Heart Failure Flashcards

1
Q

Life Expectancy from heart failure diagnosis:

A
  • 5 year mortality: 50%
  • <1 year for advanced HF
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2
Q

3 Clinical Syndromes of Heart Failure:

A
  • chronic heart failure: peripheral oedema
  • acute heart failure: pulmonary oedema
  • cardiogenic shock: low BP <90mmHg
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3
Q

LV systolic heart failure:

A
  • LV weakness +- dilation/thinning
  • due to:
    - IHD (acute MI or chronic ischaemia) c.70%
    - Hypertension
    - Inherited (autosomal dominant)
    - Alcohol excess
    - Post viral
    - Toxins (eg chemotherapy drugs)
    - Metabolic (eg hypothyroid, iron overload,
    thiamine deficiency)
    - Unknown cause (‘idiopathic’)
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4
Q

How can we measure LV function:

A
  • no single perfect measure
  • LV function depends on loading: preload = venous
    return, afterload = blood pressure)
  • LV contractility measurement should be independent
    of loading: isovolumic dP/dt, end-systolic elastance (
    difficult to measure)
  • LV ejection fraction
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5
Q

Ejection fraction =
Stoke Volume =

A

stroke volume/ end-diastolic volume
end-diastolic volume - end-systolic volume

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6
Q

Systolic Heart Failure - Haemodynamics:

A
  • decreased LV contractility (WEAK): reduced stroke
    volume
  • increased LV diastolic pressure
  • increased LV end diastolic volume (DILATED)
  • reduced LV ejection fraction: systolic heart failure =
    Left ventricular ejection fraction <40%, normal LVEF = 55-70%
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7
Q

Signs and symptoms of systolic heart failure occur at what %

A

<40% of left ventricular ejection fraction

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8
Q

Heart Failure pathophysiology:

A

insert
right and left sided heart failure can occur independently

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9
Q

Heart Failure Symptoms:

A
  • breathlessness: exertional, orthopnoea, paroxysmal
    nocturnal dysponea
  • fatigue
  • leg swelling
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10
Q

How do we classify heart failure?

A
  • NYHA, New York Heart Association severity
    classification
  • class 1 = asymptomatic
  • class 2 = mild symptoms with day to day activities
  • class 3 = moderate symptoms with minor exertion
  • class 4 = symptoms at rest
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11
Q

The patient with heart failure diagram

A

insert

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12
Q

Signs of Heart Failure:

A
  • elevated JVP = right atrial pressure
  • oedema: ankles, shins, thighs, genitals, trunk, ascites,
    pleural effusion
  • Lung Crackles (Inspiration, Bases):
    - low volume pulse, low BP
    - tachycardia, increased RR
    - displaced apex beat
    - murmur (functional MR (mitral regurgitation)
    - liver enlargement (hepatomegaly) (tender right
    quadrant) (mildly low liver function)
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13
Q

Ascites

A

swelling in abdomen

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14
Q

Heart Failure Investigations:

A
  • ECG
  • BNP = brain natriuretic peptide
  • echocardiogram
  • cardiac MRI
  • cardiac catherterisation
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15
Q

ECG in heart failure:

A
  • rarely normal in patients with heart failure
  • tall complexes = LV hypertrophy
  • broad complexes = left bundle branch block
  • T wave inversion
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16
Q

BNP in heart failure:

A
  • brain natriuretic peptide (blood test)
  • released by the left atrium (LA), in response to
    increased LA pressure
  • sensitive for HF, therefore used as a screening test
  • not specific
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17
Q

Investigations 1 diagram

18
Q

Echocardiogram in heart failure:

A
  • LV dimensions/functions
  • LV ejection fraction
  • estimate intra-cardiac pressuresnnbfb
19
Q

Cardiac MRI in heart failure:

A
  • LV dimensions/function
  • LV ejection fraction
  • characterise myocardial pathology
20
Q

Cardiac Catheterisation:

A
  • LV dimensions/function
  • direct measurement of intra-cardiac
    pressures
  • coronary angiography
21
Q

Left Sided Heart Failure:

A
  • acute presentation (MI)
  • elevated left heart pressures transmitted
    back to the pulmonary capillaries
  • pulmonary oedema occurs when
    pulmonary capillary pressure >25mmHg,
    serum albumin = c.25g/L
  • in the most extreme cases, unable to
    maintain cardiac output: CARDIOGENIC
    SHOCK:
    - cold, clammy
    - thready pulse
    - SBP <90mmHg
22
Q

Right Heart Failure Mechanisms:

A

insert diagram
- decreased left ventricular contractility,
which increases PA pressure, which
increases RV pressure, which increases RA
pressure leading to peripheral oedema

23
Q

Left Heart Failure Mechanisms:

A

insert diagram
- decreased LV contractility, which increases
left ventricular end diastolic pressure,
which increases left atrial pressure
- which increases pulmonary venous
pressure

24
Q

Right Sided Heart Failure:

A
  • chronic presentation
  • most commonly due to left hearted
    disease
  • elevated left heart pressures BUT
  • LA dilates and LA/PV pressure <25mmHg
  • pressure transmitted back to
    PA,RV,RA,SVC/IVC:
    - elevated JVP
    - leg oedema
    - pleural effusion/ ascites
25
Cor Pulmonale: - is - caused by - results in
- right sided heart failure due to chronic lung disease - many causes: COPD, lung fibrosis, pulmonary hypertension - elevated pulmonary artery pressures - pressure transmitted back to RV, RA, SVC/IVC: high JVP, leg oedema, pleural effusions/ ascites
26
Preload diagram
insert - preload is important, degree of preload is important to make sure the heart is stretched enough - but if preload is too high, increases cardiac output because increased venous return to the heart
27
Renin-Angiotensin-Aldosterone System
insert diagram
28
Neuro-endocrine activation in heart failure: - low cardiac output activates - mechanisms - results/consequences
- low cardiac output activates: - RAAS - Reduced renal perfusion - by multiple mechanisms: - low BP - low NaCl delivery to kidneys (macula densa cells in the DCT) - sympathetic division - increases preload, increased cardiac output but - oedema/ascites/pleural effusion - increased afterload: angiotensin mediated vasoconstriction
29
RAAS activation diagram
insert
30
RAAS activation 2 diagram
insert
31
Sympathetic Activation in the heart:
insert - sympathetic activation is meant to restore the patient back to normal - if over activated , heart becomes weak and tired - increases heart rate (beta 1 receptors activated) and hence increases contractile force - short term: increases cardiac output - long term: worsens heart failure (flogging a dead horse)
32
Diastolic Heart Failure:
- due to prolonged sympathetic activation - heart failure but LV systolic function is GOOD: HFpEF = heart failure with preserved ejection fraction - chronic heart failure syndrome but: - normal LV volume - LV ejection fraction >40% - due to increased LV stiffness, hence reduced compliance - causes same cascade of increased pressures - LV dilation
33
Sympathetic activation and the arterial system:
- vasoconstriction (alpha 1) - increases systemic vascular resistance (SVR) - increases afterload - in the short term: maintains arterial blood pressure - long term: increases workload on already weakened heart (making dying horse run uphill)
34
Diastolic Heart Failure Mechanisms:
- insert - LV stiffness increases, increases LA pressure, which increases pulmonary venous pressure causing pulmonary oedema, if prolonged can increase pressure on RV, RA, PA
35
Therapeutic targets of chronic heart failure:
- fluid retention: loop diuretic (furosemide) - angiotensin II production: ACE inhibitor (ramipril) - Angiotensin II receptors: Angiotensin receptor inhibitor (Losarten) - Aldosterone antagonists: Spironolactone - Sympathetic system: beta blockers (bisprolol)
36
LV diastolic failure is commonly seen in
elderly patients hypertension, diabetes, atrial fibrillation
37
LV diastolic heart failure is classified as a -------- cardiomyopathy
restrictive
38
LV diastolic heart failure aetiology:
- amyloid heart disease - sarcoidosis - severe LV hypertrophy: hypertension, hypertrophic cardiomyopathy
39
Chronic heart failure: advanced therapeutics: Fluid Retention:
- Dapaglifozin: - SGLT-2 inhibitors - reduces glucose reabsorption in the kidney - osmotic diuresis - Neprilysin inhibitors: - sacubatril usually used with an angiotensin antagonist (Valsartan) - I(small f) inhibitor: Ivabradine
40
Acute Heart Failure Management:
PODMAN INSERT SLIDE