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Finals: Medicine > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

Define the term “heart failure”

A

Clinical syndrome resulting in signs and symptoms because of an abnormality of the cardiac structure and/or function

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2
Q

Define the term “acute heart failure”

A

Acute heart failure refers to the sudden onset or worsening of the symptoms of heart failure

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3
Q

Acute heart failure may present with or without a background history of pre-existing heart failure.

What is the name given to acute heart failure without a bakcground of heart failure

A

de-novo acute heart failure

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4
Q

Acute heart failure may present with or without a background history of pre-existing heart failure.

What is the name given to acute heart failure with a background of heart failure

A

Decompensated acute heart failure

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5
Q

What are the two types of heart failure based on ejection fraction

A

Heart failure with reduced ejection fraction (HF-rEF)

Heart failure with preserved ejection fraction (HR-pEF)

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6
Q

Which type of heart failure typically has systolic dysfunction

a) Heart failure with reduced ejection fraction (HF-rEF)
b) Heart failure with preserved ejection fraction (HF-pEF)

A

a) Heart failure with reduced ejection fraction (HF-rEF)

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7
Q

Which type of heart failure typically has dystolic dysfunction

a) Heart failure with reduced ejection fraction (HF-rEF)
b) Heart failure with preserved ejection fraction (HF-pEF)

A

b) Heart failure with preserved ejection fraction (HF-pEF)

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8
Q

At what level is left ventricular ejection fraction refers to as reduced

A

< 35 %

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9
Q

What is the normal range of left ventricular ejection fraction

A

50-70%

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10
Q

Name a classification tool used in classifying heart failure based on the severity of symptoms

A

New York Heart Association Functional classification

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11
Q

What does “Left ventricular ejection fraction (LVEF)” refer to?

A

LVEF refers to how much blood is ejected from the left ventricle with each contraction

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12
Q

Left ventricular ejection fraction (LVEF) is measured by?

A

Measured using echocardiograph (ECHO)

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13
Q

What are the various grades of the New York Heart Association Functional classification

A

Graded from class 1 to 4, with class 1 being the least symptomatic and class 4 being the most symptomatic

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14
Q

Name some of the risk factors associated with heart failure

A
  • Previous cardiovascular disease e.g., coronary heart disease
  • Older age
  • History of Diabetes
  • Family history of ischaemic heart disease or cardiomyopathy
  • Excessive alcohol intake or smoking
  • Cardiac arrhythmias
  • History of systemic conditions associated with heart failure e.g., sarcoidosis and haemochromatosis
  • Previous chemotherapy
  • Drugs that may exacerbate heart failure include NSAIDs, steroids, calcium channel blockers e.g., diltiazem and verapamil
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15
Q

Name some of the causes of heart failure with reduced ejection fraction (HF-rEF)

A

Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
Arrhythmias

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16
Q

Name some of the causes of heart failure with perserved ejection fraction (HF-pEF)

A

Hypertrophic obstructive cardiomyopathy
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis

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17
Q

Define Stroke volume

A

The amount of blood pumped out of the heart from each contraction.

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18
Q

Define Heart rate

A

The number of times the heart beats each minute

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19
Q

Define cardiac output

A

The amount of blood pumped out of the heart in one minute

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20
Q

What is the equation for cardiac output

A

CO = HR x SV

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21
Q

What is the equation for stroke volume

A

SV = End diastolic volume - End systolic volume

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22
Q

Define End-diastolic volume (EDV)

A

The amount of blood in the ventricles at the end of the loading phase/diastole, just before it is about to contract

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23
Q

Define end-systolic volume (ESV)

A

The amount of blood remaining in the ventricle at the end of systole

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24
Q

Define preload

A

Refers to how much the ventricular cardiomyocytes are stretched as a result of the pressure end-diastolic volume puts on them

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25
Q

Define afterload

A

Pressure or load against which the ventricles must contract

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26
Q

Define inotropy

A

Refers to myocardial contractility i.e. the force of muscular contractions

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27
Q

Define pulse pressure

A

Difference between systolic and diastolic blood pressure

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28
Q

Define mean arterial pressure

A

The average arterial pressure throughout one cardiac cycle.

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29
Q

What is the equation for mean arterial pressure

A

MAP = Diastolic BP + 1/3 Systolic BP

30
Q

What happens in the heart during systole

A

When the ventricles depolarise/contract

31
Q

What happens in the heart during diastole

A

The heart is repolarise/relaxation

32
Q

Define Frank-Starling Law?

A

An increase end-diastolic volume causes an increase in preload. The increase in stetch of the cardiomyocytes of the left ventricle will increase the systolic force (stroke volume) causing an increase in cardiac output

↑ EDV ⇒ ↑ Preload ⇒ ↑ Stroke Volume ⇒ ↑ Cardiac Output

33
Q

Describe the pathophysiology of heart failure

A
  • As the heart fails the ventricular ejection fraction decreases i.e. the amount of blood that is ejected from the ventricles with each contraction
  • This leads to an increase in end systolic volume (ESV) which in turn causes an increase in end-diastolic volume (EDV)
  • A healthy heart would be able to compensate with this increase (as stated by Frank-Starling law)
  • A failing heart however cannot compensate via the Frank-Starling law, as the heart is unable to increase its preload. Thus, there is a reduction in stroke volume and cardiac output.
34
Q

What are some of the symptoms of heart failure

A
  • Breathlessness – worsened by exertion
  • Fatigue – reduced exercise tolerance
  • Cough – frothy white/pink sputum
  • Peripheral oedema
  • Reduced exercise tolerance
  • Orthopnoea – shortness of breathing when lying flat
35
Q

Name some of the signs of heart failure

A
  • Raised jugular venous pressure (JVP)
  • Displaced apex beat
  • Gallop rhythm (third heart sound)
36
Q

What are the 4 components of the diagnostic workup of a patient with heart failure

A
  • Clinical presentation
  • B-type natriuretic peptide (BNP) blood test
  • Echocardiogram (ECHO) – diagnostic test
  • ECG
37
Q

What is B-type natriuretic peptide (BNP)

A

B-type natriuretic peptide (BNP)

It is a protein which is released from the ventricles in response to myocardial stretch

38
Q

B-type natriuretic peptide (BNP) is sensitive test but not specific for heart failure.

What does this mean?

A

Sensitive - if its negative it cannot be heart failure

Specific - if its positive, heart failure is a possibility however it is raised by other conditions as well

39
Q

What is the normal level of B-type natriuretic peptide (BNP)

A

<400ng/mL

40
Q

What is the raised level of B-type natriuretic peptide (BNP)

A

>400ng/mL

41
Q

What is the name of the other natriuretic peptide that could be used in heart failure instead of B-type natriuretic peptide (BNP)

A

N-terminal pro-B-type natriuretic peptide (NT proBNP)

42
Q

What other conditions cause a rise in B-type natriuretic peptide (BNP)

A

Diabetes, sepsis, old age, hypoxaemia such as PE and COPD, kidney disease and liver cirrhosis

43
Q

What is the main investigation for the confirmation diagnosis of heart failure

A

Echocardiogram (ECHO)

44
Q

What features of the ECHO are you checking in heart failure

A

Ventricular dysfunction is normally measured by the ejection fraction

<40% = heart failure with reduced ejection fraction (HF-rEF)

> 40% but raised BNP = Heart failure with preserved ejection fraction (HF-pEF)

45
Q

Ventricular dysfunction <40% is diagnostic for what type of heart failure

A

Heart failure with reduced ejection fraction (HF-rEF)

46
Q

Ventricular dysfunction >40% (with a positive BNP) is diagnostic for what type of heart failure

A

Heart failure with preserved ejection fraction (HF-pEF)

47
Q

What ECG features may be present in heart failure

A

May reveal underlying causes of the heart failure e.g. ischaemic changes or arrhythmias

48
Q

Name the 5 radiological features of heart failure on chest x-ray

A
  • Alveolar oedema (indicated by “Cotton wool” appearance, perihilar consolidation, bat wing configuration)
  • Kerley B lines (caused by interstitial oedema)
  • Cardiomegaly (cardiothoracic ratio >0.5)
  • Upper lobe venous diversion
  • Pleural effusions (seen as blunting of the costophrenic angle, often bilaterally)
49
Q

Bedside treat to investigate heart failure

A
  • Observations
  • Blood pressure
  • Urinalysis – signs of renal failure
  • Blood glucose – for underlying diabetes that may be contributing
50
Q

Blood tests to investigate heart failure

A
  • Full blood count (FBC) - exclude anaemia, infective cause.
  • Urea and electrolytes (U&Es) - exclude renal failure as a cause of oedema.
  • Thyroid function tests (TFTs) - exclude thyroid disease, a non-cardiac cause of HF
  • Cholesterol- cardiovascular risk stratification.
  • Liver function tests (LFTs) -exclude liver failure as a cause of oedema.
51
Q

The management of heart failure is split into 3 categories

A

Lifestyle changes

Pharmaceutical intervention

Surgical options

52
Q

What type of heart failure is lifestyle changes an important aspect of the management

A

Heart failure with reduced ejection fraction (HF-rEF)

AND

Heart failure with preserved ejection fraction (HR-pEF)

53
Q

What type of heart failure is pharmaceutical intervention an important aspect of the management

A

Heart failure with reduced ejection fraction (HF-rEF)

54
Q

Name some of the lifestyle modification that can aid in the management of heart failure

A
  • Smoking cessation
  • Salt and fluid restriction (improves mortality)
  • Supervised cardiac rehabilitation
55
Q

What is the 1st line pharmaceutical intervention for heart failure

A

ACE inhibitors and beta blockers

56
Q

If patient is on ACEi and beta block but their symptoms of heart failure persistent what is the next line therapy?

A

ACEi + Beta blocker + Mineralocorticoid receptor antagonists (MRA)

57
Q

Mineralocorticoid receptor antagonists (MRA) are contraindicated in what group of patients?

A

Contraindicated in hyperkalaemia, hyponatraemia, acute kidney injury

58
Q

What type of diuretics can be useful in managing a patient’s heart failure symptoms (but does not impact their mortality)

A

Loop diuretics such as furosemide or bumetanide

59
Q

Describe the mechanism of action of loop diuretics

A

Loop diuretics inhibit the sodium-potassium-chloride cotransporter in the thick ascending limb

This transporter normally reabsorbs a lot of sodium so inhibition causes a rise in distal tubular concentration of sodium, water stays with the sodium

This leads to increased water and sodium loss.

60
Q

Name some of the side effects of loop diuretics

A

Dehydration and reduced serum sodium and potassium

61
Q

Give an example of a loop diuretic

A

Furosemide

62
Q

Give an example of an Angiotensin-converting enzyme (ACE) inhibitors

A

Ramipril

63
Q

Describe the mechanism of action of Angiotensin-converting enzyme (ACE) inhibitors

A

ACEi inhibits the conversion of Angiotensin I to Angiotensin II

Angiotensin II can no longer stimulate the release of aldosterone from the adrenal glands

Aldosterone is important for sodium reabsorption (which is followed by water) and potassium and hydrogen secretion

This this decreases blood volume.

64
Q

Name some of the side effects of an Angiotensin-converting enzyme (ACE) inhibitors

A

Dry cough

Hypotension

Renal impairment thus renal function must be checked prior to initiation and repeat tests within 1-2 weeks

65
Q

Give an example of an Angiotensin receptor blockers (ARBs)

A

Losartan

66
Q

What is the mechanism of action of Angiotensin receptor blockers (ARBs)

A

ARBs inhibit the binding of angiotensin II to angiotensin I by competitive binding to the angiotensin I receptors.

67
Q

Give an example of a beta blocker

A

Bisoprolol

68
Q

What is the mechanism of action of beta blockers

A

Act to reduce sympathetic activity, an important compensatory mechanism that causes vasoconstriction increasing the systemic resistance i.e. afterload and thus it reduces the strain of the myocardium

69
Q

beta-1 receptors are found predominantly where?

A

In the heart

70
Q

beta-2 receptors are found predominantly where?

A

Found in the lungs

71
Q

Give an example of a Mineralocorticoid receptor antagonists (MRA)

A

Spironolactone

72
Q

What is the mechanism of action of Mineralocorticoid receptor antagonists (MRA)

A

MRA binds to the mineralocorticoid receptor causing the inhibition of aldosterone. Aldosterone is important for sodium reabsorption (which is followed by water) and potassium and hydrogen secretion.

This decreases blood volume, putting less strain on the myocardium

Finals: Medicine (91 decks)

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