HEART FAILURE Flashcards
Definition
Chronic, progressive condition in which the heart muscle is unable to pump enough blood through to maintain the cardiac output to meet demand —> insufficient oxygen delivery to tissues and fluid accumulation of lungs
Clinical Features (3)
- Dyspnea is the essential feature of congestive heart failure
- Left-sided HF associated with symptoms that are predominately respiratory, such as dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, and easy fatigability
- Right sided HF mainly associated with peripheral edema, ascites, raised JVP, and hepatomegaly
Heart failure with Reduced Ejection Fraction (HF - REF) (6)
- EF is low (<45%)
- Systolic dysfunction, contraction impaired
- Dilatation of the heart, high LV volume
- Added S3 sound
- Main causes: - MI (CAD), Valvular heart disease, dilated cardiomyopathy
- Has effective therapies. The lower the EF, the poorer the survival
Heart failure with Preserved Ejection Fraction (HF - PEF) (6)
- EF is equal or more than 50%
- Diastolic dysfunction, relaxation impaired
- Not dilated; Normal LV volume but high LV end-diastolic pressure
- Added S4 sound
- Main causes: LVH, HTN (initially preserved EF but overtime the heart may dilate and lead to systolic dysfunction and reduced EF
- No large scale trials. Can only treat underlying cause, control heart rate to prolong diastole, and diurese the patient
NYHA classification of heart failure severity
- Class I: no symptoms with ordinary physical activity
- Class II: mild limitation of physical activity. Symptoms with ordinary physical activity
- Class III: marked limitation of physical activity. Symptoms with less than ordinary physical activity
- Class IV: unable to perform any physical activity. Symptoms at rest
Investigations - Echocardiogram (7)
- Single most important diagnostic test
- Transthoracic echo best initial test
- Estimates ejection fraction: HF-REF vs HF-PEF (systolic vs diastolic dysfunction)
- Shows chamber dilation or hypertrophy
- Underlying cause (wall motion abnormality, valvular disease, cardiomyopathy)
- Severity of LV dysfunction
- Follow up effect of treatment
Investigations - ECG (4)
- Arrhythmias (e.g. heart block, A.Fib)
- HF-REF —> evidence of CAD and old MI
- HF-PEF —> evidence of LVH
- Holter monitor may be needed to detect paroxysmal arrhythmias
Investigations - Chest X-ray (5)
- Cardiomegaly (dilated cardiomyopathy)
- Dilated upper lobe veins due to congestion
- Pulmonary edema (bat wing appearance)
- Kerly lines due to interstitial edema
- Pleural effusion
Investigations - Blood tests (4)
- CBC (to look for anemia as a precipitating factor)
- Renal and liver profile
- BNP (normal BNP excludes CHF; used to determine etiology of acute dyspnea: cardiac vs respiratory)
- Thyroid function (esp. in those with A.Fib, both hypo and hyperthyroid —> HF)
Investigations - Cardiac catheterization (2)
- Precise valve diameters and septal defects
- For diagnosis of ischemic HF and revascularization
Treatment - Improve survival (5)
1- ACEI/ARB
- Must be given to all patients at all stages
2- B-blockers
- Benefit only with Metoprolol, Bisoprolol, Carvedilol (mneumonic: MBC)
- Anti-ischemic, antiarrhythmic, decrease in HR
- Not given in the acute treatment of HF episode, but improves survival in maintenance treatment
3- Mineralocorticoid antagonists (Spironolocatone)
- Added in more advanced stages of HF (class III and IV)
- SE: hyperkalemia and gynecomastia (less with eplerenone)
4- Hydralazine and isosorbide dinitrates
- Used as vasodilator therapy if an ACEI/ARB can’t be used
5- ARNI (Angiotensin receptor-neprilysin inhibitor)
- Combination of valsatran (ARB) and sacubitril (neprilysin inhibitor)
Treatment - Improve symptoms (2)
1- Diuretics
- started from initial therapy
- loop diuretics e.g. furosemide
2- Digitalis
- controversial; used to control symptoms in symptomatic patients on both ACEI and BB)
Treatment - Device Therapy (2)
1- ICD (implantable cardioverter-defibrillator)
- Reduces sudden death from ventricular arrhythmias
- Indications:
- EF < 30% on optimal medical therapy
- Previous cardiac arrest due to VT/VF
- Previous MI with non-sustained VT on 24 h monitoring and EF < 35%
- Long QT syndrome, Brugada syndrome, HOCM
2- CRT (cardiac resynchronization therapy) - AKA: biventricular pacemaker
- Persistent symptoms of HF, EF < 35%
- LV systolic dysfunction, dilated, wide QRS
Treatment - Surgery (3)
1- Coronary revascularization (if the cause is CAD): to prevent further ischemia and promote recovery of function —> improve symptoms and survival
2- Valve repair/replacement (if the cause is Valvular heart disease)
3- Cardiac transplantation in end-stage HF
