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clinical > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What is heart failure (AKA CCF)?

A

A collection of diseases in which there is a low CO - any pathological process damaging pump action can cause this

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2
Q

Classifications of heart failure?

A
  1. Left heart failure
  2. Right heart failure
  3. Mixed

a) Acute esp. acute LVF
b) Chronic

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3
Q

Main cause of signs and symptoms in heart failure?

A

Fluid retention

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4
Q

Main causes of left-sided heart failure?

A

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

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5
Q

Main causes of right-sided heart failure?

A

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

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6
Q

Symptoms of left-sided heart failure?

A

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)

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7
Q

Clinical signs of left ventricular failure?

A

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)

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8
Q

Changes on CXR with left ventricular failure?

A

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)

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9
Q

Symptoms of right-sided heart failure?

A

Peripheral oedema (ankles/sacrum)

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10
Q

Clinical signs of right-sided heart failure?

A

Oedema (ankle/sacral)

Elevated JVP (>4cm above sternal angle)

Hepatomegaly (enlarged liver)

Ascites (oedema in abdomen)

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11
Q

CXR findings in right-sided heart failure?

A

Majority are normal as right ventricle is not very visible

May see lung disease that is the causes of the right-sided HF

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12
Q

Treatments of CCF, depending on cause?

A

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

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13
Q

Problem in fast AF?

A

Heart rate is so high that ventricles do not fully empty before filling occurs; so, AF must be slowed down

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14
Q

What is the standard medical treatment for CCF?

A

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

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15
Q

Diuretics used in heart failure?

A

Thiazide diuretics for mild CCF only

Loop diuretics are more commonly used, e.g: furosemide

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16
Q

Side effects of loop diuretics?

A

Loss of K+ (dangerous as both hypo/hyperkalaemia are arrhythmogenic)

Conincidental drugs, e.g: ACEI, spironolactone) help retain and normalise K+

17
Q

Examples of ACEIs?

A

Captopril
Enalapril
Lisinopril

All end with -PRIL

18
Q

Side effects of ACEIs?

A

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

19
Q

Examples of Angiotensin II Receptor Blockers (ARBs)?

A

Losartan
Valsartan

All end in - ARTAN

20
Q

Use of β-blockers in heart failure?

A

Good in medium-long term BUT worsen CCF in short-term/acutely

START LOW, GO SLOW

21
Q

Initial risks with β-blockers in heart failure?

A

Hypotension

Worsening dyspnoea

22
Q

Main β-blockers used in heart failure?

A

Due to clinical trails usage:
Bisoprolol (β1-selective)
Carvedilol (non-selective + α blockade)

23
Q

Use of spironolactone in heart failure?

A

Used in SEVERE CCF

24
Q

Side effects of spironolactone?

A

Hyperkalaemia
Renal dysfunction
Hynaecomastia (also an anti-androgen and so males can grow breasts; this can be painful)

25
Q

Why is Ivabridine used in heart failure and when?

A

Slows HR ONLY in sinus rhythm

Only used if HR is fast despite use of β-blockers

26
Q

What is Sacubitril-Valsartan?

A

Combo ARB and Neprilysin inhibitor:

Neprilysin inhibitor blocks natriuretic peptide breakdown and boost levels of it

27
Q

When is Sacubitril-Valsartan used in heart failure?

A

Will replace ACEIs in moderate-severe heart failure in the future

28
Q

Why are Implantable Cardiac Defibrillators used in patients with heart failure?

A

Heart failure patients tend to die in 2 ways:

  1. Can worsen over a few months
  2. Appear fine and there is sudden cardiac death due to arrhythmia

The ICD detects sinus rhythm and defibrillates the patient when an arrhythmia occurs

29
Q

When is Cardiac Resynchronisation Therapy (CRT) used?

A

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

30
Q

What does CRT involve?

A

3 pacemakers are inserted to force the left and right ventricle to contract simultaneously; blood flow is smoother and there is increased CO

31
Q

Safety issues with digoxin?

A

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

32
Q

Side effects of digoxin?

A

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

33
Q

When are 2 of the different effects of digoxin good or bad?

A

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

34
Q

Therapy for ACUTE left ventricular failure?

A
  1. Sit up
  2. Oxygen, however care must be taken in COPD
  3. IV furosemide
  4. 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

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