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Cardiovascular System > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What is heart failure?

A

Heart failure is when the heart is not working as well as it should - so there’s reduced cardiac output.

But it does not mean that the heart has stopped or is going to stop at any moment.
It’s a structural abnormality of the heart

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2
Q

What is heart failure defined by?

A

How sudden the symptoms come on - (chronic or acute)

How much blood the heart managed to pump with each heartbeat - (preserved or reduced ejection volume)

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3
Q

What are the symptoms of heart failure?

A
  • Shortness of breath
  • Persistent coughing or wheezing
  • Ankle swelling
  • Reduced exercise tolerance
  • Fatigue

(CAN BE accompanied by pulmonary crackles and pulmonary oedema

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4
Q

What does heart failure mean in terms of fluids?

A

Patients with heart failure carry a lot of water weight.

Heart failure = High Fluids

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5
Q

What vaccinations must be offered to people with heart failure?

A

Annual influenza and pneumococcal disease vaccines

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6
Q

What is done to diagnose heart failure?

A

A physical examination - faster pulse, enlarged heart, fluid retention like swollen ankles.

A blood test - measure B-type natriuretic peptide (BNP) OR N-terminal pro-B-type natriuretic peptide. They increase in heart failure.

And other test like: ECG, Chest X-rays and blood and urine tests.

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7
Q

What physical examination is done to diagnose heart failure?

A
  • Faster than normal pulse
  • Enlarged heart
  • Signs of fluid retention (e.g. swollen ankles, enlarged liver, crackles in the lungs)
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8
Q

What blood test is done to diagnose heart failure?

A
  • B-type natriuretic peptide (BNP)
  • N-terminal pro B-type natriuretic peptide (NT-proBNP)

Both increase in heart failure

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9
Q

What are some non-drug management for acute heart failure?

A
  • Lifestyle changes (e.g. smoking cessation, exercise, reduced alcohol etc)
  • Daily weighing (weight gain of 1.5-2kg within 2 days should be reported to GP)
  • Restrict salt in diet (less than 6g daily)
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10
Q

What are the drugs used for acute heart failure?

A
  • ACE inhibitor/ARB -

(perindopril, ramipril, captopril, enalapril, lisinopril, quinapril, fosinopril /
valsartan, losartan, candesartan

  • Beta blocker that are licensed for heart failure - NBC, Nebivolol, Bisoprolol, Carvedilol
  • Calcium channel blocker (ONLY amlodipine) - for pts with HF and angina
  • Diuretics - Loops for relief of breathlessness and oedema in fluid retention.
    Thiazides used for mild fluid retention and eGFR > 30.

Mineralocorticoid receptor antagonist (MRA) - spironolactone/eplerenone.

Digoxin, hydralazine, sacubitril valsartan, Ivabradine & nitrates - for pts with worsening heart failure

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11
Q

What is the management for chronic heart failure?

A

IF PRESERVED EJECTION FRACTION:
Manage comorbidities such as hypertension,
AF, ischaemic heart disease, and diabetes in line with NICE guidance.

Offer a personalised exercise-based cardiac rehabilitation programme unless condition is unstable.

IF REDUCED EJECTION FRACTION:
Offer ACE inhibitor AND a beta blocker (one at a time and optimise each drug first).
Then an MRA (like spironolactone or eplerenone) if symptoms continue.

New - Dapagliflozin 10mg OD.
And Empagliflozin 10mg OD.

If intolerant to ACEI, us ARBs.

Consider hydralazine and nitrate if intolerant of ACE inhibitor/ARB.

Diuretics for congestive symptoms and fluid retention.

If symptoms worse, seek specialist advice and consider:
- Replacing ACEi/ARB with sacubitril valsartan if ejection fraction is <35

  • Adding Ivabradine for sinus rhythm if heart rate is >75 and ejection fraction is <35.
  • Adding hydralazine and nitrate (especially if of African-Caribbean descent)
  • Digoxin for heart failure with sinus rhythm to improve symptoms.
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12
Q

What must be offered to both heart failure preserved and reduced ejection fraction?

A

Offer a personalised exercise-based cardiac rehabilitation programme unless condition is unstable

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13
Q

If symptoms persist for chronic heart failure, what should be done?

A

Seek specialist advice and they can do the following:

  1. Replace ACEi/ARB with sacubitril with valsartan if ejection fraction <35%
  2. Add Ivabradine for sinus rhythm with heart rate >75 and ejection fraction <35%
  3. Add hydralazine and nitrate (esp if patient is of African or Caribbean descent)
  4. Digoxin for heart failure with sinus rhythm to improve symptoms
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14
Q

What do Diuretics help with?

A

They help to relieve breathlessness and oedema in patients with fluid retention

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15
Q

Which diuretics is preferred?

A

Loop diuretics

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16
Q

When are thiazide diuretics used and preferred?

A

In mild fluid retention and eGFR >30mL/min/1.72m2

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17
Q

When should spironolactone be avoided?

A

In hyperkalaemia or renal failure

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18
Q

Which calcium channel blocker is used in heart failure?

A

Amlodipine ONLY!

No other calcium channel blocker should be used as they reduce cardiac contractility

19
Q

What re-assessments do specialist do when symptoms continue to persist?

A
  • Cardiac resynchronisation therapy
  • Implantable cardioverter defibrillator
20
Q

Which drugs worsen heart failure?

A

NSAIDs - retain sodium
CCB - except

Stop all these drugs as they worsen heart failure

21
Q

How do you know when to start with an ACE or BB first?

A

ACE first - if patient has diabetes or fluid retention

BB - if patient has angina

22
Q

What is the side effect of ACEi?

A

Dry cough

23
Q

What are the three types of acute coronary syndrome?

A
  1. Unstable angina
  2. Non-ST elevated myocardial infarction (NSTEMI)
  3. ST elevated myocardial infarction (STEMI)
24
Q

What is myocardial infarcation?

A

A heart attack or cardiac arrest

25
Q

What is the cause of acute coronary syndrome?

A
  • Cholesterol builds up over time in the coronary artery and forms a plaque
  • Plaque ruptures from within a coronary artery causing a complete or partial block
  • Obstruction restricts blood supply to the heart
  • Lack of oxygen to the heart leads to an ischaemia (chest pain/angina)
  • If obstruction is extensive, some of the heart muscle begins to die (necrosis), leading
    to a myocardial infarction
26
Q

What’s the difference between NSTEMI and STEMI?

A

NSTEMI – Partial obstruction of coronary artery resulting in the death of some muscle cells.

NS = Not Serious

STEMI – Complete obstruction of coronary artery resulting in the death of cardiac muscle.

STEMI - Serious

27
Q

What are the symptoms of Angina?

A
  • Chest pain (sharp, stabbing, tight, heavy, dull), which spreads to left arm, neck, jaw, or back
  • Triggered by physical exertion or stress
  • Usually stops within a few minutes of resting
  • Nausea, fatigue, shortness of breath, sweating, dizziness
28
Q

What is the difference between stable angina and unstable angina?

A

STABLE angina: symptoms occur during physical activity or stress and stop on resting,
therefore symptoms are predictable.

UNSTABLE angina: symptoms occur whilst resting, last longer, are more recurring and chest pain is more severe, therefore symptoms are unpredictable.

29
Q

What is the initial management of unstable angina and nstemi?

A

GIVE ASAP:

  • Glyceryl trinitrate (sublingual/buccal) - asap for pain relief
    OR IV opioids like Morphine.
  • Aspirin 300mg
  • Oxygen if needed - if signs of hypoxia, pulmonary oedema, or continuing myocardial ischaemia
  • Insulin (if hyperglycaemic (Glucose >11mmol/l)

1) Aspirin 300mg and clopidogrel
* Aspirin 300mg chewed or dispersed
* Alternatives to clopidogrel include prasugrel or ticagrelor

THEN:
2) Antithrombin (Fondaparinux sodium)

3) ) Unfractionated heparin, LWMH (for significant renal impairment)

30
Q

What are nitrates used for in the initial management of unstable angina and nstemi?

What types do you use and what do you give next if ineffective?

A
  • Use to relieve ischaemic pain
  • If sublingual GTN is ineffective, give IV or buccal GTN, or IV isosorbide dinitrate.
  • If pain continues, give IV diamorphine or IV morphine and an antiemetic
31
Q

What is the management of STEMI?

A

INITIAL MANAGEMENT:
Same as NSTEMI but with the addition of an ACE inhibitor

LONG TERM MANAGEMENT:
Same as NSTEMI but with the addition of a statin

32
Q

What is the short term treatment for stable angina?

A

Sublingual glyceryl trinitrate should be used as a preventative measure immediately
before activities that are known to bring on an attack.

33
Q

What is the long term treatment for stable angina?

A
  • Beta blockers are first-line therapy.
  • If beta blocker is contraindicated, give a rate-limiting calcium channel blocker.
  • Give beta blocker AND calcium channel blocker if beta blocker alone fails to control
    symptoms.
  • If the above fails, consider adding ivabradine, nicorandil, or ranolazine.
  • Consider ACE inhibitor, especially if the patient has diabetes
34
Q

What is the use of nitrates in Angina?

A

They are potent coronary vasodilators,
however; the principal benefit is a reduction in venous return, which reduces left
ventricular work.

35
Q

What are the side effects of nitrates?

A
  • Flushing
  • Headaches
  • Postural hypotension
36
Q

How long does Glyceryl Trinitrate (GTN) last?

A

It’s effects only last 20-30 minutes.

37
Q

What forms is GTN available in?

A

Sublingual tablets, sublingual spray or patches

38
Q

What is the Prophylaxis of angina?

A

ONE sublingual tablet (or ONE to TWO sprays) before activity like to causes angina

39
Q

What is the treatment of angina?

A

ONE sublingual tablet (or ONE to TWO sprays) repeated after 5 minutes if required.

If symptoms have not resolved after 3 doses, emergency medical attention should be sought.

40
Q

How do you avoid the risk of tolerance of Nitrates?

A

All nitrates have a risk of tolerance, therefore:
* Take MR preparations only ONCE daily where possible.

  • For twice-daily preparations, take the second dose 6-8 hours after the first dose, NOT 12 hours afterwards.
  • For patches, leave them off for 8-12 hours in each 24-hour period (usually overnight).
41
Q

How must GTN tablets be dispensed and discard?

A
  • Should be supplied in a glass bottle of no more than 100 tablets
  • Closed with a foil-line cap
  • No cotton wool or wadding
  • Discard after 8 weeks of opening (same applies to rectal ointment)
42
Q

What’s the secondary prevention for ACS?

A

Initiate this in ALL patients NSTEMI or STEMI

  1. Cardiac rehabilitation (lifestyle interventions, smoking etc)
  2. ACEi / ARB
  3. BB - alternative is Diltiazem / verapamil
  4. Dual anti-platelet therapy - Aspirin + clopidogrel for 12 months
  5. Dual/Triple therapy WITH anticoagulant - for patient that have a high cardiac biomarker -
    (Aspirin +/ Clopidogrel + Rivaroxaban
  6. Statin (always for secondary prevention of ACS)
43
Q
A

Cardiovascular System (9 decks)

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