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heart failure Flashcards

1
Q

Define HF

A

Progressive clinical syndrome characterised by structural or functional abnormalities of the heart that produces raised intracardiac pressure and/or reduced cardiac output at rest and/or at exercise

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2
Q

3 main categories

A
  • reduced EF
  • mildly reduced EF
  • preserved EF
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3
Q

symptoms of HF

A
  • persistent cough/wheeze
  • SOB
  • ankle swelling
  • reduced exercise tolerance
  • fatigue
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4
Q

3 signs of HF

A
  • pulmonary oedema
  • basal crepitations (pulmonary cackles)
  • elevated jugular venous pressure
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5
Q

Risk factors for HF

A
  • CAD
  • MI
  • Hypertension
  • AF
  • DM
  • FHx HF or sudden cardiac death <40
  • Male
  • Smoker
  • Elderly
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6
Q

most common cause of HF

A

CAD

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7
Q

HF often co-exists with other comorbidities e.g

A
  • CHD
  • CKD
  • AF
  • Hypertension
  • Dyslipidaemia
  • Obesity
  • Diabetes mellitus
  • COPD
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8
Q

most common cause of HF in Afro/Afro-Caribbean

A

more likely to develop HF secondary to hypertension

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9
Q

relationship between comorbids and HF prognosis

A

worse prognosis of HF if pt has comorbidities

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10
Q

Complications of HF

A
  • CKD
  • AF
  • depression
  • cachexia (weakness and wasting of body)
  • sexual dysfunction
  • sudden cardiac death
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11
Q

Pregnant women/given birth within 6 months and suspected to have HF

A
  • arrange emergency admission or
  • seek immediate specialist advice
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12
Q

what to do if HF is suspected clinically

A
  • admission if pt has severe symptoms
  • measure natriuretic peptide level (NT-pro-BNP)
  • 12-lead ECG in all people
  • consider other tests to evaluate for other factors and exclude other conditions
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13
Q

serum natriuretic peptide levels

A
  • normal: HF unlikely
  • > 2k ng/l (235pmol/l) - urgent referral for specialist assessment and transthoracic ECG within 2 weeks
  • 400-2k ng/L (47-236) refer for above within 6 weeks
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14
Q

does level of natrueitic peptide indicate type of HF

A

No - does not differentiate between different types (e.g. if reduced, preserved EF etc)

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15
Q

name 2 markers that are strong RF and prognostic markers of poor outcomes in pt with suspected HF

A
  • anaemia
  • high platelet: lymphocyte % (low lymphocyte count)
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16
Q

what to do in pt with HF due to valve disease

A

refer for specialist assessment and give advice regarding follow up

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17
Q

natriuretic peptide levels may be reduced by

A
  • BMI >35
  • drugs e.g. diuretics, ACEi, ARB, BB, MRA (e.g. spironolactone)
  • afro-caribbean
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18
Q

natriuretic peptide levels may be elevated by

A
  • > 70
  • LV hypertrophy, MI, tachycardia
  • RV overload
  • hypoxia
  • pulmonary hypertension
  • pulmonary embolism
  • CKD (eGFR <60)
  • sepsis
  • COPD
  • DM
  • liver cirrhosis
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19
Q

differential diagnosis - conditions causing breathlessness

A
  • COPD
  • Asthma
  • PE
  • Lung cancer
  • Anxiety
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20
Q

differential diagnosis - conditions causing peripheral oedema

A
  • Prolonged inactivity or venous insufficiency causing dependent oedema
  • Nephrotic syndrome
  • Drugs e.g. DHP-CCBs, NSAIDs
  • Hypoalbuminemia (from renal or hepatic disease)
  • Pelvic tumour
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21
Q

differential diagnosis - other conditions

A
  • obesity
  • severe anaemia or thyroid disease
  • bilateral renal artery stenosis
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22
Q

define HF with reduced ejection fraction

A

LV loses its ability to contract normally and therefore presents with ejection fraction of less than 40%

23
Q

HF with preserved ejection fraction

A

LV loses its ability to relax normally and therefore the ejection fraction is normal or only mildly reduced

24
Q

what is the New York Heart Association (NYHA) functional classification tool used for

A

Used to define the progression of chronic HF according to severity of symptoms and limitations to physical activity

25
Q

HF is considered to be stable or chronic when

A

Symptoms remain unchanged for at least one month despite optimal treatment

26
Q

lifestyle treatment in pt with HF to reduce risk progression and associated comorbidities

A
  • smoking cessation
  • reduced alcohol
  • increase exercise if appropriate
  • weight control
  • increase fruit and veg
  • reduce saturated fats
  • salt intake <6g daily
27
Q

Use of salt substituted containing potassium in pt with HF

A

AVOID to reduce risk of hyperkalaemia

28
Q

non-drug treatment options in pt with HF and REF <40%

A

Implantable cardioverter defibrillators and cardiac resynchronisation therapy

29
Q

Which vaccines are recommended in pt with HF?

A
  • Pneumococcal
  • Annual influenza
30
Q

A patient who is on atenolol 100mg BD for angina has been diagnosed with HF. would you change the medication?

A

Change BB to one licensed for use in HF: bisop, carved, nevibolol

31
Q

Review of meds when a pt is diagnosed with HF

A
  • stop drugs which may cause or worsen HF e.g. RLCCB and SA DHP CCBs as these reduce cardiac contractility
  • except amlodipine - pt with HF and angina can be treated with this
32
Q

drug treatment for CHF with REF

A
  • 1st line: ACEi + BB (bisop, carved, nebivolol)
  • If ACEi not tolerated, ARB (cande, losart, valsart)
    • Preferred initial treatment may be with ACEi if pt has DM or signs of fluid overload and BB can make symptoms of HF worse
    • do not offer ACE I if clinical suspicion of haemodynamically significant valve disease
  • If symptoms persist, + MRA (spirono, eplerenone)
  • Intolerant of ACEi + ARB: specialist advice on. hydralazine + nitrate (esp for Afro/Caribbean)
  • If symptoms persist, speak to specialist re amiodarone, digoxin, entresto, ivabradine, empag, dapagliflozi
33
Q

Drug treatment for chronic HF with reduced ejection fraction - fluid overload

A
  • Offer loop diuretic (toras, furos, bumet) for relief of breathlessness and oedema
  • Thiazides may only be of benefit in pt with mild fluid retention and eGFR >30
  • titrate does according to clinical response and adjust as needed
  • if symptoms persist, seek advice from HF specialist
34
Q

Monitoring drug treatment - ACEi, ARBs, MRAs

A
  • imitation: check serum K + Na, renal function, BP before
  • then check 1-2 weeks after starting
  • and at each dose increment
  • once stable, monitor monthly for 3 months, then at least every 6 months, and when pt is acutely unwell
35
Q

monitoring drug treatment - BB

A

on initiation and after each dose change: HR, BP, symptom control

36
Q

Treatment of CHF with preserved EF

A
  • review and stop any drugs that cause/worsen HF e.g. CCBs
  • managed under care of HF specialist
  • low to medium dose loop diuretic for fluid retention - up to 80mg furosemide or equivalent
  • if pt fails to respond, seek advice from specialist - may consider empag or dapag
37
Q

Summarise what management of people with HF with mildly reduced ejection fraction includes

A

Offer diuretic if symptoms f fluid overload
Consider offering an ACEi, BB ( + MRA if symptoms persist)

38
Q

additional management for all pt with HF

A
  • is antupalatelet drug indicated e.g. clopidogrel?
  • is a statin indicated?
  • screen for anxiety and depression
  • offer annual flu vaccine and once only pneumococcal vaccine
  • assess nutritional status (BMI) and refer as needed
  • childbearing age: contraception & pregnancy advice
39
Q

monitoring weight

A
  • Advise pt to check weight e.g. daily, weekly, or fortnightly, depending on clinical judgement.
  • Weigh at same time of day (e.g. after waking and voiding but before dressing or eating).
  • Advise what to do if there is sudden and sustained weight gain (e.g. > 2 kg in 3 days).
  • Options include seeking medical advice, increasing the diuretic dose, reducing fluid intake, or a combination of actions.
  • The pt should understand that deterioration can occur without weight gain.
40
Q

maintaining fluid balance

A
  • Severe symptomatic heart failure: restrict fluid intake
  • e.g. to <1.5–2 L / day to relieve symptoms
  • or consider a weight-based fluid restriction e.g 30 mL/kg body weight, or 35 mL/kg body weight over 85 kg
  • Restriction of hypotonic fluids may improve hyponatraemia.
  • Fluid intake should not be excessively restricted to reduce the risk of dehydration.
  • People should seek medical advice if they feel thirsty, light headed, or dizzy, as this may be a sign of hypotension or hypovolaemia
41
Q

what to do if acutely unwell (e.g. diarrhoea and vomiting)

A
  • If stale HF and taking ACEI, ARB, diuretic or MRA: maintain fluid intake and stop drugs until recover & eating and drinking normally
  • Sick day rules
  • Be aware of risk of AKI if pt unwell or dehydrated
  • If severe of uncontrolled HF or symptoms of diarrhoea and vomiting persist, seek medical advice re meds and checking renal function & electrolytes
42
Q

nutritional status advice

A
  • If the BMI is under 18.5 kg/m2, consider referring the person for dietetic advice.
  • If the BMI is over 30 kg/m2, give advice on maintaining a healthy weight.
43
Q

Driving - DVLA

A
  • Group 1 entitlement (cars, motorcycles): can continue as long as no symptoms that distract drivers attention, DVLA don’t need to be notified
  • Group 2 entitlement (lorries, buses): disqualified from driving if symptomatic. re licensing may be permitted if LVEF is at least 40% and there is no disqualifying condition
44
Q

What to do if a patient had syncope or pre syncope (unless clearly due to postural hypotension)

A

Refer to a cardiologist as this may be due to ventricular tachycardia, particularly in people who have a reduced ejection fraction (HF-REF).

45
Q

examples of loop diuretics and dosages

A
  • Furosemide 20-40mg daily
  • Bumetanide 0.5-1.0 mg daily
  • Torasemide 5-10mg daily
46
Q

when is use of digoxin in pt with HF given and why?

A
  • for pt in sinus rhythm as ADD ON THERAPY in worsening symptoms severe HF despite optimal treatment
  • although it doesn’t reduce mortality, it may decrease symptoms and hospitalisations due to acute exacerbations
  • routine monitoring of serum levels not recommended in pt with HF
47
Q

which 2 conditions affects the management of HF in pt with these conditions?

A

AF
CKD

48
Q

patients should be advised to weigh themselves daily and report a weight gain of ….

A

report weight gain of more than 1.5-2 kg in 2 days to HF specialist or GP

49
Q

advice for pt with dilutional hyponatraemia (aka water intoxication)

A

only restrict fluid intake

50
Q

implantable cardioversion defibrillators and cardiac resynchronisation therapy are treatment options in..

A

pt with HF and REF of less than 35%

51
Q

anticoagulation should be considered for pt in sinus rhythm with HF if…

A

Hx thromboembolism, LV aneurysm or intracardiac thrombus

52
Q

advanced HF

A
  • breathlessness common symptom
  • may even occur with optimal management and in absence of clinical pulmonary oedema
  • long-term oxygen therapy not recommended but may be considered if there are comorbidities that would benefit from it e.g. COPD
53
Q

which drug should you initiate first in HF : BB or ACEi? and when would you introduce the other?

A
  • use clinical judgement
  • only initiate other drug once pt is stable on existing treatment
  • initiate at low dose and slowly titrate up to max - in pt with CKD, lower doses and slower titration should be considered
54
Q

CCBs should be avoided in heart failure because they reduce cardiac contractility and so can worsen symptoms. The exception is this drug, which can be used cautiously in stable HF

A

amlodipine

pre reg afsha CV (38 decks)

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