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Y4 - CCC & PC > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What are the 3 mechanisms by which SOB can arise?

A

Not enough oxygen reaching the lungs:
due to breathing issues, such as asthma + COPD

Not enough oxygen getting into the blood:
this is due to V/Q mismatch - e.g. PE or pulmonary fibrosis

Not enough oxygen reaching tissues of the body:
this is due to issues with the heart - it is not pumping oxygenated blood sufficiently

^ also anaemia + shock

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2
Q

What is cardiac output?

A

the volume of blood pumped by the heart in one minute

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3
Q

What is the definition of heart failure?

A

the failure of the heart to maintain the cardiac output (CO) required to meet the body’s metabolic demands

not enough oxygen reaches the rest of the body

CO is RELATIVE to the body’s metabolic demands

CO can be normal, the demands of the body just increased, and this is still HF

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4
Q

What are the 3 ways to classify heart failure?

A
  • acute or chronic
  • left or right
  • high output state or low output state
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5
Q

What is meant by chronic HF?

A

a long-term condition in which the heart fails to maintain an adequate CO for the needs of the body

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6
Q

What is meant by acute heart failure?

What are the 2 causes?

A

rapid onset of the symptoms / signs of HF that requires urgent management

  • can be caused by acute coronary syndrome
  • OR decompensation of chronic HF

ACS - e.g. heart attach damages the heart and causes it to fail

decompensation - patient has chronic HF that suddenly gets worse due to an exacerbating factor

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7
Q

What is the main difference between acute and chronic HF?

A
  • signs / symptoms are similar, but differ in severity
  • investigations are similar
  • management is DIFFERENT - acute HF is a medical emergency
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8
Q

What is congestive heart failure and how does it usually occur?

A

CHF = RHF + LHF

  • often a patient has LHF before the pressure backs up into the pulmonary circulation and then into the right heart

if you see the symptoms / signs of RHF, this DOES NOT mean that the person doesn’t also have LHF

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9
Q

What is meant by low output state HF?

A

this occurs when the heart fails to pump in response to normal exertion

the cardiac output (CO) is reduced

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10
Q

What is meant by high output state HF?

A

the cardiac output (CO) is normal, but the metabolic demands of the body have increased

the CO is insufficient to meet the increased metabolic demands

e.g. hyperthyroidism, pregnancy, anaemia

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11
Q

What are the 3 categories of causes of chronic LHF?

A

Valvular:
the aortic and mitral valves are present on the left

Muscular:
when the muscles are weakened / damaged, the heart cannot pump efficiently, reducing CO

Systemic

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12
Q

What are the valvular causes of LHF?

A
  1. aortic stenosis
  2. aortic regurgitation
  3. mitral regurgitation
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13
Q

What are the muscular causes of LHF?

A
  1. ischaemic heart disease (IHD)
  2. cardiomyopathy
  3. myocarditis
  4. arrhythmias (AF)
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14
Q

What are the systemic causes of LHF?

A
  1. hypertension
  2. amyloidosis
  3. drugs (e.g. cocaine, chemo)

HTN - left heart pumps into the systemic circulation, so if pressure is increased, pressure in the aorta is also increased

this increases the afterload, which backs up into the LH to cause HF

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15
Q

What are the 2 categories of causes of chronic RHF?

A
  • lung-related causes
  • valvular causes

ALSO LHF that leads to RHF = congestive HF

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16
Q

What are the lung-related causes of RHF?

A
  • pulmonary hypertension (cor pulmonale)
  • pulmonary embolism
  • chronic lung disease (e.g. interstitial LD, cystic fibrosis)

the RH pumps into the pulmonary artery, so when the pressure is increased, this backs up into the RH

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17
Q

What are the valvular causes of RHF?

A
  • tricuspid regurgitation
  • pulmonary valve disease
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18
Q

What mnemonic can be used to remember that conditions that cause high output HF?

A

NAP MEALS

N - nutritional (B1 / thiamine deficiency)
A - anaemia
P - pregnancy

M - malignancy
E - endocrine
A - AV malformations
L - liver cirrhosis
S - sepsis

the strain on the heart is greater as these conditions require a greater CO

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19
Q

What are the 3 most common causes of high output HF and why does this occur?

A

Pregnancy:
due to the metabolic demands of a second person

Anaemia:
the blood isn’t carrying enough oxygen, so the heart needs to compensate + pump harder

Hyperthyroidism:
* there is a high BMR meaning increased metabolic demands

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20
Q

In general, what are the symptoms of LHF and RHF caused by?

A

LHF:
* LH receives blood from the pulmonary circulation

  • blood congesting backwards leads to pulmonary oedema + SOB

RHF:
* RH receives blood from the systemic circulation

  • blood congesting backwards leads to peripheral swelling + oedema

think - “what happens if fluid is congested backwards?”

21
Q

What are the respiratory symptoms associated with LHF?

A

Dyspnoea:

  • paroxysmal nocturnal dyspnoea (PND)
  • exertional dyspnoea
  • orthopnoea

Other symptoms:

  • nocturnal cough
  • +/- pink frothy sputum
  • general fatigue
22
Q

What questions can be used to assess SOB, PND and orthopnoea?

A

SOB:
* how far can you walk without getting breathless?
* how many flights of stairs can you climb?

orthopnoea:
* have you noticed anything that makes SOB worse?
* how many pillows do you sleep with at night? has this changed recently?

PND:
* do you ever wake up at night gasping for air?

23
Q

How can the signs of LHF be divided?

A

Heart signs:
* these are signs of whatever is causing the HF

Lung signs:
* these are signs that result from the HF

24
Q

What are the heart signs associated with LHF?

A
  • raised HR + RR
  • irregularly irregular heartbeat
  • pulsus alternans
  • displaced apex beat
  • S3 gallop rhythm
  • S4 in severe HF
  • murmur (AS, MR or AR)
25
Q

What is pulsus alternans?

Why does this usually occur in HF + what is it associated with?

A
  • arterial pulse waveform showing alternating strong and weak beats
  • it is due to decreased ventricular performance
  • occurs when HF is due to resistance to LV ejection - HTN, aortic stenosis, coronary atherosclerosis

it is often associated with an S3 gallop rhythm

26
Q

What is the S3 gallop rhythm and why does it occur?

A
  • it is the “third heart sound”
  • it occurs just after S2 when the mitral valve opens + blood enters the LV
  • it is caused by large volumes of blood hitting a very compliant LV
27
Q

Why might S3 occur in HF patients?

When is it normal?

A
  • it is a sign of an overly compliant LV
  • the myocardium is often dilated and overly compliant in HF

it can be normal in young people, athletes and pregnant women

28
Q

What is the S4 heart sound and why does it occur?

A
  • the “atrial gallop” which is nearly always abnormal
  • it occurs when blood strikes a LV that is non-compliant
  • atrial contraction forces blood through the AV valves
  • it occurs in severe HF where there is LV hypertrophy preventing relaxation of the LV
29
Q

In general, what type of conditions produce an S3 and S4 heart sound?

A
  • S3 is produced by any condition creating an overly compliant LV
  • S4 is produced by any condition creating a noncompliant LV
30
Q

What are the symptoms of RHF?

A
  • fatigue
  • reduced exercise tolerance
  • anorexia
  • nausea
  • nocturia (due to fluid retention)

symptoms (ext nocturia) are more non-specific and it is more about signs

31
Q

What are the signs associated with RHF?

A
  • swelling of the face
  • raised JVP
  • TR murmur, raised HR + RR
  • ascites / hepatomegaly
  • ankle oedema
  • sacral pitting oedema

all the signs relate to peripheral swelling

32
Q

What bedside investigations are performed for HF?

A

ECG:
* to rule out MI due to SOB

33
Q

What blood tests are performed in HF and why?

A
  • FBC - to rule out anaemia causing SOB
  • U&Es
  • LFTs
  • TFTs - to rule out hyperthyroidism
  • !!! BNP !!!
34
Q

What imaging might be performed in HF and why?

A
  • CXR - if patient has signs of concurrent pulmonary oedema
  • transthoracic echocardiography (TTE)

TTE is the gold-standard for diagnosing HF

imaging is only performed if directed to do so by the blood results

35
Q

How can levels of BNP be used to direct HF investigations?

A

BNP is sensitive, but not specific

  • if BNP is low, then HF is unlikely
  • if BNP is high, a TTE is required to confirm diagnosis

it is sensitive as it is released every time the heart muscle stretches (which occurs in HF)

it is NOT specific as many other heart conditions can cause raised BNP

36
Q

What is the diagnostic test for HF?

A

transthoracic echocardiogram (TTE) coupled with doppler

Doppler allows for visualisation of the blood flow in the heart

37
Q

What 2 parameters can be visualised / calculated using TTE with Doppler?

A

Structure / function of heart:
visualising this may show the cause of HF

Calculating ejection fraction:
* this is the % of blood present in the LV that is pumped during systole
* a normal value is 50-70%

38
Q

What is meant by heart failure with reduced EF (HFrEF)?

Why does this occur?

A
  • occurs when EF is < 40%
  • this indicates an inability of the ventricle to contract normally, causing HF

previously called systolic HF

39
Q

What is heart failure with preserved EF?

Why does this occur?

A
  • occurs when EF > 50%
  • it indicates an inability of the ventricle to relax and fill normally

previously called diastolic HF

40
Q

Why might a CXR be performed in HF?

A

to assess for pulmonary oedema if a patient is breathless

41
Q

What are the characteristic features of HF on a CXR?

A

ABCDE:

A - alveolar oedema
B - Kerley B lines
C - cardiomegaly
D - dilated upper lobe vessels
E - effusion

the effusion is a transudative pleural effusion

42
Q

How can a diagnosis of HF be made without investigations?

A

a clinical diagnosis can be made using the Framingham criteria

requires 2 majors or 1 major + 2 minors

43
Q

What are the 4 stages in the management of chronic HF?

A
  • treat the underlying cause - to prevent worsening of the damage
  • treat exacerbating factors - to relieve symptoms
  • lifestyle modifications
  • drugs (ABD)

chronic HF can’t be “cured” so tx aims at prolonging life + alleviating symptoms

44
Q

What are the 3 main drugs given to chronic HF patients and why?

A

ACE inhibitors:
given to all patients with LV dysfunction to reduce BP
(enalapril, perindopril, ramipril)

Beta-blockers:
to reduce the O2 demand on the heart
(bisoprolol, carvedilol)

Diuretics:
use if evidence of fluid retention
(loop diuretics - furosemide
or K+ sparing - spironolactone)

45
Q

Why might a HF patient be given an ARB?

A

if the ACEi is not tolerated as it can produce a cough

46
Q

What additional medications are sometimes used in HF?

A

Hydralazine + nitrates:
considered in Afro-Caribbean patients

Digoxin:
improves symptoms, but not mortality

cardiac resynchronisation therapy:
aims to improve timings of contraction of atria + ventricles

47
Q

What are the 5 steps involved in treatment of acute HF?

A
  • sit the patient upright
  • give 60-100% oxygen
  • IV diamorphine 2.5-5mg
  • GTN infusion
  • IV furosemide 40-80mg

it is a MEDICAL EMERGENCY - so ABC procedure must be performed first

48
Q

What mnemonic can be used to remember the stages of acute HF management?

A

DMONS

D - diuretics
M - morphine
O - oxygen
N - nitrates
S - sit-up

(not in correct order)

49
Q

What is the prognosis of HF like?

A
  • it has a very poor prognosis that is worse than most cancers
  • 50% severe HF patients die within 2 years

Y4 - CCC & PC (34 decks)

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