Heart failure Flashcards
What are the causes of heart failure?
Ischaemic heart disease
-hypertension
-valvular heart disease
-AF
-Cardiomyopathy
-HIV
What is the patient demographic for HFPF
-Obese
-Hypertensive
-elderly
what would be considered as a bad prognosis in HF?
-High NT-proBNP
-renal impairment
-Old
-co-morbidity
-frequent admissions with heart failure
Investigations for heart failure
-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
when else can BNP be elevated?
-AFib
-RV strain
What are the three classical symptoms of aortic stenosis?
Chest pain
Fatigue
Sob
CXR in Heart failure?
-Cardiomegaly
-Pleural effusions
-Curly B signs
-Alveolar bat wing signs
-pleural effusions
-Perihilar shadowing
-Air bronchograms
-Increased width of vascular pedicle
Management for heart failure ?
-Lifestyle modification :
-smoking cessation
-reduce alcohol
salt restriction
-fluid restrict- especially if patient is hyponatrreimic
-weight monitoring
Medication regimen for HF?
-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.
Types of Pacemakers:
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
What type of murmur is heard in aortic stenosis?
-Ejection systolic murmur, radiating to carotid and neck
Investigation and managemet od aortic stenosis?
-Surgery
-ECHO
-Transcatheter aortic valve implantation (TAVI)
-
Symptoms of aortic regurgitation?
-often patients are asymptomatic
- murmur associated with collapsing pulse and head bobbing- De Musset’s sign
Pathophysiology of aortic regurg?
Increased load in the LV- causes increased pressure and eventual dilatation and HF
Causes of Aortic regurg?
-Congenital abnormalities
-calcific degeneration
-rheumatic disease
-infective endocarditis
-Marfans syndrome
Investigations of Aortic regurgitations
-Echocardiography
when should you consider surgery for Aortic stenosis?
-very severe symptoimatically
-Asymptomatic with root dilatation >5.5cm
-Asymptomatic with early LV dysfunction EF<50%
What is the average interval of diagnosis to onset of symptoms for patients with mitral regurgitation?
16 years- patients are usually asymptomatic for years
What are the causes of Mitral regurg?
-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
Investigations for MR:
-Pan systolic murmur- usually radiates to the axilla
-Assessed by ECHO
When is surgery required in patients with Mitral valve regurg?
- 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%
What are the two surgical options for mitral regurg?
-Valve repair - more preferable has a higher mortality rate compared to replacement
-Valve replacement
What is an example of Ischaemic MR and what would be the treatment requirement?
- 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)
What are the causes of infective endocarditis?
-Prosthetic valve
-Poor dentition
-mitral valve prolapse
-Rheumatic heart disease
-Congenital heart disease
Common causative organisms of infective endocarditis
-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%
-
Why are blood cultures negative in 5% of endocarditis patients?
-Because the patients may have had antimicrobial drugs recently
-There maybe slow growing organisms
-HACEK organisms- which are slow growing gram negative
Symptoms of IE?
-Unexplained fever
-Bacteraemia
-Systemic illness weight loss
-New murmur
Investigations for IE
-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
What is the basis for diagnosis?
Two major criteria, one major and three minor or five minor
what are the Major criteria for IE?
-Positive blood cultures
-Endocardial involvement
-positive ECHO
-new regurg
-dehisence of prosthesis
what is the minor criteria for IE?
-Predisposing valvular/ cardiac abnormality
-IV drug user
-fever >38
-embolic phenomenon
-vasculitic phenomenon
-suggestive but not definitive blood cultures
-suggestive echo
What is an embolic/vasculitic phenomenon?
-This is when part of the vegetation breaks away lodges elsewhere- causing embolus and vasculitis.
Management of IE
-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
What further monitoring is required after meds in IE?
-Weekly ECHOS
-ECG twice weekly
-Blood test twice weekly
When should you consider surgery in IE?
-moderate severe cardiac failure
-degeneration of prosthetics
-incompetent valves
-systemic embolism
-relapse after meds
-valve obstruction
-fungal infections
