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CCC > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What is heart failure?

A

Heart failure = ability to maintain circulation of blood is impaired as a result of structural or functional impairment of ventricular filling or ejection. Heart unable to pump enough blood to meet metabolic needs

2 types:

=> HF with reduced ejection fraction

=> HF with preserved ejection fraction

  • Ejection fraction = % of blood leaving the heart with each contraction - measured using ECHO
  • left and right heart failure / congestive heart failure is out-dated
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2
Q

INFO:

Reduced ejection fraction <35-40%

HF-rEF patients typically have systolic dysfunction (impaired myocardial contraction during systole), whereas HF-pEF patients have diastolic dysfunction (impaired ventricular filling during diastole).

A

INFO:

Systolic dysfunction:
=> Ischaemic heart disease
=> Dilated cardiomyopathy
=> Myocarditis
=> Arrhythmias
Diastolic dysfunction:
=> Hypertrophic obstructive cardiomyopathy
=> Restrictive cardiomyopathy
=> Cardiac tamponade
=> Constrictive pericarditis
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3
Q 
Left ventricular failure typically results in:
=> Pulmonary oedema
- dyspnoea
- orthopnoea
- paroxysmal nocturnal
- dyspnoea
- bibasal fine crackles
A 
Right ventricular failure typically results in:
=> peripheral oedema
- ankle/sacral oedema
=> raised jugular venous pressure
=> hepatomegaly
=> weight gain due to fluid retention
=> anorexia ('cardiac cachexia')
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3
Q

What are the causes of heart failure?

A 
1. Myocardial disease:
=> Coronary artery disease (most common).
=> Hypertension.
=> Cardiomyopathies:
=> Familial.
=> Infective.
=> Auto-immune.
=> Toxins e.g. alcohol or cocaine
=> Pregnancy.
=> Infiltrative (for example sarcoidosis, amyloidosis, haemochromatosis, connective tissue disease)
  1. Valvular heart disease (for example aortic stenosis).
  2. Pericardial disease
    => Constrictive pericarditis.
    => Pericardial effusion.
  3. Congenital heart disease
  4. Arrhythmias (e.g. atrial fibrillation / other tachyarrythmias).
6. High output states:
=> Anaemia.
=> Thyrotoxicosis.
=> Phaeochromocytoma.
=> Septicaemia.
=> Liver failure.
=> Arteriovenous shunts.
=> Paget's disease.
=> Thiamine (vitamin B1) deficiency.
  1. Volume overload
    => End-stage chronic kidney disease.
    => Nephrotic syndrome.
  2. Obesity
  3. Drugs including:
    => Alcohol.
    => Cocaine.
    => NSAIDS, beta-blockers, and calcium-channel blockers (may worsen pre-existing heart failure).
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4
Q

When to suspect heart failure:

What are the typical symptoms of chronic HF?

A

Breathlessness — on exertion, at rest, on lying flat (orthopnoea) or waking from sleep (paroxysmal nocturnal dyspnoea).

Cough - may be worse at night and assoc. with pink/frothy sputum

Cardiac wheeze

Bibasal crackles

Right-sided heart failure: Fluid retention

  • ankle oedema
  • raised JVP
  • hepatomegaly
  • ascites / bloating sensation

Cardiac cachexia *may be hidden by weight gained secondary to oedema

Weight loss (cardiac cachexia) - occurs in 15% of patients but may be hidden under weight gained secondary to oedema

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5
Q

When to suspect heart failure:

What are the risk factors?

A

Coronary artery disease including previous history of myocardial infarction, hypertension, atrial fibrillation, and diabetes mellitus.

Drugs, including alcohol

Family history of heart failure or sudden cardiac death under the age of 40 years.

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6
Q

When to suspect heart failure:

What do you examine for when suspecting HF?

A

Tachycardia (heart rate > 100 bpm) and pulse rhythm.

Laterally displaced apex beat, heart murmurs, and third or fourth heart sounds (gallop rhythm).

Hypertension.

Raised jugular venous pressure.

Enlarged liver (due to engorgement).

Respiratory signs

  • tachypnoea,
  • basal crepitations,
  • pleural effusions

Dependent oedema (legs, sacrum), ascites.

Obesity.

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7
Q

When to suspect heart failure:

How do you diagnose chronic HF?

A

BNP blood test as first line for all patients with suspected HF

If BNP levels are high => arrange specialist assessment including trans thoracic echo within 2 weeks

If BNP levels are raised => arrange specialist assessment including trans thoracic echo within 6 weeks

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8
Q

What is BNP?

A

B-type natriuretic peptide (BNP) = hormone produced by left ventricular myocardium in response to strain.

Effects of BNP = vasodilation, diuretic and natriuretic, suppresses both sympathetic tone and RAAS system

High levels = poor prognosis

  1. High levels:
    => BNP >400pg/ml
    => NTproBNP >2000pg/ml
  2. Raised levels:
    => BNP 100-400 pg/ml
    => NTproBNP 400-2000pg/ml
  3. Normal levels:
    => BNP <100pg/ml
    => NTproBNP <400 pg/ml

*low conc. of BNP <100 makes HF very unlikely but raised levels prompts further investigation to confirm diagnosis.
NICE recommends BNP as a helpful test to rule out HF diagnosis

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9
Q

Which factors increase and decrease BNP levels?

A 
Increase BNP levels:
=> Left ventricular hypertrophy
=> Ischaemia 
=> Tachycardia
=> Right ventricular overload
=> Hypoxaemia (inc. pulmonary embolism)
=> GFR <60 ml/min (chronic kidney disease)
Decrease BNP levels:
=> Obesity
=> Diuretics
=> ACE inhibitors 
=> Beta-blockers
=> ARB
=> Aldosterone antagonists

*effective treatment lowers BNP levels therefore BNP levels used in guiding treatment

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10
Q

When to suspect Heart Failure:

What is the New York Heart Association (NYHA) classification for the severity of heart failure?

A

NYHA Class I
=> No symptoms
=> No limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations

NYHA Class II
=> Mild symptoms
=> Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea

NYHA Class III
=> Moderate symptoms
=> Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms

NYHA Class IV
=> Severe symptoms
=> Unable to carry out any physical activity without discomfort: symptoms of HF at rest and increased discomfort with physical activity

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11
Q

When to suspect Heart Failure:

What is the management for chronic heart failure?
First, second and third line and vaccinations

A

First line: ACE-i and Beta-Blocker
=> one drug should be started at a time - clinical judgement on which to start
=> Beta-Blocker licensed to treat HF inc. bisoprolol, carvedilol, nebivolol
*ACE-i and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction

Second line: Aldosterone antagonist (mineralocorticoid receptor antagonist)
=> e.g. spironolactone and eplerenone
*both ACE-i and aldosterone antagonist cause hyperkalaemia => MONITOR POTASSIUM!!

Third line: should be initiated by a specialist
=> Ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

  1. Ivabradine:
    Criteria: sinus rhythm >75/min and a left ventricular fraction <35%
  2. Sacubitril-valsartan
    Criteria: left ventricular fraction <35%
    => Considered in HF with reduced ejection fraction who are symptomatic on ACE-i and ARBs
    => Should be initiated following ACE-i or ARB wash-out period
  3. Digoxin
    => not proven to reduce mortality in patients with HF but may improve symptoms due to its inotropic effects
    => strongly indicated if AF co-existent
  4. Hydralazine in combination with nitrate esp. in Afro-carribbean patients
  5. Cardiac resynchronisation therapy if widened QRS (e.g. left bundle branch block) complex on ECG

Vaccinations:

  1. Annual influenza vaccine
  2. Offer one-off pneumococcal vaccine (booster every 5 years for CKD, splenic dysfunction)
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12
Q

Chronic Heart Failure management continued:

A
  1. HF with reduced ejection fraction
    a) Prescribe loop diuretics for fluid overload symptoms relief

b) ACEi and Beta blocker
=>ACEi if patient has diabetes or signs of fluid overload
=> Beta blocker if patient has angina
*aim of treatment is to improve symptoms, prevent worsening of symptoms and increase survival => symptoms should improve within a few months

  1. HF with preserved ejection fraction

a) Prescribe loop diuretic - 80mg furosemide to relieve symptoms of fluid overload
b) Refer to specialist

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13
Q

Heart failure: Self-management plans

A
  1. Advice to report worsening symptoms of HF inc. breathlessness, fatigue, ankle or abdominal swelling and rapid weight gain
  2. Monitor weight to detect fluid retention either daily, weekly or fortnightly
    - weigh at same time of day i.e. after waking and voiding
    - report any changes
  3. Avoid excessive salt intake - should not exceed 6g
    - don’t substitute salt with products high in potassium as it can cause hyperkalaemia due to ACE-i
  4. Severe symptomatic HF - restrict fluid intake to 1.5-2L/day to relieve symptoms
  5. Smoking cessation
  6. Restrict alcohol consumption / maintain limit
  7. Regular low intensity physical exercise activity recommenced for stable HF => refer to supervised exercise based rehab programme
  8. Stable HF can resume normal sexual activity that doesn’t provoke underlying symptoms
  9. Driving:
    => Cars/motorcyles - can continue driving if asymptomatic. Don’t need to notify DVLA
    => Lorries/buses - can’t drive if symptomatic. Relicensing allowed if left ventricular ejection fraction is 40%
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14
Q

What to do if acutely unwell (diarrhoea and vomiting) and has HF?

A

People with stable heart failure taking an ACE-inhibitor, an angiotensin II receptor antagonist (AIIRA), a diuretic, or an aldosterone antagonist should maintain their fluid intake and stop treatment with these drugs until they recover and are eating and drinking normally.

=> risks of AKI if acutely unwell and dehydrated

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15
Q

When to refer a person with HF to specialists?

A

=> Severe heart failure (NYHA class IV).
=> Heart failure that does not respond to treatment in primary care or can no longer be managed in the home setting.
=> Heart failure resulting from valvular heart disease.
=> Left ventricular ejection fraction of 35% or less.

Consider referral for a person with heart failure and a comorbidity such as chronic kidney disease or chronic obstructive pulmonary disease

16
Q

Follow up for Heart Failure:

  1. Follow up interval within 2 weeks if patient’s clinical condition or drugs have changed
  2. Every 6 months if person’s condition is stable.
    => Monitor serum urea, electrolytes and eGFR every 6 months
  3. Monitor NTproBNP levels in people <75 years of age to guide optimum drug treatment
A
  1. Assess person’s functional capacity - ability to perform everyday activity using NYHA classification
  2. Provide self-management plan
  3. Assess fluid status by checking for:
    => Changes in body weight
    => Oedema (abdomen, sacrum, genitalia and ankles)
    => Raised JVP
    => Fine lung crepitations
    => Hepatomegaly
    => Postural drop in BP of >20mmHg suggests hypovolaemia

ii) Assess nutritional status
7. Review medications
8. Ensure patient offered supervised group exercise based heart failure rehabilitation programme.
9. Ensure immunisations up to date

17
Q

ACE-i adverse effects:

  1. Hypotension - can cause dizziness, light headedness and confusion
    => if hypotension is symptomatic but there is no signs of fluid overload then consider reducing dose
  2. Deterioration in renal function
    => monitor renal function after starting ACE-i, after each dose increase and every 3-6 months
    => refer to specialist if renal function significantly reduced
  3. Hyperkalaemia
    => monitor serum electrolytes after starting, after each dose increase and every 3-6 months
  4. Dry cough
    => if cough is intolerable, consider switching to AIIRA
A
  1. Angio-oedema
    => higher in afro-caribbean
  2. Rash
  3. GI symptoms inc. N&V, dyspepsia, diarrhoea, constipation and abdominal pain
18
Q

Beta-blocker adverse effects:

  1. Deteriorating symptoms of HF i.e. fluid overload, fatigue
  2. Hypotension
  3. Bradycardia
A
  1. Dizziness, headache, syncope
  2. N&V, diarrhoea and constipation
  3. Sexual dysfunction inc. loss of libido / erectile dysfunction
19
Q

Diuretics adverse effects:

  1. Mild gastrointestinal disturbances, pancreatitis, and hepatic encephalopathy.
  2. Hyperglycaemia.
  3. Acute urinary retention.
  4. Water and electrolyte imbalance — including hyponatraemia, hypochloraemia, hypokalaemia, hypomagnesaemia, and hypocalcaemia.

=> Symptoms of electrolyte imbalance depend on the type of disturbance and include:
i) Sodium deficiency — confusion, muscle cramps, muscle weakness, loss of appetite, dizziness, drowsiness, and vomiting.

ii) Potassium deficiency — neuromuscular symptoms (muscular weakness and paralysis), intestinal symptoms (including vomiting and constipation), renal symptoms (polyuria), and cardiac symptoms (including palpitations). Severe potassium depletion can result in paralytic ileus, confusion, and coma.
iii) Magnesium and calcium deficiency — tetany and heart rhythm disturbances (very rare).

A
  1. Hypotension, hypovolaemia, dehydration

6. Metabolic alkalosis with increased doses

20
Q

AIIRAs adverse effects:

  1. Hypotension
  2. Deterioration in renal function
  3. Hyperkalaemia
A

.

CCC (11 decks)

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