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Heart Failure Flashcards

1
Q

What is heart failure?

A

Reduced cardiac output.

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?

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
What is the cause of acute coronary syndrome?
* 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
What's the difference between NSTEMI and STEMI?
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
What are the symptoms of Angina?
* 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
What is the difference between stable angina and unstable angina?
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
What is the initial management of unstable angina and nstemi?
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
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?
* 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
What is the management of STEMI?
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
What is the short term treatment for stable angina?
Sublingual glyceryl trinitrate should be used as a preventative measure immediately before activities that are known to bring on an attack.
33
What is the long term treatment for stable angina?
* 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
What is the use of nitrates in Angina?
They are potent coronary vasodilators, however; the principal benefit is a reduction in venous return, which reduces left ventricular work.
35
What are the side effects of nitrates?
* Flushing * Headaches * Postural hypotension
36
How long does Glyceryl Trinitrate (GTN) last?
It's effects only last 20-30 minutes.
37
What forms is GTN available in?
Sublingual tablets, sublingual spray or patches
38
What is the Prophylaxis of angina?
ONE sublingual tablet (or ONE to TWO sprays) before activity like to causes angina
39
What is the treatment of angina?
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
How do you avoid the risk of tolerance of Nitrates?
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
How must GTN tablets be dispensed and discard?
* 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
What's the secondary prevention for ACS?
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

Cardiovascular System (8 decks)

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