Heart Failure Flashcards
What are the common and less common causes of heart failure in the uk?
Common - Coronary artery disease, hypertension, idiopathic, toxins (alcohol/chemotherapy), genetics.
Less common - Valve disease, infections (Chaga’s), congenital heart disease, metabolic (hemochromatosis, amyloidosis) and pericardial disease (TB)
What are different ways of classifying heart failure?
- By ejection fraction (reduced or preserved),
- By systolic (unable to pump blood efficiently) vs diastolic dysfunction (impaired filling),
- Acute vs chronic
What are some causes of systolic dysfunction heart failure?
- Ischaemic heart disease,
- Dilated cardiomyopathy,
- Myocarditis
- Arrhythmias
What are some causes of diastolic dysfunction?
- Hypertrophic obstructive cardiomyopathy,
- Restrictive cardiomyopathy,
- Cardiac tamponade,
- Constrictive pericarditis
Explain the signs and symptoms of left heart failure
Symptoms: SOB on exertion, orthopnoea, PND, nocturnal cough (+/- pink frothy sputum), fatigue.
Signs: Tachypnoea, bibasal crackles, cyanosis, CRT >2 sec, hypotension, pulsus alternans, S3 gallop, functional mitral regurg
What are the clinical features of right heart failure?
Symptoms: Ankle swelling, weight gain, abdominal swelling and discomfort, anorexia and nausea.
Signs: Raised JVP, pitting peripheral oedema, tender smooth hepatomegaly, ascites, transudative pleural effusions.
What are the investigations for heart failure?
First line = NT-proBNP. If not raised then HF is excluded
Others: ECG (look for cause), transthoracic echo (can show valvular dysfunction and ejection fraction), bloods (U&Es, LFTs, TFTm glucose and lipids), chest-X ray
What are the Chest X ray findings of heart failure?
ABCDEF
A - Alveolar oedema,
B - Kurly B lines (interstital oedema)
C - Cardiomegaly
D - upper lobe Diversion,
E - pleural Effusions
F - Fluid in horizonal fissure
What are some other causes of a raised BNP?
- LVH,
- Ischemia,
- Tachycardia,
- Hypoxia,
- eGFR < 60,
- Sepsis,
- COPD,
- Diabetes,
- Age > 70,
- Liver cirrhosis
What is the main pharmacological treatment for chronic heart failure?
ACEi/Angiotensin Receptor Neprilysin Inhibitor
Beta blocker,
Mineralocorticoid receptor antagonist (spironolactone)
SGLT2i (Gliflozin)
Loop diuretics for fluid retention
BAMS
1st line - ACE-inhibitor and a beta-blocker (one drug at a time)
2nd line - Add spironolactone and SGLT2 inhibitor
3rd line - Sacubitril-valsartan
What drugs are used in patients of afro-Caribbean descent?
Hydralazine (vascular muscle relaxant) and Isosorbine mononitrate
What is the normal function of angiotensin II
Vasoconstriction,
Sodium and water retention
Triggers aldosterone secretion,
Stimulates ADH release and SNS activation
Increases blood volume and vascular resistance.
What is the mechanism of angiotensin receptor neprilysin inhibitor
Sacubitril inhibits neprolysin which is an enzyme which breaks down BNP. BNP is important as it encourages vasodilation, natruresis, diuresis and inhibiton of fibrosis
What are the different devices used in the treatment of heart failure with reduced ejection fraction?
ICD (Implantable cardiovertable defibrillator)
CRT-D (cardiac resynchronisation therapy with defibrillator CRT with ICD)
CRT-P (cardiac resynchronisation therapy with only pacing)
What classes of NYHA HF are given what devices?
Lower class - ICD as these patients are more likely to die of an arrhythmia.
High classes - CRT as they are more likely to die of heart failure
Also depends on whether patients have a LBBB and their QRS length. Non ischaemic patients are less likely to benefit from ICD
Describe the use of ivabradine?
It is a sinus node inhibitor which is a class 2 recommendation in patients with HR > 70 BPM
Will lower HR
sinus rhythm > 75/min and a left ventricular fraction < 35%
Name some ventricular assist devices and their uses
Pulsatile/continuous (Continuous is better) flow LVADs
Usually used while patients wait for heart transplant but sometimes can be used as a long term treatment. They are only given to patients with greatly reduced ejection fraction
What is acute heart failure?
It is the sudden onset or worsening of the symptoms of heart failure. It can be the initial presentation of heart failure (de-novo AHF)
What are the causes of de-novo AHF?
- Ischaemia (most common),
- Viral myopathy,
- Toxins,
- Valve dysfunction
What are common precipitating factors for decompensation of CHF which leads to AHF?
- Acute coronary syndrome,
- Hypertensive crisis,
- Acute arrhythmia,
- Valvular disease
What are the different categories of acute heart failure?
- With or without hypoperfusion
- With or without congestion
What is the first line treatment for acute heart failure?
LNOP
- IV Loop diuretics
- IV or sublingual nitrates only if myocardial ischaemia, severe HTN, aortic regurg or mitral valve disease
- Oxygen to targets 94-98%
- Position up right
What is the second line treatment for acute heart failure?
If in resp failure - CPAP
If hypotensive/cardiogenic shock then - Ionotropes (beta agonists, eg, isoprenaline, dobutamine) or vasporessors
