Heart failure Flashcards
Typical heart failure symptoms
breathlessness
ankle swelling (peripheral oedema)
fatigue
Typical heart failure signs
elevated JVP
pulmonary crackles
peripheral oedema
What is the New York Heart Association (NYHA) functional classes?
classify severity of cardiovascular disability through severity of exertional dyspnoea or discomfort at rest
class 1 = no limitations on activity
class 2 = comfortable at rest, ordinary physical activity causes symptoms
class 3 = comfortable at rest, patients have marked limitation of physical activity
class 4 = patients have symptoms even at rest
How is ejection fraction calculated?
stroke volume = end-diastolic volume - end-systolic volume
ejection fraction = (stroke volume/end-diastolic volume)x100
What is HFpEF?
heart failure with preserved ejection fraction
Causes of HFpEF/diastolic heart failure
hypertension
diabetes
obesity
old age
restrictive cardiomyopathies (amyloidosis, HCM, Fabry’s)
HOCM
cardiac tamponade
restrictive pericarditis
Pathophysiology of HFpEF
impaired LV relaxation
increased LVEDP
reduced diastolic filling
reduced cardiac output
Causes of HFrEF
ischaemic heart disease (post-MI)
dilated cardiomyopathy
myocarditis
infiltration (eg. haemochromatosis or sarcoidosis)
What is HFrEF?
heart failure with reduced ejection fraction
What is heart failure and what can it also be called?
when the heart is unable to pump sufficiently to maintain blood flow to meet the body’s needs
congestive cardiac failure (CCF)
congestive heart failure (CHF)
Describe high output cardiac failure
cardiac output is normal but there is an increase in peripheral metabolic demands which exceed those that can be met with maximal cardiac output
Causes of high output cardiac failure
AAPPTT
anaemia
arteriovenous malformation
paget’s disease
pregnancy
thyrotoxicosis
thiamine deficiency
Clinical features of left heart failure
pulmonary congestion (pressure builds up behind the left heart)
systemic hypoperfusion (reduced left heart output)
NB Sometimes left sided heart failure can lead to pulmonary congestion which in turn also pushes the right ventricle into failure. In these cases signs and symptoms of both left and right sided heart failure may be present
Symptoms caused by pulmonary congestion
SOBOE
orthopnoea
paroxysmal nocturnal dyspnoea
nocturnal cough (+ pink frothy sputum)
Signs caused by pulmonary congestion
tachypnoea
bibasal fine crackles on lung auscultation
Signs caused by systemic hypoperfusion
cyanosis
prolonged capillary refill time
hypotension
Less common signs of left heart failure
Pulsus alternans (alternating strong and weak pulse)
S3 gallop rhythm (produced by large amounts of blood striking a compliant left ventricle)
features of functional mitral regurgitation
Clinical features of right heart failure
venous congestion (pressure builds up behind the right heart)
pulmonary hypoperfusion (reduced right heart output)
Venous congestion symptoms
ankle swelling
weight gain
abdominal distension + discomfort
anorexia/nausea
Venous congestion signs
raised JVP
pitting ankle/sacral oedema
tender smooth hepatomegaly
ascites
transudative pleural effusions (typically bilateral)
Primary care investigations for heart failure
12 lead ECG
NTproBNP
Blood tests (FBC, U&E, LFTs, thiamine, B12/folate, vitamin D, calcium, magnesium, HbA1c)
CXR
Secondary care investigations for heart failure
echocardiogram
cardiac MRI
invasive angiogram
cardiac CT coronary angiogram
nuclear imaging
What is BNP released?
released by the ventricles in response to myocardial stretch
What BNP level would warrant an urgent 2 week referral for a trans-thoracic echocardiogram?
> 2000
400-2000 = 6 week referral
What % is considered reduced ejection fraction heart failure?
<40%
[>40% with raised BNP = HFpEF]
Heart failure CXR findings
ABCDEF
Alveolar oedema
kerley B lines
Cardiomegaly
upper lobe blood Diversion
pleural Effusions
Fluid in horizontal fissure
Heart failure lifestyle modifications
smoking cessation
salt and fluid restriction
supervised cardiac rehabilitation
Pharmacological management of heart failure
ACE-i + B-blocker (improve mortality)
- ARB if intolerant to ACE-is
- hydralazine + nitrate if intolerant to ACE-i + ARB
Loop diuretics (eg. furosemide, bumetanide) - improve symptoms, not mortality
if symptoms persist and NYHA class 3/4 consider:
- aldosterone antagonists (eg. spironolactone, eplerenone) - improve mortality
- hydralazine + nitrate for afro-caribbean patients
- ivabradine if in sinus rhythm and impaired EF
- angiotensin receptor blocker
Digoxin - useful for those with AF, worsens mortality but improves morbidity
What surgical/device management options are available for heart failure?
cardiac resynchronisation therapy
ICDs in certain circumstances
Initial management of acute heart failure (pulmonary oedema)
sit patient up
oxygen therapy (normally aiming sats >94%)
IV furosemide 40mg or more (further doses as necessary) and close fluid balance (aim negative balance)
SC morphine
Advanced management or acute heart failure (pulmonary oedema)
normally in HDU or ITU
CPAP (reduces hypoxia and helps to push fluid out of alveoli)
intubation + ventilation
furosemide infusion
dopamine infusion (inhibits sympathetic drive and therefore increases myocardial contractility)
intra-aortic balloon pump (if in cardiogenic shock)
ultrafiltration (if resistant to or contraindicated diuretics)
GTN infusion no longer routinely used in heart failure
Adverse effects of beta-blockers
bradycardia
hypotension
fatigue
dizziness
Adverse effects of ACE-inhibitors
hyperkalaemia
renal impairment
dry cough
lightheadedness
fatigue
GI disturbances
angioedema
Adverse effects of spironolactone
hyperkalaemia
renal impairment
gynaecomastia
breast tenderness/hair growth in women
changes in libido
Adverse effects of furosemide
hypotension
hyponatraemia
hypokalaemia
Adverse effects of hydralazine/nitrate
headache
palpitation
flushing
Adverse effects of digoxin
dizziness
blurred vision
GI disturbances
