heart failure Flashcards
what is definition of heart failure?
insufficient cardiac output to meet body’s requirements despite adequate filling pressures
leads to decreased organ perfusion
what classification is used to describe heart failure?
New York Heart Association - 5 classes
what are the 5 classes of NYHA for heart failure?
class 1- no limitation to physical activity
class 2- slight limitation of activity - dyspnoea + fatigue w moderate activity (climbing stairs)
class 3- marked limitation of activity + dyspnoea with minimal activity
class 4- severe limitation of activity + symptoms at rest
class 5- bed confinement
what system is used to diagnose chronic cardiac failure?
framingham criteria- 2 major criteria + 2 minor
what investigations would you do for heart failure?
bedside- ECG
bloods- FBC UE BNP TFT glucose lipids
imaging- CXR, ECHO
what is the general management of chronic heart failure?
primary/secondary cardiovascular risk
- stop smoking, decrease salt intake, optimise weight
- aspirin, statins, cardio rehab
treat precipitants/cause
- underlying cause- valve disease, arrhythmias, ischaemia
- exacerbating factors- anaemia infection, high BP
what is first line medical management of chronic heart failure?
ACE-I + beta blocker + loop diuretic
what is second line medical management of chronic heart failure?
get specialist advice
spironolactone/eplerenone
ACE-i and ARB
vasodilators- hydralazine + ISDN
what is third line medical management in chronic heart failure?
digoxin
cardiac resynchronisation therapy +/- ICD
what are invasive therapies you can consider for chronic heart failure?
cardiac resynchronisation +/- ICD
intra-aortic balloon counterpulsaiton
LVAD- left ventricular assist device- helps pump
heart transplant
how to treat acute pulmonary oedema?
PODMAN
P- position- sit up
O- oxygen
D- diuretic
M- morphine + anti-emetic
A-
N- nitrate- if SBP>100- IV nitrate (ISMN 2-10mg IV) or GTN 2 puffs or 2x300ug tabs SL unless sbp<90. if SBP<100 treat as cardiogenic shock + consider inotropes
if worsens- consider CPAP, nitrate infusion, haemodialysis
what are the causes of severe pulmonary oedema?
cardiogenic- MI, arrythmia, fluid overload (renal, iatrogenic)
non-cardiogenic- ARDS (sepsis, post-op, trauma), upper airway obstruction, neurogenic (HI)
what are clinical signs of severe pulmonary oedema?
distressed, sweaty, cyanosed
tachycardic, tachypnoeic
raised JVP
S3/Gallop Rythm
bibasal creps
pleural effusion
wheeze- cardiac asthma
how does morphine help in pulmonary oedema?
pulmonary venodilators -> decrease preload -> optimise position on starling curve
what blood tests would you do in severe pulmonary oedema?
FBC UE troponin BNP ABG
how would you treat cardiogenic shock?
oxygen
morphine/anti-emetic
consider need for dobutamine
treat underlying cause
bloods- FBC UE ABG troponin
what is cardiogenic shock?
inadequate tissue perfusion primarily due to cardiac dysfunction
what are the causes of cardiogenic shock?
MI HEART
MI
hyperkaelaemia
endocarditis- valve destruction
aortic dissection
rhythm disturbance
tamponade
obstructive- tension pnthx, massive PE
what are the causes of cardiac tamponade?
trauma
lung/breast ca
pericardiits
MI
bacteria eg TB
what are the signs fo tamponade?
becks triad- low bp, raised jvp, muffled heart sounds
kussmaul’s sign- raised JVP on inspiration
pulsus paradoxus- pulse fades on inspiration
what is the management of cardiac tamponade?
pericardiocentesis - under ECHO guidance
what are the 3 compensatory mechanisms of heart failure?
franks-starling law/mechanism
myocardial hypertrophy
neurohormonal system
how does the frank-starling mechanism compensate in heart failure?
increased preload -> increased stroke vol
incomplete chamber emptying -> increased preload -> increases CO by increasing SV
detremental in long-term - severe HF, frank-starling curve is flatter than normal, so even large increase in end-diastolic vol has little effect on SV/CO.
increased ventricular end diastolic vol -> increased atrial pressure -> increased pulmonary pressure
how does myocardial hypertrophy compensate in heart failure?
increased ventricular mass = cell hypertrophy (size) + hyperplasia (numbers)
- pressure overloaded hypertrophy
if CO is due to higher afterload/higher arterial pressure
concentric hypertrophy- muscle thickens due to synthesis of sarcomeres in parallel -> decreased compliance -> increased end systolic vol-> increased atrial pressure -> increased pulmonary pressure - volume overloaded hypertrophy
increased end diastolic vol -> ventricle stretches/dilates -> cannot generate enough force to pump blood
eccentric hypertrophy- heart balloons out due to synthesis of sarcomeres in series
