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General med - Cardiovascular > Heart failure > Flashcards

Heart failure Flashcards

1
Q

Raised levels of which parameter is indicative of a poor prognosis in heart failure

A

N-terminal pro-B-type natriuretic peptide

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2
Q

When should patients with a high NT-proBNP be referred

A

Patients with suspected heart failure and an NT-proBNP level above 2,000 ng/litre should be referred urgently to have a specialist assessment and transthoracic echocardiography within 2 weeks

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3
Q

Which factors can reduce levels of serum natriuretic peptides

A

Obesity
African or African-Caribbean family origin
Diuretics
ACE inhibitors, beta blockers and ARBs

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4
Q

Causes of raised serum natriuretic peptides besides heart failure

A 
Age over 70 years 
Left ventricular hypertrophy 
Ischaemia
Tachycardia 
Right ventricular overload 
Hypoxaemia(from PE) 
Renal dysfunction
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5
Q

1st line treatment for heart failure with reduced ejection fraction

A

ACE inhibitor + beta blocker

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6
Q

When should ACE inhibitors not be offered in suspected heart failure

A

If there is also clinical suspicion of a haemodynamically significant valve disease until it has been assessed by a specialist

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7
Q

Which parameters should be measured and monitored in ACE inhibitor therapy

A

Serum sodium and potassium
Renal function and blood pressure
Before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increment

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8
Q

Alternative to ACE inhibitors in treatment of heart failure with reduced ejection fraction

A

ARB

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9
Q

Alternative to ACE inhibitors and ARBs in treatment of heart failure with reduced ejection fraction

A

Consider hydralazine in combination with nitrate for people who have heart failure with reduced ejection fraction

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10
Q

Which medication can be added to patients who continue to have heart failure with reduced ejection fraction already on ACE inhibitors(or ARB) and a beta-blocker

A

Mineralocorticoid receptor antagonists

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11
Q

When is ivabradine recommended in management of chronic heart failure

A

NYHA class II to IV stable chronic heart failure with systolic dysfunction

Sinus rhythm with a HR of 75bpm or more

Combination with standard therapy

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12
Q

When is sacubitril valsartan recommended in management of chronic heart failure

A

NYHA class II to IV symptoms

Left ventricular ejection fraction of 35% or less

Patients are already taking a stable dose of angiotensin-converting enzyme(ACE) inhibitors or ARBs

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13
Q

When is digoxin recommended in management of chronic heart failure

A

Recommended for worsening or severe heart failure with reduced ejection fraction despite first-line treatment for heart failure

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14
Q

Why should response to medicines be closely monitored in patients with CKD and heart failure with reduced ejection fraction

A

Increased risk of hyperkalaemia

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15
Q

Management of heart failure with a preserved ejection fraction

A

Loop diuretics
Ca2+ blockers
Amiodarone

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16
Q

Which parameters should be tested in people taking amiodarone

A

Liver and thyroid function tests

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17
Q

Advice regarding vaccinations in people with heart failure

A

Offer annual vaccination against influenza

Vaccination against pneumococcal disease

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18
Q

Advice regarding salt and fluid restriction in people with heart failure

A

No need to routinely advise people to restrict sodium or fluid consumption

Restrict fluids for people with dilutional hyponatraemia

Reduce intake for people with high levels of salt and/or fluid consumption

Advise to avoid salt substitutes that contain potassium

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19
Q

Interventional procedures for heart failure

A

Coronary revascularisation(not routinely offered for people with reduced ejection fraction)

Cardiac transplantation(only if severe refractory symptoms or refractory cardiogenic shock)

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20
Q

Non-pharmacological interventions in management of heart failure

A

Implantable cardioverter defib and cardiac resychronisation therapy

Cardiac rehabilitation

Palliative care

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21
Q

Types of heart failure

A

Systolic/diastolic
Right-sided/Left-sided
High-output

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22
Q

What does systolic heart failure refer to

A

Inability of the myocardium to generate a sufficient cardiac output due to left ventricle not being able to contract completely

AKA heart failure with reduced ejection fraction

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23
Q

Formula for cardiac output

A

CO = Heart rate x Stroke volume

24
Q

What is stroke volume dependent on

A

Preload
Contractility
Afterload(inverse)

25
Q

Definition of preload

A

Initial stretching of the cardiac myocytes prior to contraction

26
Q

Definition of afterload

A

Pressure against which the heart must work to eject blood during systole(systolic pressure)

The lower the afterload, the more blood the heart will eject with each contraction

27
Q

Conditions which affect contractility which leads to systolic HF

A 
Myocardial infarction(Anterior/Lat esp) 
Dilated cardiomyopathy
28
Q

Conditions which cause an increased preload with a background of reduced contractility leading to systolic HF

A

Mitral regurgitation

Aortic regurgitation

29
Q

Definition of diastolic heart failure

A

Preserved left ventricular function characterised by a stiff left ventricle with decreased compliance and impaired relaxation which leads to increased end diastolic pressure

30
Q

Conditions which reduce preload causing diastolic heart failure

A

MI
Restrictive cardiomyopathy(amyloidosis)
Constrictive pericarditis

31
Q

Conditions which increase afterload causing diastolic heart failure

A

Hypertension
Aortic stenosis
Coarctation of aorta
Hypertrophic obstructive cardiomyopathy

32
Q

Causes of increased afterload leading to right sided heart failure

A

Pulmonic stenosis
Pulmonary hypertension
Pulmonary embolism
Cor pulmonale secondary to COPD/underlying lung disease

33
Q

Causes of increased preload with a background of reduced contractility leading to right sided heart failure

A

Pulmonary regurgitation

Tricuspid regurgitation

34
Q

Causes of reduced contractility leading to right sided heart failure

A 
Inferior MI (II, III, aVF) 
Myocarditis
35
Q

Most common cause of right sided heart failure

A

Left sided heart failure

36
Q

What is high output cardiac failure

A

When there is normal cardiac function but it is still insufficient to supply the demand of the body

37
Q

Causes of high output heart failure

A

Severe anaemia
Thiamine deficiency(wet beri beri)
Thyrotoxicosis

38
Q

Which population is prone to thiamine deficiency

A

Chronic alcoholics

39
Q

How does thiamine deficiency lead to high output cardiac failure

A

Inhibition of pyruvate dehydrogenase leading to accumulation of pyruvate which causes a build up of lactic acid

Lactic acid causes vasodilation of arterioles which leads to AV shunting

40
Q

What is paroxysmal nocturnal dyspnoea

A

Experience of suddenly waking at night with a severe attack of SOB and cough

Symptoms improve after a few mins

41
Q

What causes PND

A

Fluid settles across a large surface area of lungs during sleep which sinks to lung bases and upper lungs become clear on standing up

Respiratory centre becomes less responsive during sleep so effort does not increase in response to reduced o2 sats –> pulmonary congestion and hypoxia

Less adrenaline circulating during sleep meaning that myocardium is more relaxed and reduces cardiac output

42
Q

First line medical treatment of chronic heart failure (ABAL)

A 
ACE inhibitor(ramipril) 
Beta blocker(bisoprolol) 
Aldosterone antagonist(spironolactone) 
Loop diuretics(furosemide)
43
Q

In which patients should ACE inhibitors be avoided

A

Patients with valvular heart disease

44
Q

When are aldosterone antagonists used in heart failure

A

When there is reduced ejection fraction and symptoms are not controlled with an ACEi and beta blocker

45
Q

What is cor pulmonale

A

Right sided heart failure caused by respiratory disease

Increased pressure and resistance in pulmonary arteries results in right ventricle being unable to effectively pump blood out of the ventricle and into the pulmonary arteries

46
Q

Respiratory causes of cor pulmonale

A 
COPD(most common) 
PE 
Interstitial lung disease 
Cystic fibrosis 
Pulmonary pulmonary hypertension
47
Q

Presentation of cor pulmonale

A 
Hypoxia 
Cyanosis 
Raised JVP 
Peripheral oedema 
Third heart sound 
Murmurs 
Hepatomegaly due to back pressure in hepatic vein
48
Q

Second-line treatment for heart failure

A

Aldosterone antagonist such as spironolactone and eplerenone

should be remembered that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored

49
Q

When is ivabradine recommended in heart failure management

A

sinus rhythm > 75/min and a left ventricular fraction < 35%

50
Q

When is digoxin indicated in heart failure management

A

digoxin has also not been proven to reduce mortality in patients with heart failure.

It may however improve symptoms due to its inotropic properties
it is strongly indicated if there is coexistent atrial fibrillation

51
Q

In which group of patients may hydralazine in combination with nitrate be particularly effective

A

Afro-caribbean patients

52
Q

Indications for cardiac resynch therapy

A

indications include a widened QRS (e.g. left bundle branch block) complex on ECG

53
Q

Most common precipitating causes of acute heart failure

A

Acute coronary syndrome
Hypertensive crisis
Acute arrhythmia
Valvular disease

54
Q

Causes of de-novo acute heart failure

A

De-novo heart failure is caused by and increased cardiac filling pressures and myocardial dysfunction usually as a result of ischaemia. This causes reduced cardiac output and therefore hypoperfusion. This, in turn can cause pulmonary oedema.

Other less common causes of de-novo AHF are:
Viral myopathy
Toxins
Valve dysfunction

55
Q

Factors which decrease BNP

A

Obesity
Diuretics
ACE inhibitors
Beta-blockers

General med - Cardiovascular (13 decks)

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