Heart Failure Flashcards
Define Cardiac failure.
Inability of the Cardiac Output to meet the body’s demands despite normal venous pressures.
Describe the epidemiology of cardiac output?
Heart failure has prevalence of 1-2% and 5 year mortality approaching 50%.
Median age @ presentation is 76 years.
Males more commonly affected.
What is low output cardiac failure?
CO is decreased and fails to rise with onset of exertion
Give examples of causes of low output cardiac failure.
Pump failure:
Systolic/diastolic HF, reduced HR…
Excessive preload:
Mitral regurg, fluid overload…
Chronic excessive afterload:
Aortic stenosis, hypertension.
What is high output cardiac failure?
Rare
occurs wieh ouput is normal or increased in the face of extreme needs, failure occurs when CO fails to meet needs.
Give examples of causes of high output cardiac failure.
Anaemia, pregnancy, hyperthyroidism, paiget’s disease…
Give symptoms of Left ventricular failure
Dyspnoea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough (+/- pink frothy sputum), wheeze, nocturia, cold peripheries, weight loss, muscle wasting.
Give causes of right ventricular failure.
LVF, pulmonary stenosis, lung disease.
Give symptoms of R ventricular failure.
Periph oedema (up to thighs, sacrum, abdo wall), ascites, nausea, anorexia, facial engorgement, pulsation in neck and face (tricuspid regurg), epistaxis.
What are possible signs indicating heart failure?
Examination can be normal.
Exhaustion, cool peripheries, cyanosis, reduced blood pressure, narrow pulse pressure, pulsus alternans, displaced apex (LV dilatation), RV heave (Pulm hypertension), murmurs of mitral or aortic valve disease, wheeze.
What are the Framingham criteria?
Used to diagnose congestive heart failure.
Presence of 2 major criteria or 1 major and two minor criteria.
What is the New York Association Classification of Heart failure severity?
1 (Mild) No limit of physical ability.
2 (Mild to moderate) Slight limit to physical ability.
-Comfortable at rest by dyspnoea and fatigue on ordinary physical activity.
3 (Moderate) Marked limit of physical activity.
-Comfortable at rest but dyspnoea and fatigue on less than ordinary physical activity.
4 (severe) Symptoms at rest.
What investigations would you perform for heart failure?
Bloods:
FBC, Cardiac enzymes or troponin in serum.
ECG may show evidence of ischaemia
X ray chest
Echocardiography
What would be shown on a chest x ray to indicate left ventricular failure?
(Pulmonary oedema)
ABCDE!
A leveolar oedema (bat wings) B Kerley B lines (interstitial oedema) C ardiomegaly D ilated prominent upper lobe vessels E Pleural Effusion.
How would you manage a patient with Heart failure?
Contributing factors should be treated.
Number of drugs can be used: Diuretics ACE inhibitors Angiotensin II receptor blockers Beta blockers Hydralazine and isosorbide mononitrate Inotrophic drugs.
Non pharmacological approaches include advice on low salt diet, smoking and drinking cessagion and increasing exercise.
In some cases cardiac resynchronisation therapy, coronary revascularisation, valve surgery or cardiac transplantation may be considered.
Why would you use diuretics in heart failure? What are: Loop diuretics? Spironolactone? Metolazone?
Promote fluid loss thereby reducing ventricular preload and releaving breathlessness and peripheral oedema.
Loop diuretics:
eg furosemide
Result in brisk and short lived diuresis with rapid release of symptoms
Spironolactone
Weak K+ sparing diuretic aldosterone antagoist used in moderate to severe heart failure.
Metolazone
Powerful thiazide diuretic, generally reserved for use in severe intractable HF
Why use ACE inhib in heart failure?
Reduce levels of circulating catecholamines, vascular resistance and afterload.
They can cause renal dysfunction and should be introduced slowly and monitored.
Avoid in aortic stenosis.
Why use angiotensin II receptor blockers in HF?
used either with ACE inhib or as alternative if px intolerant to ACE.
Why use beta blockers in HF?
Improve left vent ejection fraction and in absence of contraindications are recommended for all px with HF caused by LV systolic dysfunction.
Why use hydralazine + isosorbide mononitrate in HF?
Reduce afterload.
Less effective than ACE inhib.
Only used in px intolerant to both ACE & angiotensin II receptor blockers.
Why use inotropic drugs in HF?
Used occasionally in px with low CO.
How do you manage a patient with acute cardiac failure?
ABCDE
Px sit upright and given oxygen.
Morphine relieves distress and acts as vasodilator, reducing preload and afterload.
Larve i.v. doses of diuretics given and repeated if necessary.
Reduction of preload with i.v. nitrates should also be considered in indiv without hypotension.
If px fails to respond continuous positive airways pressure or non invasive ventilation may improve oxygen delivery.
Reduction of preload
