Heart Failure Flashcards

1
Q

What are symptoms of left heart failure?

A
  • dyspnoea
  • PND
  • nocturnal cough
  • nocturia
  • cold peripheries
  • weight loss
  • poor exercise tolerance
  • orthopnoea
  • wheeze (cardiac asthma)
  • fatigue
  • muscle wasting
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2
Q

What are signs of LHF?

A
  • crackles heard over lung bases (due to pulm oedema)
  • cardiomegaly (->displaced apex beat)
  • S3 gallop rhythm (due to rapid ventricular filling)
  • pulsus alternans (alternating weak + strong in severe LVF)
  • murmurs of mitral or aortic valve disease
  • cyanosis
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3
Q

What are symptoms of right heart failure?

A
  • peripheral oedema (up to thighs, sacrum, abdominal wall)
  • ascites
  • nausea
  • anorexia
  • facial engorgement
  • epistaxis (nosebleed)
  • pulsation in face + neck
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4
Q

What are signs of RHF?

A
  • peripheral oedema
  • raised JVP (accentuated by h-j reflux)
  • parasternal heave
  • ascites
  • hepatomegaly + tenderness
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5
Q

What is the NYHA classification for heart failure?

A
  • Class I - no symptoms, no limitation
  • Class II - mild symptoms, slight limitation on PA: comfortable at rest, but ordinary activity results in fatigue, palps or dyspnoea
  • Class III - moderate symptoms, marked limitation on physical activity: comf at rest, but less than ordinary acitvity results in symptoms
  • Class IV - severe symptoms, unable to carry out any physical activity without discomfort: symptoms of HF are present even at rest w/ inc discomfort w/ any physical acitivty
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6
Q

Diagnosis of congestive cardiac failure requires presence of at least 2 major criteria or 1 major criterion + 2 minor criteria (Framingham criteria)

What are these criteria?

A
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7
Q

How would you quantify the patient’s dyspnoea in history taking - ie. what sort of Qs?

A
  • how far can you walk before you get short of breath?
  • problems taking stairs or walking up hills?
  • any problems breathing when lying flat?
  • how many pillows do you sleep on?
  • do you wake up at night trying to catch your breath?
  • nocturnal cough? any sputum? colour?
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8
Q

Explain the mechanisms by which cardiac failure causes of shortness of breath

A
  • heart failure causes backlog of blood into pulmonary veins increasing pressure
  • increased pulmonary venous pressure -> increases hydrostatic pressure
  • -> increases filtration pressure
  • causes fluid accumulation in the interstitium + alveoli
  • leads to impaired gas exchange at alveoli
  • causing dyspnoea
  • interstitial oedema occurs >20mmHg
  • alveolar oedema occurs at >25mmHg
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9
Q

Which investigations are important for heart failure?

A

If ECG + BNP are normal, heart failure is unlikely and an alternative diagnosis should be considered; if either is abnormal, then echocardiography required.

  • bloods - BNP, FBC (anaemia), U+E
  • CXR
  • ECG -> underlying arrhythmia? LV hypertrophy (HT)?
  • echocardiography -> LV dysfunction
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10
Q

What are the strutural abnormalities on CXR for heart failure?

A
  • Alveolar bat wings
  • Kerley B lines
  • Cardiomegaly
  • Dilated prominent upper lobe vessels
  • Pleural Effusion
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11
Q

What is the acute/emergency management of a patient with cardiac failure?

A

The immediate goal in acute decompensated heart failure is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that airway, breathing + circulation (ABC) are adequate.

  1. sit pt upright
  2. oxygen (100% if no lung disease)
  3. IV access + monitor ECG, treat any arrhythmias
  4. investigations while continuing tx
  5. diamorphine 1.25-5mg IV slowly
  6. furesomide 40-80mg IV slowly
  7. GTN 2 puffs
  8. necessary investigations, examination + history
  9. if systolic >= 100 mmHg -> start nitrate infusion
  10. if pt worsening: more furosemide, consider CPAP
  11. if systolic <100mmHg -> treat as cardiogenic shock + refer to ICU

LMNOPP = loop diuretics, (morphine), nitrates, oxygen, positioning, positive airway pressure

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12
Q

What is the non-pharmacological management of cardiac failure?

A
  • treat underlying cause if possible
  • treat exacerbating factors (anaemia, thyroid disease, infection, bp)
  • avoid exacerbating factors (NSAIDs, negative inotropes eg. Verapamil)
  • annual flu vaccine, one-off pneumococcal vaccine
  • lifestyle changes
    • smoking + alcohol cessation
    • decrease salt intake
    • maintain optimal weight + nutrition
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13
Q

What is the pharmacological treatment for heart failure?

A
  • first-line: ACEi and a beta-blocker
  • second-line: either
    • aldosterone antagonist
    • ARB
    • or a hydralazine in combo w/ nitrate (in black pts)
  • if symptoms persist: digoxin or ivabradine
  • diuretics for fluid overload
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14
Q

How do diuretics help in heart failure?

A
  • loop diuretics to relieve symptoms
  • promote renal salt + water excretion by inhibiting Na/K/Cl reabsorption at ascending limb of LoH -> loss of fluid -> reduces preload -> reduces congestion
  • eg. furosemide or bumetanide
  • increase dose as necessary
  • SE: low K+, renal impairment
  • monitor U+E and add K+-sparing diuretic (spironalactone) if hypokalaemic, predisposition to arrhythmias, concurrent digoxin therapy, or pre-existing K+-losing conditions
  • if refractory oedema, consider adding thiazide
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15
Q

How do ACE inhibitors help in heart failure?

A
  • consider in all those w/ left ventricular systolic dysfunction
  • improves symptoms and reduces mortality
  • increase renal salt + water excretion + reduce afterload
  • if cough is a problem, an ARB may be substituted
  • SE: hyperkalaemia (as it counters aldosterone), angioedema, cough, first-dose hypotension
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16
Q

How do beta-blockers help in heart failure?

A
  • eg. carvediol
  • reduce mortality
  • reduce heart rate + force of contraction -> reduced cardiac workload
  • use w/ caution: ‘start low and go slow’
  • use in pts w/ confirmed left ventricular systolic dysfunction
17
Q

How do mineralocorticoid receptor antagonists help in heart failure?

A
  • spironolactone
  • reduced mortality by 30% when added to conventional therapy
  • use in: post-MI pts w/ LVSD and in those symptomatic despite optimal therapy
  • it is potassium sparing but little risk of significant hyperkalaemia, even when given with ACE-i
  • U+E should be monitored (esp if pt has known CKD)
  • eplerenone is an alternative is spironalactone not tolerated
18
Q

How does digoxin help in heart failure?

A
  • improves symptoms
  • benefit in those w/ CCF + AF
  • slows HR (-ve chronotropic) -> allows more time for ventricles to fill during diastole
  • inc cardiac contracility (+ve inotropic)
  • increases AVN delay (-ve dromotropic)
  • used in pts in sinus rhythm who remain in severe HF despite ACEi, b-blockers and diuretics
  • monitor U+E; maintain K+ 4-5mmol/L as hypokalaemia risks digoxin toxicity and vice versa
19
Q

How do vasodilators help in heart failure?

A
  • combo of hydralazine (SE: drug-induced lupus) and isosorbide dinitrate should be used if intolerant of ACEi/ARBs
  • reduces mortality
  • also reduce mortality when added to standard therapy (incl ACEi) in black patients w/ heart failure
  • isosorbide dinitrate reduces preload by causing venodilatation
  • hydralazine is an arterial vasodilator which acts to reduce afterload