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Yr 3 Cardiovascular > Heart failure > Flashcards

Heart failure Flashcards

1
Q

What is heart failure?

A

any structural or functional disorder that impairs the ability of the heart to function as a pump to support a physiological circulation
This can be due to an inability for the heart to fill will blood correctly (diastolic) , or an inability of the heart to eject blood effectively (systolic)

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2
Q

What is the incidence of heart failure in the UK per 1000?

A

2 in 1000

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3
Q

What is preload?

A

the amount of sarcomere stretch experienced by cardiomyocytes at the end of ventricular filling during diastole

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4
Q

Describe how increasing preload reduces cardiac function in heart failure:

A

1) in heart failure, less blood is ejected from the heart. The remaining blood increases diastolic volume which stretches cardiomyocytes
2) too much preload leads to a depression in ventricular function and stroke volume

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5
Q

What is left sided heart failure?

A

Inability of left ventricle to pump adequate amount of blood

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6
Q

Describe how heart failure can lead to oedema:

A

as ejection fraction falls, diastolic volume increases
this creates a backpressure that increases venous pressure allowing fluid to pool in the interstitium

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7
Q

What is outflow resistance?

A

the resistance against which the ventricle contracts

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8
Q

Give 3 factors that determine outflow resistance:

A
  1. Pulmonary and systemic resistance
  2. Physical properties of the vessel wall
  3. Volume of the blood ejected
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9
Q

What does Inotropy refer to?

A

force of contraction

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10
Q

Describe how heart failure affects salt and water levels in the body:

A

The increased venous pressure leads to salt and water retention while the reduced cardiac output reduces the systemic blood pressure, activating the RAAS system, also enhancing salt and water retention

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11
Q

Give 3 ways in which the myocardium remodels in heart failure:

A
  1. Hypertrophy
  2. Loss of myocytes
  3. increased interstitial fibrosis
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12
Q

Describe how endothelial function changes in HF:

A

endothelial responsiveness to nitric oxide reduces, reducing vasodilatory properties

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13
Q

What is systolic heart failure?

A

where ventricles cannot contract properly

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14
Q

What is the ejection fraction threshold for systolic heart failure?

A

less than 40%

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15
Q

What is diastolic heart failure?

A

where ventricles cannot relax and fill normally causing increased filling pressures

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16
Q

What is another name for diastolic heart failure?

A

heart failure with preserved ejection fraction

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17
Q

Give 6 common causes of heart failure:

A

1) ischaemic heart disease (35-40%)
2) cardiomyopathies (30-34%)
3) hypertension (15-20%)
4) valvular disease
5) kidney disease
6) IV fluids in frail, elderly patients

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18
Q

How does hypertension cause heart failure?

A

it increases pressure against which the left ventricle is pumping against, reducing ejection fraction and thus increasing pre-load

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19
Q

How do valvular diseases cause heart failure?

A

regurgitation leaves more blood in the left ventricle, decreasing the ejection fraction and thus increasing preload

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20
Q

Give 2 ways in which kidney disease can cause heart failure:

A

1) electrolyte imbalances can cause arrhythmias
2) poor kidney function increases circulating volume and hence vascular resistance

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21
Q

Give 8 risk factors for heart failure:

A

1) male sex
2) obesity
3) old age
4) dyslipidaemia
5) alcohol abuse
6) diabetes
7) sleep apnoea
8) smoking

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22
Q

Give 4 key symptoms of heart failure:

A

1) exertional dyspnoea (often secondary to pulmonary oedema)
2) orthopnoea (breathlessness laying flat)
3) paroxysmal nocturnal dyspnoea ( an attack of severe shortness of breath and coughing that generally occurs at night.)
4) fatigue

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23
Q

Give 8 signs associated with heart failure:

A

1) tachycardia
2) increased JVP
3) cardiomegaly
4) third and fourth heart sounds
5) bi-basal lung crackles (from oedema)
6) pleural effusion
7) peripheral ankle oedema
8) ascites

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24
Q

What is congestive heart failure?

A

failure of both right and left ventricles, which is common

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25
What is low-output HF?
heart failure resulting from reduced cardiac output [most common type] – also referred to as HFrEF – Heart Failure reduced Ejection Fractions
26
What is high output HF?
heart failure that occurs in normal or high cardiac output due to metabolic demand and supply mismatch, either due to reduced blood oxygen carrying capacity [anaemia] or increase body metabolic demand [thyrotoxicosis] – also referred to as HFpEF – Heart Failure preserved Ejection Fraction
27
How does ischaemic heart diease cause heart failure?
Causes impaired ventricular function, therefore reduced contractility function and hf
28
What is mean arterial pressure?
Cardiac output x total peripheral resistance
29
What is the pathophysiology of heart failure?
1. Heart failure causes a drop in mean arterial pressure that initially stimulates baroreceptors that feed back onto the medullary cardiovascular centre. 2. MCVC tries to increase and maintain the mean arterial pressure by reducing the vagal tone and increase sympathetic tone, leading to increase heart contractility and rate therefore output. 3. The sympathetic system also stimulates the contraction of arteries (increasing total peripheral resistance) and veins (increasing venous return) and the release of adrenaline from the adrenal medulla, which stimulate all of the above actions. 4. the RAAS system is also stimulated in HF due to reduced kidney perfusion caused by reduced MAP, vasoconstriction and direct sympathetic stimulation. 5. The RAAS system releases aldosterone and ADH causing sodium and water retention. 6. These mechanisms are beneficial initially as they increase blood volume, therefore venous return, stroke volume and heart rate therefore maintaining a high cardiac output however eventually worsening the situation.
30
How does a increased total peripheral resistance worsen HF?
Increase afterload therefore increasing workload and strain on the heart Tissue underperfusion leading to ischemia RAS system stimulation
31
How does increased HR worsen HF?
Increase workload and therefore oxygen demand of the heart
32
How does fluid retention worsen HF?
1. Increase stretching of the heart eventually leading to dilatation of ventricles which possess reduced contractility 2. Fluid build up causes fluid transudation into interstitial tissue causing peripheral and pulmonary oedema 3. Hyponatremia and hypokalemia
33
What is pink frothy sputum indicative of?
pulmonary oedema
34
What are 3 signs of fluid overload?
Peripheral oedema – ankles +/- sacrum Ascites Elevated JVP [venous congestion]
35
Give 4 CXR signs associated with heart failure:
1) cardiomegaly 2) pulmonary congestion 3) pulmonary oedema 4) Kerly B lines
36
What are Kerly B lines?
Horizontal lines in the bases of the lung fields indicative of fluid in the interlobular septa
37
Give 4 types of investigation used to diagnose heart failure:
1) CXR 2) ECG 3) echocardiography 4) bloods
38
What is an echocardiogram used to assess in heart failure investigations? (4)
1) chamber dimension 2) ejection fraction (systolic and diastolic function) 3) wall abnormalities 4) cardiomyopathies
39
Where and when is atrial natriuretic peptide produced?
atrial myocytes in response to stretch
40
What is the effect of ANP? (3)
1) induces diuresis 2) induces natriuresis 3) suppresses RAAS system (overall reducing blood pressure)
41
What is natriuresis?
excretion of sodium in the urine
42
Where and when is B-type natriuretic peptide produced?
ventricles in response to wall stress
43
What condition are elevated levels of circulating ANP associated with?
congestive heart failure
44
What is the effect of BNP? (2)
1) relaxing smooth muscle in blood vessels 2) enhancing diuresis (overall reducing blood pressure)
45
where is C-type natriuretic peptide secreted from?
CNS and endothelium
46
Describe the steps in managing acute/ sudden deterioration heart failure (hint: Pour SOD):
1) 'Pour away' (stop) their IV fluids 2) sit the patient upright 3) give oxygen 3) diuretics
47
Give 4 factors that need to be monitored in order to establish a patient's fluid balance:
1) fluid intake 2) urine output 3) U+Es 4) daily body weight
48
Name the 5 groups of key heart failure drugs used in chronic management:
1) ACE inhibitors 2) beta blockers 3) diuretics 4) angiotensin II receptor antagonists (ARBs) 5) aldosterone antagonists
49
Give 4 side effects of ACE inhibitors:
1) cough 2) hyperkalaemia 3) renal dysfunction 4) hypotension
50
How do loop diuretics work?
they act by promoting the renal excretion of salt and water by blocking tubular reabsorption of Na+ and Cl-
51
Give two examples of loop diuretics:
1) furosemide 2) bumetanide
52
Give an example of a thiazide diuretic:
Bendroflumethiazide
53
Give 3 examples of ARBs?
1) candesartan 2) losartan 3) valsartan
54
When are ARBs used to manage chronic heart failure?
when ACE inhibitors are contraindicated
55
Give an example of an aldosterone antagonist:
Spironolactone
56
Give an example of an inotrope drug:
noradrenalin
57
When would a patient be given inotropes for heart failure?
in severe cases
58
What is an inotrope?
An inotrope is a type of medicine that affects the contraction of the heart muscle. Positive inotropes stimulate and increase the force of contraction, while negative inotropes weaken the force of muscular contractions, decreasing the heart's workload
59
What drugs will most patients be treated with?
ACEi and diuretic
60
If a patient is intolerant to ACEi and ARBs what might be considered?
Hydralazine + Nitrates
61
Who should beta blockers be avoided?
Patients with fluid overload Advice is to treat the fluid overload first and then start beta-blocker once euvolaemic
62
What are 4 contradictions for beta blockers?
Asthma 2nd or 3rd degree heart block Sick sinus syndrome Sinus bradycardia (<50bpm)
63
What is the difference between thiazide and loop diuretics?
thiazide causes a more gentle and slower onset diuresis, often used first line in milder forms of heart failure
64
When is digoxin considered as treatment?
Sinus rhythm patients that remain symptomatic even after other pharmacological interventions (third line after ACE-i and diuretics) Patients with severely impaired left ventricular function Recurrent hospital admissions Treating AF in CHF Amiodarone in arrhythmic patients
65
WHAT IS THE OFFICAL STEP-WISE APPROACH FOR TREATMENT OF HEART FAILURE?
ACE inhibitors or ARB ADD diuretic ADD beta-blocker (once euvolaemia) ADD aldosterone antagonist (spironolactone or amiloride) then – increase all above to maximum tolerated doses CONSIDER ARNI (and cease ACE-i) for patients who remain with an EF <40% CONSIDER ivabridine CONSIDER another vasodilator, e.g. isosorbide dinitrate or hydralazine CONSIDER digoxin CONSIDER implantable cardiac devices
66
What causes right sided heart failure most commonly?
Left sided heart failure
67
What does right sided heart failure lead to?
1. Systemic venous congestion therefore peripheral oedema and hepatic congestion and tenderness
68
Right ventricular failure is often caused by pulmonary hypertension secondary to chronic lung disease such as: (4)
1) COPD 2) pulmonary fibrosis 3) bronchiectasis 4) recurrent pulmonary emboli
69
Give 3 heart failure symptoms that are associated more so with right ventricular failure:
1. Peripheral oedema 2. Hepatomegaly 3. Raised JVP
70
What is commonly found on the history and exam of left sided heart failure?
Fatigue Poor exercise tolerance Syncope (sudden drop in blood pressure and heart rate) Systemic hypotension Cold peripheries Slow capillary refill Peripheral cyanosis Weight loss Nocturia Pulsus alternans Mitral regurgitation S3/S4 gallop (left-sided)
71
What is commonly found on the history and exam of right sided heart failure?
Left failure symptoms if decreased RV output leads to LV underfilling Nausea Anorexia Facial engorgement Epistaxis (nose bleed) Tricuspid regurgitation S3/S4 gallop(right-sided)
72
What are pulsus alternans:
arterial pulse waveform showing alternating strong and weak beats. ➢Almost always LV systolic impairment ➢Carries a poor prognosis
73
What is Kussmaul's sign?
A paradoxical rise in JVP on inspiration or a failure in the appropriate fall of the JVP with inspiration
74
What is alveolar oedema?
'Bat wing' shadowing on CXR feature of left sided heart failure
75
What is congestive heart failure?
when the heart muscle is overworked due to stress, high blood pressure, arteriosclerosis, and fluids begin to collect in the body tissues
76
Give 8 conditions that cause congestive heart failure:
1) coronary artery disease and MIs 2) restrictive cardiomyopathies 3) hypertension 4) constrictive pericarditis 5) arrhythmias 6) congenital defects 7) valvular defects 8) heart block

Yr 3 Cardiovascular (31 decks)

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