Heart Failure Flashcards
List 6 symptoms of heart failure.
Dyspnoea Orthopnoea PND (paroxysmal nocturnal dyspnoea) Dry cough Peripheral oedema Fatigue/tiredness
List 6 signs of heart failure, e.g. what you would find in a cardiac exam.
Peripheral oedema (ankles, sacrum) Elevated JVP Third heart sound Displaced apex beat Lung crepitations (indicating pulmonary oedema) Pleural effusion
Outline the classification of heart failure.
Class I - no symptoms
Class II - mild
- Mild angina, mild SOB
- Slight limitations to ordinary activity
Class III - moderate
- Marked limitation in activity
- Comfortable only at rest
Class IV - severe
- Severe limitation in activity
- Symptomatic even at rest
List 5 common causes of heart failure in the UK.
Coronary artery disease (MI) Hypertension Idiopathic Toxins (e.g. alcohol, chemotherapy) Genetics
List 6 less common causes of heart failure in the UK.
Valve disease Infections Congenital heart disease Metabolic causes (e.g. haemochromatosis, thyroid disease) Pericardial disease Endocardial disease
What are the 4 types of heart failure?
HF-REV (reduced ejection fraction)
HF-PEV (preserved ejection fraction)
Chronic/congestive HF
Acute/decompensated HF
What are the features of HF-REV compared to HF-PEV?
HF-REV:
- More common in young males
- Often caused by CAD
HF-PEV:
- More common in elderly females
- Often caused by hypertension
What 4 investigations would you do in heart failure?
What 7 blood tests would you request?
ECG
CXR
Echo
Bloods, including:
- U&Es
- LFTs
- FBC
- Troponin
- Thyroid function tests
- Haemoglobin
- Natriuretic peptides
What is the surgical treatment of mild-moderate heart failure?
Devices, e.g.
- Pacemaker (ICD)
- Cardiac resynchronisation therapy
What is the surgical treatment of severe heart failure?
- Cardiac resynchronisation therapy (biventricular pacing)
- Ventricular assist devices (LVAD)
- Heart transplant
What are inotropic drugs?
What are positive inotropes?
What are negative inotropes?
Drugs which affect strength of heart contraction
POSITIVE inotropes INCREASE strength of contractility
NEGATIVE inotropes DECREASE strength of contractility
List, in order, the treatment of heart failure with reduced ejection volume (HF-REV). (9)
- Diuretics
- Beta blockers and ACE inhibitors
- Add MRA (aldosterone antagonist)
- Start sucubitril/valsartan (ARB plus neprilysin inhibitor)
a. STOP ACE inhibitors and ARBs - Add ivabradine (sinus node inhibitor)
- ICD (pacemaker) or cardiac resynchronisation therapy (CRT)
- Digoxin
- Hydralazine isosorbide dinitrate
- Heart transplant
List 2 examples of MRAs (aldosterone antagonists).
Spironolactone
Eplerenone
List 2 examples of beta blockers used in heart failure.
Carvedilol
Bisoprolol
List 1 example of an ACE inhibitor used in heart failure.
Perindopril
List 2 examples of ARBs used in heart failure.
Candesartan
Valsartan
What type of drug is sucubitril/valsartan?
Describe its mechanism of action. (3)
ARB plus neprilysin inhibitor
MECHANISM OF ACTION:
1. Valsartan - angiotensin receptor blocker (prevents vasoconstriction)
- Sucubitril - neprilysin inhibitor
a. Normally, neprilysin degrades natriuretic peptides
b. When this is inhibited, there are more natriuretic peptides
c. Therefore more vasodilation
Which 2 medications do you need to stop when you prescribe sucubitril/valsartan?
ACE inhibitors
ARBs
What type of drug is ivabradine?
Describe its mechanism of action. (1)
List 2 other indications.
Sinus node inhibitor
MECHANISM OF ACTION:
1. Inhibits If current propagation in SAN
INDICATIONS:
When beta blockers are contraindicated, e.g.
-Hypertension
-Peripheral vascular disease
What is cardiac resynchronisation therapy?
Biventricular pacing
What is an ICD?
Implantable cardioverter defibrillator
Describe the mechanism of action of digoxin. (4)
- Inhibits Na+/K+ pump, causing increased intracellular Na+
- This causes increased activity of Na+/Ca2+ exchanger to remove Na+
a. This causes increased levels of intracellular Ca2+ - This has a positive inotropic effect, i.e. increases strength of contraction
- This also decreases rate of conduction through AVN
What type of drug is hydralazine isosorbide dinitrate?
Describe its mechanism of action. (2)
Hydralazine - vasodilator
Isosorbide dinitrate - nitrate
MECHANISM OF ACTION:
1. Hydralazine causes vasodilation
- Isosorbide dinitrate is converted to NO, which causes vasodilation
Describe the pathophysiology of heart failure. (5)
- Myocardial injury causes left ventricular systolic dysfunction
- This causes a perceived decrease in circulating volume/pressure
- This causes neurohumoral activation, e.g.
a. Sympathetic nervous system
b. RAAS - This causes haemodynamic changes, e.g.
a. Systemic vasoconstriction - This creates a cycle which keeps worsening the decreased circulating volume/pressure
What features would you look for on an echocardiogram in heart failure? (3)
Chamber size
Systolic/diastolic function
Valve function
After the diagnostic tests for heart failure (CXR, echo, bloods and ECG), which further investigations could you do? (5)
Coronary angiography Exercise tolerance test Ambulatory ECG monitoring Myocardial biopsy Genetic testing
How would you treat HF-PEV? (3)
No disease modifying therapy
Symptomatic management, e.g.
- Diuretics
- Statins
How would you treat acute heart failure? (6)
MEDICAL THERAPY:
- Morphine
- Inotropic drugs (e.g. dopamine, dobutamine, milrinone)
- Nitrates
- Diuretics (frusemide)
PROCEDURES:
- Ultrafiltration
- Bileval/continuous positive airway pressure
Apart from pharmacological therapy, which other treatment would you use for chronic heart failure? (3)
- Lifestyle factors, e.g.
a. Smoking cessation
b. Reduce salt intake - Treat underlying cause, e.g.
a. Arrhythmias
b. Valve disorders - Avoid exacerbating drugs, e.g.
a. NSAIDs
b. Verapamil
