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4th year passmedicine by topic > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What are the features of chronic heart failure?

A 
dyspnoea
cough
orthopnoea
paroxysmal nocturnal dyspnoea
wheeze ('cardiac wheeze')
bibasal crackles on examination
signs of right-sided heart failure: raised JVP, ankle oedema and hepatomegaly
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2
Q

What is specific about chronic heart failure cough?

A

may be worse at night and associated with pink/frothy sputum

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3
Q

People with heart failure sometimes lose weight

A 
true
weight loss ('cardiac cachexia'): occurs in up to 15% of patients. Remember this may be hidden by weight gained secondary to oedema
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4
Q

What is the first line investigation for suspected chronic heart failure?

A

N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test first-line

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5
Q

If NT‑proBNP results are ‘high’ what should you do?

A

arrange specialist assessment (including transthoracic echocardiography) within 2 weeks

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6
Q

If NT‑proBNP results are ‘raised’ what should you do?

A

arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks

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7
Q

What is BNP?

A

B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels are associated with a poor prognosis.

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8
Q

What are high, raised and normal levels of NTproBNP?

A

> 2000 pg/ml (236 pmol/litre)
400-2000 pg/ml (47-236 pmol/litre)
< 400 pg/ml (47 pmol/litre)

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9
Q

What factors Increase BNP levels?

A 
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
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10
Q

What factors decrease BNP levels?

A 
Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists
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11
Q

What are high, raised and normal levels of BNP?

A

> 400 pg/ml (116 pmol/litre)
100-400 pg/ml (29-116 pmol/litre)
< 100 pg/ml (29 pmol/litre)

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12
Q

What classification is widely used to classify the severity of heart failure?

A

New York Heart Association (NYHA)

4 classes

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13
Q

What is NYHA Class I?

A

no symptoms

no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations

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14
Q

What is NYHA Class II?

A

mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea

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15
Q

What is NYHA Class III?

A

moderate symptoms

marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms

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16
Q

What is NYHA Class IV?

A

severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

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17
Q

first-line treatment for all patients is?

A

ACE-inhibitor and a beta-blocker

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18
Q

Which beta-blockers licensed to treat heart failure in the UK?

A

isoprolol, carvedilol, and nebivolol.

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19
Q

ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with what?

A

preserved ejection fraction

20
Q

Second-line treatment is?

A

aldosterone antagonist

spironolactone and eplerenone

21
Q

Which drugs in management of heart failure can cause hyperkalaemia?

A

both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia

22
Q

Which electrolyte should be monitored in management of heart failure?

A

Potassium

Hyperkalaemia

23
Q

Third line management is?

A 
should be initiated by a specialist. 
Options include ivabradine
sacubitril-valsartan
hydralazine in combination with nitrate
digoxin 
cardiac resynchronisation therapy
24
Q

What is the criteria for prescribing Ivabridine?

A

sinus rhythm > 75/min and a left ventricular fraction < 35%

25
Q

What is the criteria for prescribing sacubitril-valsartan?

A

left ventricular fraction < 35%
is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
should be initiated following ACEi or ARB wash-out period

26
Q

When is digoxin strongly indicated?

A

coexistent atrial fibrillation

27
Q

Which drugs have not been proven to reduce mortality in patients with heart failure but may however improve symptoms?

A

Digoxin - inotropic properties

loop diuretics such as furosemide, but important role in managing fluid overload

28
Q

When is hydralazine in combination with nitrate strongly indicated?

A

Afro-Caribbean patients

29
Q

When is cardiac resynchronisation therapy strongly indicated?

A

widened QRS (e.g. left bundle branch block) complex on ECG

30
Q

What vaccines should be offered to people with heart failure?

A

offer annual influenza vaccine
offer one-off pneumococcal vaccine
adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years

31
Q

Acute heart failure (AHF) is life-threatening emergency

A

true
HF is a term used to describe the sudden onset or worsening of the symptoms of heart failure. Thus it may present with or without a background history of pre-existing heart failure.

32
Q

Decompensated acute HF is more common and presents with a background history of HF

A

true

66-75%

33
Q

At what age does acute heart failure usually present

A

after the age of 65-years

34
Q

AHF is usually caused by what?

A

reduced cardiac output that results from a functional or structural abnormality.

35
Q

What is De novo heart failure?

A

AHF without a past history of heart failure
increased cardiac filling pressures and myocardial dysfunction usually as a result of ischaemia. This causes reduced cardiac output and therefore hypoperfusion. This, in turn can cause pulmonary oedema.

36
Q

What are the common and uncommon causes of de novo heart failure?

A 
Common: ischaemia
less common causes of de-novo AHF are:
Viral myopathy
Toxins
Valve dysfunction
37
Q

What are the most common precipitating causes of acute AHF are?

A 
Acute coronary syndrome
Hypertensive crisis
Acute arrhythmia
Valvular disease
There is generally a history of pre-existing cardiomyopathy
38
Q

What are the symptoms of AHFt?

A

Breathlessness Cyanosis
Reduced exercise tolerance Tachycardia
Oedema

39
Q

What are the signs of AHFt?

A 
Elevated jugular venous pressure
Faitgue	
Displaced apex beat
Chest signs: classically bibasal crackles but may also cause a wheeze
S3-heart sound
40
Q

Over 90% of patients with AHF have a normal or increased blood pressure

A

true

41
Q

Why do blood tests for AHF?

A

to look for any underlying abnormality such as anaemia, abnormal electrolytes or infection.

42
Q

What does CXR show in AHF?

A

pulmonary venous congestion, interstitial oedema and cardiomegaly

43
Q

Why do blood echo for AHF?

A

this will identify pericardial effusion and cardiac tamponade

44
Q

B-type natriuretic peptide is diagnostic of AHF

A 
false
 raised levels (>100mg/litre) indicate myocardial damage and are supportive of the diagnosis.
45
Q

How do you manage acute heart failure?

A 
oxygen
IV loop diuretics
opiates
vasodilators
inotropic agents
CPAP
ultrafiltration
mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices

Consideration should be given to discontinuing beta-blockers in the short-term.

4th year passmedicine by topic (96 decks)

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