Heart failure

Question 1

What are the causes of heart failure?

Answer 1

Ischaemic heart disease
-hypertension
-valvular heart disease
-AF
-Cardiomyopathy
-HIV

Question 2

What is the patient demographic for HFPF

Answer 2

-Obese
-Hypertensive
-elderly

Question 3

what would be considered as a bad prognosis in HF?

Answer 3

-High NT-proBNP
-renal impairment
-Old
-co-morbidity
-frequent admissions with heart failure

Question 3

Investigations for heart failure

Answer 3

-Renal function
-FBC
-LFTS - to check for hepatic congestion
-TFTs- thyroid function
-Ferritin and transferritin- hemochromatosis in younger patients
-NT-proBNP levels < 100 indicate normal- above does not however, necessarily equate to acute heart failure
-Echo- poorly left ventricle
-Cardiac

Question 4

when else can BNP be elevated?

Answer 4

-AFib
-RV strain

Question 4

What are the three classical symptoms of aortic stenosis?

Answer 4

Chest pain
Fatigue
Sob

Question 5

CXR in Heart failure?

Answer 5

-Cardiomegaly
-Pleural effusions
-Curly B signs
-Alveolar bat wing signs
-pleural effusions
-Perihilar shadowing
-Air bronchograms
-Increased width of vascular pedicle

Question 5

Management for heart failure ?

Answer 5

-Lifestyle modification :
-smoking cessation
-reduce alcohol
salt restriction
-fluid restrict- especially if patient is hyponatrreimic
-weight monitoring

Question 6

Medication regimen for HF?

Answer 6

-Diuretics- loop- Furosemide 40-500mg daily (IV if fluid overloaded) or bumetanide- better alternative for oedematous patients
bendroflumethazide-2.5mg od- added to loop diuretic - of potassium depletion- balance with ACEi or spironolactone if persistent- 25 mg od
-ACEi- useful in hypertensive patients - improve exercise tolerance
-ARBs- valsartan and candesartan- titrate over a couple of weeks
-ARNI- Angiotensin receptor- neprilysin inhibitor- Sacubitril/valsartan - only for HFRF
-Beta blockers- safe to prescribe if patients systolic BP is >100 and HR >60bpm- Carvedilol- increase the dosage slowly start 3.125mg BD for 2 weeks- double dosage every two weeks- until 25 mg.
bisoprolol- 1.25mg OD for 1 week - double in a week and then 3.75mg OD for week- then 4 then 5, then finally 7.5 mg for 4 weeks and finally 10mg OD
-Vasodilators-Hyralazine or isosorbide mononitrate
-Ivabradine- should be given in patients who can’t tolerate B blockers- avoid with ca2+ channel blockers- does not impact blood pressure so good alternative for hypotensive HF patients.
-Nitrates- reduce preload, reduce pulmonary oedema and ventricular size - good for valve disease and if there is underlying ischaemic heart disease.

Question 6

Types of Pacemakers:

Answer 6

CRT- cardiac resynchronisation pacemaker- used in LBBB- pacing at septum and lateral wall - returns narrow QRS complexes
ICDs- they are not for symptom improvement - prevent sudden cardiac death- it detects HF and cardioverts VT/VF

Question 7

What type of murmur is heard in aortic stenosis?

Answer 7

-Ejection systolic murmur, radiating to carotid and neck

Question 8

Investigation and managemet od aortic stenosis?

Answer 8

-Surgery
-ECHO
-Transcatheter aortic valve implantation (TAVI)
-

Question 9

Symptoms of aortic regurgitation?

Answer 9

-often patients are asymptomatic
- murmur associated with collapsing pulse and head bobbing- De Musset’s sign

Question 10

Pathophysiology of aortic regurg?

Answer 10

Increased load in the LV- causes increased pressure and eventual dilatation and HF

Question 11

Causes of Aortic regurg?

Answer 11

-Congenital abnormalities
-calcific degeneration
-rheumatic disease
-infective endocarditis
-Marfans syndrome

Question 12

Investigations of Aortic regurgitations

Answer 12

-Echocardiography

Question 13

when should you consider surgery for Aortic stenosis?

Answer 13

-very severe symptoimatically
-Asymptomatic with root dilatation >5.5cm
-Asymptomatic with early LV dysfunction EF<50%

Question 14

What is the average interval of diagnosis to onset of symptoms for patients with mitral regurgitation?

Answer 14

16 years- patients are usually asymptomatic for years

Question 15

What are the causes of Mitral regurg?

Answer 15

-Mitral valve prolapse- secondary to Marfans- occurrs in 1-2% of people- the prognosis is worse when there is moderate it sever Mitral regurg and when the EF is< 50%
-Rheumatic heart disease
-Infective endocarditis
-Ruptured chordae or ruptured papillary muscles - can have severe MR

Question 16

Investigations for MR:

Answer 16

-Pan systolic murmur- usually radiates to the axilla
-Assessed by ECHO

Question 17

When is surgery required in patients with Mitral valve regurg?

Answer 17

• It is required in patients who are severely symptomatic or patients who are asymptomatic but have a lowered ejection fraction of less than 30-60%

Question 18

What are the two surgical options for mitral regurg?

Answer 18

-Valve repair - more preferable has a higher mortality rate compared to replacement
-Valve replacement

Question 19

What is an example of Ischaemic MR and what would be the treatment requirement?

Answer 19

• dilated cardiomyopathy- which is when the ventricle walls become thin and poor contractors- this is when ACEi are required- as it is a type of heart failure. (maybe bisoprolol and carvedilol)

Question 20

What are the causes of infective endocarditis?

Answer 20

-Prosthetic valve
-Poor dentition
-mitral valve prolapse
-Rheumatic heart disease
-Congenital heart disease

Question 21

Common causative organisms of infective endocarditis

Answer 21

-Streptococci- 4-16% mortality
-Staph aureus - most common in IV drug users - Much higher mortality roughly 50%
staphylococci- coagulase negative- usually caused by prosthetic valves
-Enterococcal - indicate lower GI involvement
-Candida or aspergillus- common in immunosuppressed patients - Mortality very high in these cases 50%
-

Question 22

Why are blood cultures negative in 5% of endocarditis patients?

Answer 22

-Because the patients may have had antimicrobial drugs recently
-There maybe slow growing organisms
-HACEK organisms- which are slow growing gram negative

Question 23

Symptoms of IE?

Answer 23

-Unexplained fever
-Bacteraemia
-Systemic illness weight loss
-New murmur

Question 24

Investigations for IE

Answer 24

-FBC
-CRP
-U&E
LFTS
-Urine Dip analysis for bacteria
-CXR
-ECG
-Blood cultures- 3-6 sets from different sets over a couple of hours- you can delay the antibiotic treatment if patient is stable to get better samples- if cultures are negative and you still suspect IE- samples can be taken in a special media for slow growing organisms
-ECHO - transthoracic or transesophageal - more sensitive

Question 25

What is the basis for diagnosis?

Answer 25

Two major criteria, one major and three minor or five minor

Question 26

what are the Major criteria for IE?

Answer 26

-Positive blood cultures
-Endocardial involvement
-positive ECHO
-new regurg
-dehisence of prosthesis

Question 27

what is the minor criteria for IE?

Answer 27

-Predisposing valvular/ cardiac abnormality
-IV drug user
-fever >38
-embolic phenomenon
-vasculitic phenomenon
-suggestive but not definitive blood cultures
-suggestive echo

Question 28

What is an embolic/vasculitic phenomenon?

Answer 28

-This is when part of the vegetation breaks away lodges elsewhere- causing embolus and vasculitis.

Question 29

Management of IE

Answer 29

-Antibiotic therapy - central venous line
STREP- benzylpenicillin or vancomycin if allergic to penicillin and low dose gentamicin (80mgbd)
ENTEROCOCCI- Amoxicillin IV (or vancomycin) and low dose gentamicin
STAPH- flucloaxicillin- ( benzylpenicillin is penicillin sensitive or Vancomycin if allergic) and gentamicin

Question 30

What further monitoring is required after meds in IE?

Answer 30

-Weekly ECHOS
-ECG twice weekly
-Blood test twice weekly

Question 31

When should you consider surgery in IE?

Answer 31

-moderate severe cardiac failure
-degeneration of prosthetics
-incompetent valves
-systemic embolism
-relapse after meds
-valve obstruction
-fungal infections