Heart Failure Flashcards
What is heart failure (AKA CCF)?
A collection of diseases in which there is a low CO - any pathological process damaging pump action can cause this
Classifications of heart failure?
- Left heart failure
- Right heart failure
- Mixed
a) Acute esp. acute LVF
b) Chronic
Main cause of signs and symptoms in heart failure?
Fluid retention
Main causes of left-sided heart failure?
IHD causing past MIs
Cardiomyopathy (primary heart muscle disease of unknown cause)
Valvular disease preventing blood flow, e.g: aortic stenosis, or an incompetent valve, e.g: aortic regurgitation
Main causes of right-sided heart failure?
Secondary to left-sided HF
Cor pulmonale - lungs are hypoxic due to disease and so pulmonary vessels vasoconstrict; right side of heart must work harder against resistance and will eventually fail
Congenital heart disease more often cause right-sided HF than left-sided
Symptoms of left-sided heart failure?
Dyspnoea on exertion and, if progression occurs, at rest
Orthopnoea - when lying flat, effect of gravity causes fluid in lungs; many people prop themselves up with pillows
Paroxysmal Nocturnal Dyspnoea
Pulmonary oedema causes sudden dyspnoea and pink, frothy sputum (not deep red of haemoptysis)
Clinical signs of left ventricular failure?
Tachycardia to compensate for decreased CO
Fine crepitations (AKA crackles) on auscultation of lung bases
Pleural effusion where fluid fills the pleural space
S3
(S3 + tachycardia in a patient = gallop rhythm)
Changes on CXR with left ventricular failure?
Cardiomegaly (heart shadow should be around 50% the width between the ribs)
Bats wing shadow, esp. in lower zones
Interstitial fluid (black lungs will appear whiter, part. in hilar regions due to oedema)
Symptoms of right-sided heart failure?
Peripheral oedema (ankles/sacrum)
Clinical signs of right-sided heart failure?
Oedema (ankle/sacral)
Elevated JVP (>4cm above sternal angle)
Hepatomegaly (enlarged liver)
Ascites (oedema in abdomen)
CXR findings in right-sided heart failure?
Majority are normal as right ventricle is not very visible
May see lung disease that is the causes of the right-sided HF
Treatments of CCF, depending on cause?
If cause is previous MIs or cardiomyopathies:
Standard medical therapy of CCF
For cor pulmonale:
Diuretics - to excrete fluid
Oxygen - to treat lung disease
These are the only therapies used
For valvular disease:
Ideally, surgery to replace valve
For fast AF:
Digoxin
DC shock
Problem in fast AF?
Heart rate is so high that ventricles do not fully empty before filling occurs; so, AF must be slowed down
What is the standard medical treatment for CCF?
Diuretics - to excrete retained fluid
ACEI
β-blockers (caution required)
Spironolactone (severe cases only) - aldosterone antagonist
Digoxin (not good for heart failure + sinus rhythm; only good for heart failure + AF) Other vasodilators (e.g: nitrates, hydralazine)
Implantable cardiac defibrillators
Cardiac resynchronisation therapy
Transplantation
Diuretics used in heart failure?
Thiazide diuretics for mild CCF only
Loop diuretics are more commonly used, e.g: furosemide
Side effects of loop diuretics?
Loss of K+ (dangerous as both hypo/hyperkalaemia are arrhythmogenic)
Conincidental drugs, e.g: ACEI, spironolactone) help retain and normalise K+
Examples of ACEIs?
Captopril
Enalapril
Lisinopril
All end with -PRIL
Side effects of ACEIs?
Angioneurotic oedema is life-threatening, due to potential swelling in larynx, but rare; it is more common in black people
First dose hypotension, esp: if serum Na+ is low
Renal impairment - after ACEIs are begun, monitor UE; ACEIs can be good for diabetics and bad for those with renal artery stenosis
Dry cough - if this occurs, switch patient to an ARB
Examples of Angiotensin II Receptor Blockers (ARBs)?
Losartan
Valsartan
All end in - ARTAN
Use of β-blockers in heart failure?
Good in medium-long term BUT worsen CCF in short-term/acutely
START LOW, GO SLOW
Initial risks with β-blockers in heart failure?
Hypotension
Worsening dyspnoea
Main β-blockers used in heart failure?
Due to clinical trails usage:
Bisoprolol (β1-selective)
Carvedilol (non-selective + α blockade)
Use of spironolactone in heart failure?
Used in SEVERE CCF
Side effects of spironolactone?
Hyperkalaemia
Renal dysfunction
Hynaecomastia (also an anti-androgen and so males can grow breasts; this can be painful)
Why is Ivabridine used in heart failure and when?
Slows HR ONLY in sinus rhythm
Only used if HR is fast despite use of β-blockers
What is Sacubitril-Valsartan?
Combo ARB and Neprilysin inhibitor:
Neprilysin inhibitor blocks natriuretic peptide breakdown and boost levels of it
When is Sacubitril-Valsartan used in heart failure?
Will replace ACEIs in moderate-severe heart failure in the future
Why are Implantable Cardiac Defibrillators used in patients with heart failure?
Heart failure patients tend to die in 2 ways:
- Can worsen over a few months
- Appear fine and there is sudden cardiac death due to arrhythmia
The ICD detects sinus rhythm and defibrillates the patient when an arrhythmia occurs
When is Cardiac Resynchronisation Therapy (CRT) used?
Only for patients with prolonged QRS (bundle branch block); in this, ventricles do not contract simultaneously but milliseconds apart and so blood flow is less smooth
Only 20-30% of patients fit these requirements
What does CRT involve?
3 pacemakers are inserted to force the left and right ventricle to contract simultaneously; blood flow is smoother and there is increased CO
Safety issues with digoxin?
Has a narrow therapeutic window and so levels must be measured
It is slowly excreted by the kidneys and, e.g: in elderly renal impairment, a reduced dose is required
Side effects of digoxin?
Nausea and vomiting
Bradycardia and heart block
Any arrhythmia, e.g: ventricular tachycardia or PAT (Paroxysmal Atrial Tachycardia) with AV block - common arrhythmia in those with digoxin toxicity
When are 2 of the different effects of digoxin good or bad?
AV block:
Good in fast AF, to slow it down
Bad/toxin in those with bradycardia or heart block; until digoxin level is known, it should not be given to those with a slow HR
Ventricular irritability:
ALWAYS BAD/toxic as it can lead to ventricular arrhythmias
Therapy for ACUTE left ventricular failure?
- Sit up
- Oxygen, however care must be taken in COPD
- IV furosemide
- IV diamorphine - NOT in those with COPD as it can cause respiratory depression; this is an issue as many with heart failure are smokers and also have COPD
