what CXR findings from HF would be like

A
  • Alveolar oedema (bat’s wings)
  • Kerley B lines (interstitial oedema)
  • Cardiomegaly
  • Dilated prominent upper lobe vessels
  • Effusion (pleural)
26
Q

Describe the general priniciples of treating chronic heart failure

A

Treat the cause (arrythmias, valve disease, anaemia, thyroid disease, hypertension)

Avoid exacerbating factors (NSAIDS - fluid retention, verapamil - negative inotrope)

Lifestyle changes (less salt, weight loss, stop smoking, education)

Cardiac rehabilitation

Drugs

Surgical options (revascularisation, implantable cardioverter defibrillators, transplant)

27
Q

Name the drugs used to treat chronic heart failure

A
  1. Loop diuretics if acute (furosemide 40mg/24hr PO)
  2. ACE inhibitor (lisinopril 10mg/24hr PO)
  3. B-blockers (start low and go slow)
  4. Hydrazaline with nitrate if black
  5. 2nd line - Spironolactone (25mg/24hr PO)
  6. Digoxin (0.125-0.25mg/24hr PO) if remaining symptomatic or AF
28
Q
A
29
Q

What is furosemide used for in HF?

Give 3 side effects

What should always be monitored?

A

SYMPTOMATIC RELIEF

Can get postural symptoms; light-headedness, dizziness, polyuria

always monitor urine output

30
Q

When would you consider an alternate diagnosis of cardiogenic shock?

A

persistent hypotension with signs of hypoperfusion; cerebral/skin/renal

31
Q

What drugs are used in the ABBA therapy for heart failure?

A
  • ACE inhibitor/ARNI (or ARB if intolerant)
  • Beta blocker
  • Aldosterone antagonist
    *
32
Q

What is an ARNI and what is it used for?

A
  • Angiotensin Receptor Neprolysin Inhibitor
  • ie Sacubitril Valsartan
  • ENTRESTO (Angiotensin II Blocker)
    • treats chronic heart failure with reduced EF
  • The sacubitril/valsartan drug inhibits neprilysin and blocks angiotensin II type-I receptor, increasing the levels of peptides degraded by neprilysin.
  • Valsartan inhibits the effects of angiotensin II by blocking the AT1 receptor and by inhibiting the release of angiotensin II-dependent aldosterone.
33
Q

Give some differentials per system for causes of breathlessness

A

Cardio:

  • Arrythmias
  • HF
  • IHD

Resp

  • COPD
  • Asthma
  • PE
  • ILD
  • Pneumonia

OTHER: ANAEMIA

34
Q

Describe this CXR

A
  • Enlarged cardiac silhouette
  • Pulmonary oedema
  • Pulmonary congestion; upper lobe venous distension, Kerley B lines, peri-bronchial cuffing
  • Pleural effusions, typically bilateral
35
Q

CASE STUDY:

This patient has a BNP>2500 pg/ml, CXR: cardiomegaly, pulmonary oedema

ECG; LBBB

ECHO has reduced EF

A
  • IV Furosemide; symptomatic releif 40-80 mg; monitor urine output to check if it works
  • Oxygen and morphine
  • GTN spray 2 puffs
  • Give ACE inhibitors 2puffs
  • Check BP to check if it is safe to administer an ACEi
  • do U and E to monitor K bc of hypokalaemia from loop diuretics to monitor renal function

Phase 2CARDIORESP (11 decks)

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