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Competency > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What is the ejection fraction for HFrEF?

A

LVEF ≤40%

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2
Q

What is heart failure?

A

Inability of the ventricle to fill with or eject blood due to structural / functional cardiac disorders = reduced cardiac output (CO)

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3
Q

What is characteristic of HFrEF?

A

Dilated ventricle

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4
Q

Causes of HFrEF?

A
  • chronic coronary disease (causing IHD)
  • HTN
  • obesity
  • myocarditis
  • tachycardia
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5
Q

What is the ejection fraction for HFpEF?

A

LVEF ≥50%

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6
Q

What is characteristic of HFpEF?

A
  • impaired ventricular relaxation and filling
  • normal wall motion
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7
Q

Symptoms of HF?

A
  • fatigue, exercise intolerance
  • fluid overload: peripheral edema, dyspnea (pulmonary edema)
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8
Q

Mechanism of symptoms of HF?

A
  • fatigue & exercise intolerance: insufficient CO
  • fluid overload: back pressure effects (blood backs up -> increase pressure in artery -> fluid moves from blood vessels into interstitial space -> edema)
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9
Q

Most common cause of HFpEF?

A

HTN

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10
Q

What are the NYHA classes of HF?

A
  • I: asymptomatic HF, no limitations in physical activity caused by HF sx
  • II: slight limitation of physical activity; asymptomatic at rest, but HF sx with normal level of activity
  • III: marked limitations in physical activity because of HF sx; asymptomatic at rest
  • IV: HF sx at rest or unable to carry out any physical activity
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11
Q

In HF, what is the SHORT-term compensation to maintain CO?

A
  • increase HR & contractility: maintain CO
  • vasoconstriction of arteries: maintain BP & CO
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12
Q

In HF, what is the LONG-term compensation to maintain CO and what opposes it?

A

Maintain:
- RAAS reabsorption of Na & water by kidneys: increase intravascular vol & load heart with more blood

Opposing:
- natriuretic peptide system: oppose effects of RAAS & SNS -> increase Na (& water) excretion, vasorelaxation, anti-hypertrophic, anti-fibrotic effects in heart

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13
Q

What is the main compensatory process called in HF to maintain CO?

A

Neurohormonal activation due to activation of sympathetic system

Cardiac remodelling & ventricular hypertrophy

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14
Q

How to calculate ejection fraction? (%)

A

(amt of blood pumped out of ventricle) / (total amt of blood in ventricle after diastole)

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15
Q

Sign of venous overload?

A

increase jugular vein pressure (enlarged & distended vein in neck)

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16
Q

How does orthopnea happen?

A

Pt lies down -> remove effect of gravity that causes blood to pool in leg veins -> blood returns to LV -> LV cannot handle increase vol of blood -> back pressure effects in lungs -> dyspnea when lying down

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17
Q

How does paroxysmal nocturnal dyspnea happen?

A

Pt goes to sleep -> loses sympathetic compensation -> heart beats slower & less hard -> fluid accumulates in lungs due to redistribution of blood pooled in legs to lungs & back pressure -> pt wakes up & becomes breathless

18
Q

Difference between systolic and diastolic failure?

A
  • systolic: affect ventricles
  • diastolic: affect atriums
19
Q

Where can back pressure effects occur?

A

Lungs, liver & spleen, legs (ankles)

20
Q

What is BNP and when are they produced?

A

B-type natriuretic peptide, produced only by ventricles when they are stretched (due to fluid load aka HF)

21
Q

What are the fantastic four for pharm treatment of HF?

A
  • ARNi > ACEi > ARB
  • BB (bisoprolol, carvedilol, metoprolol)
  • MRA (spironolactone, eplerenone, finerenone)
  • SGLT2i (Dapagliflozin / empagliflozin)
    + loop diuretic for congestion (frusemide)
    + ivabradine (adjunct to BB if symptomatic with HR ≥70 bpm)
22
Q

Can you switch from ACEi to ARNi directly?

A

Cannot, must wash out period of 36h before starting ARNi

23
Q

What does ARNi stand for? Example?

A

angiotensin receptor neprilysin inhibitor

sacubitril/valsartan

24
Q

MOA of MRA?

A

Inhibit aldosterone -> prevent reabsorption of Na and hence water -> prevent water retention

25
Q

Why will SCr increase slightly when ACEi are initiated?

A

Due to renal efferent artery dilation -> slightly decreased GFR

26
Q

MOA of ARNi?

A
  • sacubitril: prodrug metabolised to active metabolite that inhibits neprilysin -> increase levels of natriuretic peptides
  • valsartan: ARB
27
Q

When can BB be started?

A

When HF sx are stable & pt is euvolemic (not in fluid overload) otherwise acute decompensated HF

28
Q

At what eGFR is MRA CI? At what eGFR does dose adjustment need to be done?

A

CI: eGFR <30
Dose adj: <50

29
Q

MRA SE?

A
  • hormonal SE (less with eplerenone): gynaecomastia, hirsutism, menstrual irregularities
  • GI SE
  • hyperK, hypoNa
30
Q

At what eGFR are the SGLT2is CI?

A
  • Dapagliflozin: eGFR <25
  • Empagliflozin: eGFR <20
31
Q

Doses of both SGLT2is?

A

10mg OD

32
Q

When can SGLT2i be started?

A

When pts are euvolemic

33
Q

SGLT2i SE?

A
  • euglycaemic ketoacidosis (DKA)
  • genitourinary tract infections
  • diuretic effect: dehydration, hypotension, hypoglycaemia, renal impairment
34
Q

Sick day advice for SGLT2i?

A

If sick (can affect glucose levels & cause vol depletion) with V/D, inability to drink/eat → stop SGLT2i → resume 24-48h after recovery (when eating & drinking normally)

35
Q

When to hold off SGLT2i for surgery?

A
  • elective: hold off 2 days before surgery (including day of surgery so total 3 days)
  • for bowel prep: hold off 2 days before procedure (including day of procedure)
  • for fasting procedures: hold off on the morning of procedure
36
Q

Diuretics MOA?

A

Inhibit Na (& water) reabsorption

37
Q

SE of loop diuretic?

A
  • photosensitivity
  • hyperuricaemia
  • increase urination
  • electrolyte disturbances: hypoK, hypoNa, hypoCa, hypoMg
38
Q

Ivabradine MOA?

A

Reduce HR by inhibiting If current in SA node

39
Q

Ivabradine SE?

A
  • phosphenes (experience of seeing light w/o light actually entering eye)
  • HA
  • dizzy
  • AF
40
Q

Meds that worsen HF?

A
  • -ve inotropic effects: non-DHP CCB, itraconazole, class I & III anti arrhythmic agents
  • water & sodium retention: NSAIDs, corticosteroids, thiazolidinediones, minoxidil
  • Proarrhythmic effects: cilostazol, stimulants
41
Q

Non-pharm for HF?

A
  • fluid restriction (use bottle to gauge)
  • reduce Na intake, salt substitution
  • K replacement (due to diuretics, ACEi/ARB, MRA)
  • body weight monitoring (same time every morning, after toilet before breakfast): 2-3kg overnight

Competency (30 decks)

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