Heart Failure Flashcards
What is heart failure?
HF is a clinical syndrome with current or prior symptoms and signs caused by a structural and/or functional cardiac abnormality and corroborated by at least on of the following:
- Elevated natriuretic peptide levels
- Objective evidence of cardiogenic pulmonary or systemic congestion by diagnostic modalities such as imaging or hemodynamic measurement at rest or with provocation
Heart failure with reduced EF (HFrEF)
- Ejection fraction
- Features
- Causes
EF <40% (systolic HF: inability of ventricle to contract normally)
Causes:
- Ischemic heart disease, AMI
- Cardiomyopathy
- Mitral regurgitation
Features:
- LV dilatation
- Globular shape
- Systolic LV dysfunction
Heart failure with preserved EF (HFpEF)
- Ejection fraction
- Features
- Causes
EF > 50% (diastolic HF: inability of ventricle to relax normally)
Features
- Normal cavity size
- Concentric hypertrophy
- Diastolic dysfunction
- Enlarged left atrium
Causes
- Constrictive pericarditis
- Cardiac tamponade
- Restrictive cardiomyopathy
- Hypertension
Heart failure with preserved EF (borderline)
- Ejection fraction
EF 41-49% aka. heart failure with mid-range EF (HFmrEF)
What is the Framingham diagnostic criteria for heart failure?
2 major criteria OR one major + 2 minor criteria
Major criteria
- Acute pulmonary edema
- Cardiomegaly
- Hepatojugular reflex
- Neck vein distension
- Paroxysmal nocturnal dyspnea or orthopnea
- Rales
- 3rd heart sound gallop
Minor criteria
- ankle oedema
- dypsnea on exertion
- hepatomegaly
- nocturnal cough
- pleural effusion
- tachycardia (>120 bpm)
What is the NYHA classification of heart failure? How does it affect treatment?
- Class I: no limitation
- Class II: slight limitation (comfortable at rest, ordinary activity results in fatigue, dyspnea, angina)
- Class III: marked limitation (comfortable at rest, less than ordinary activity lead to symptoms)
- Class IV: Inability to carry out any physical activity without discomfort, symptoms at rest.
NYHA class I/II: Focus on Prevention
- Prevent harmful ventricular remodeling
- Forestall development of symptoms
NYHA class III/IV: Focus on Treatment
- Ameliorate symptoms if present
- Reduce mortality
What is the ACC/AHA classification of heart failure?
A: High risk of developing heart failure
- HTN, CAD, DM, FHx cardiomyopathy
B: Asymptomatic heart failure
- Previous AMI, LV systolic dysfunction, asymptomatic valvular dz
C: Symptomatic heart failure (NYHA II- III)
- Known structural heart disease, SOB and fatigue, reduced exercise tolerance
D: Refractory end-stage heart failure
- Marked symptoms at rest despite appropriate medical therapy
What are the signs suggestive of heart failure?
More specific
- Elevated JVP
- Hepatojugular reflux
- 3rd heart sound
- Laterally displaced apex
Less specific
- Edema (ankle, sacral, scrotal)
- Pulmonary crepitations
- Reduced breath sounds
- Tachycardia
- Irregular pulse
- Tachypnoea (>16/min)
- Hepatomegaly
- Ascites
- Cachexia
What are the causes of right heart failure?
Typically, due to pul. pathology 🡪 HPV 🡪 ↑ Pulmonary Resistance 🡪 Cor Pulmonale
What are the investigations conducted for heart failure?
- Blood tests
- FBC, Renal Panel, LFTs, TFTs 🡪 to assess organ impairment
- BNP >100ng/L (negative predictive marker)
- Trops to elucidate ppt cause
- Iron study (ferritin + fe saturation –> associated with morbidity and mortality) - Chest X-ray (ABCDE)
- Alveolar oedema (Bat wings)
- Kerley B lines
- Cardiomegaly
- Dilated prominent upper lobe vessels
- Pleural Effusion – Effusion from HF does NOT require drainage! - ECG
- LV hypertrophy
- Arrhythmias (AF, SVT)
- Q waves → etiology of the heart failure (past MIs) - Echocardiography (mandatory for confirming diagnosis!)
- Look for cause: Valvular pathology, ASD/VSD, IHD, HCM
- Confirm the presence of LV dysfunction and assess severity - Right heart catheter (gold standard)
- Lung US: to scan lung fields (particularly at the lung bases)
- US: to look at IVC (> 2.1 cm → dilated IVC), surrogate for volume status
What are the common causes of heart failure?
- IHD***
- Hypertension
- Valvular heart disease
- Idiopathic dilated cardiomyopathy
- Alcohol
- HIV (ischemia via accelerated atherosclerosis or viral induced cardiomyopathy)
What are the causes of acute decompensation in heart failure patients?
- Non-compliance with drugs or diet***
- Cardiac ischemia
- Inadequate pre-treatment
- Arrhythmia: atrial fibrillation
- Miscellaneous factors: drugs (NSAIDs, verapamil, diltiazem, beta blockers), thyroid, PE, concurrent infections, pneumonia, influenza
- Uncontrolled HTN
- No definite factor
What are the goals of treatment of heart failure?
1) Identify and correct underlying condition causing heart failure
2) Elimination of the precipitating cause
3) Management of heart failure symptoms
- Treatment of pulmonary and systemic vascular congestion by sodium restriction and diuretics.
- Measures to increase forward cardiac output and perfusion of vital organs through the use of vasodilators and positive inotropic drugs
4) Modulation of the neurohormonal response to prevent adverse ventricular remodelling in order to slow the progression of LV dysfunction
5) Prolongation of long term survival
What is the acute management of heart failure?
- Close monitoring
- Maintain O2
• Stabilize haemodynamics:
- Effusion from HF does NOT require drainage!
1) Inotropes as needed
- First line: Dobutamine (Beta-1 Adrenergic Receptor Agonist –> Increase SV, stroke work and thus CO
- Noradrenaline (Alpha-1 Agonist, weaker Beta-1 agonist): vasoconstrictor, used in the hypotensive patients
2) Nitrates (IV GTN)
- IV GTN (0 - 300 mcg/kg/min): first line when patients are very breathless, onset 15 minutes
3) ACE-Inhibitor / ARB
• IV Captopril, Enalapril, Lisinopril
• Potent vasodilator
• Counters the neurohormonal response in HF patients
• Used in stabilised pts (oral therapy
• Beware if renal function is impaired or potassium levels elevated
4) Diuretics
• First line: IV Frusemide (loop diuretic)
• Second line: Hydrochlorothiazide (works at DCT)
Invasive measures
• Intra-aortic balloon pump (IABP)
• Extracorporeal membrane oxygenation (ECMO)
Call senior!
B-CONVINCED trial: b-blockers should not be initiated during ADHF episodes if the patient has never been on this but safe to continue on this if patient has been chronically on beta-blockers
What is the non pharmacological management of chronic heart failure?
Patient education
- Symptoms: Look out for oedema, weight gain (>2kg in 3 days), orthopnoea, coughing when lying down
- Side effects of medications: Importance of drug titration
- Carer education
- Salt restriction (2 to 3g /day) 🡪 actually more important than fluid restriction!
- Fluid restriction (1.5 to 2L/day)
- Smoking cessation and restriction/abstinence from alcohol
- Exercise training and weight loss
- Immunisation against pneumococcus and influenza
- Screening for psychological issues
- Screening for sleep disorders incl. OSA → needs to be treated to prevent readmission
What is the pharmacological management for chronic heart failure patients with reduced ejection fraction?
[Mortality benefit]
1) ACE-I
• Commonly used : Enalapril, Lisinopril, Captopril
• Contraindicated in pts with CKD / ARF; Bilateral RAS; HyperK
• Reduces Fibrosis and -ve remodeling
2) B-blockers (CMB):
• Carvedilol, metoprolol, bisoprolol
• Initiate AFTER starting Diuretics & ACE-I; when pt is no longer in cardiogenic shock
• C/I: ABCD – COPD, Asthma, Heart Block / Bradydysrhythmias, Decompensated HF
3) Aldosterone antagonist:
• Spironolactone, eplerenone
4) ARNI: Valsartan + Sacubitril
5) SGLT2-i
[Morbidity reducing]
1) Hydralazine/isosorbide dinitrate: if creatinine does not allow use for ACE-I or ARB
2) Ivabradine used when EF reduced AND patient in sinus rhythm AND max dose of b-blockers AND HR >70
3) Digoxin used when patient is very symptomatic, fast AF
4) IV iron replacement
