Heart Failure Flashcards
What is heart failure?
When cardiac output in not sufficient enough to supply the body
Describe systolic failure.
When ventricles are not contracting enough during systole resulting in reduced CO
EF will be low
Describe diastolic failure.
The inability of ventricles to relax during diastole and fill normally causing fluid to back up into lungs and peripheries
EF will be normal
What can cause diastolic failure?
Constricitve pericarditis
Constrictive cardiomyopathy
Tamponade
Hypertension
Does systolic and diastolic failure exist together?
Usually yes
What is it called when right sided and left sided heart failure exists together? Why does right heart failure occur?
Congestive cardiac failure
Mainly due to Left sided failure
What is systolic heart failure caused by?
Mainly ischaemic heart disease that causes damage to the heart
Diabetes
Cardiomyopathy
Complications of heart failure?
Renal failure
Valve dysfunction
Stroke
Pathophysiology - what is lost in heart failure that a normal healthy heart should have? Why is it lost?
When cardiac muscle is stretched more, it will contract more but this is lost
Lost because due to an increased workload on the heart due to damage, circulatory volume increases so the heart dilates to compensate (dilatation) which reduces CO and Force of contraction
What are the “compensatory” measures that activate when the heart begins to get dilated and weaker - but actually end up making things worse?
RAAS activates which increases vasoconstriction and water retention
Sypmathetic NS activates and releases NA and adrenaline increasing HR and vasoconstriction - increases afterload
Myocyte size increases and fibrosis occurs
These all worsen heart failure and start a cycle towards worsening heart failure
What is the end results of these measures?
Failing heart
Retention of salt and water leading to peripheral and pulmonary oedemas
Myocytes death and fibrosis
What are the risk factors for heart failure?
Age Smoking Diabetes Obesity Hyperlipidaemia Alcoholism Heart diseases - CAD, HT, Valves
What are the main symptoms of heart failure?
Fatigue Reduced exercise capacity Dysnpnoea Paroxysmal nocturnal dysnpnoea Orthopnea
Usually due to oedemas
Main signs of heart failure? What will be observed on an examination?
Oedeam
Tachycardia
Raised JVP
Displaced/abnormal apex beat
What will be heard on auscultation?
Chest crackles or effusion
3rd heart sound
What is the framingham criteria’s MAJOR signs of congestive heart failure?
PAINS
Paroxysmal nocturnal dysnpnoea
Acute pulmonary oedema
Increased heart size and CVP
Neck vein dilatation
S3 gallop
What is the framingham criteria’s MINOR signs of congestive heart failure?
PAIN
Pleural effusion
Ankle oedema
Increased HR >120
Nocturnal cough
How is heart disease confirmed using the framingham criteria?
2 major
or
1 major and 2 minor
What are the two main investigations, that if normal NICE suggests look for another diagnosis rather than heart failure?
ECG
BNP levels
What is an ECG looking for?
LV systolic function
If a normal ECG unlikely to be heart failrure
What is the BNP test?
Brain natriuretic peptide - suggests how far myocytes have been stretched
If conc is over 400pg/ml or 160pmol/l = heart failre
BNP is also cardioprotective as it aids water secretion and vasodilation
What else can be looked for in bloods?
FBC U's and Es LFTs - liver congestion TFTs (thyroid function) Lipid profile
What is looked for in a CxR?
ABCDE
Alveolar oedema
kerly B lines
Cardiomegaly
Dilated upper lobe vessels
plearual Effusion
Why are echo’s done?
Identify cause of heart failure and look at heart function
Systolic function Diastolic function Valve dysfunction LVH Ejection fraction
What is ejection fraction ranges?
What does a reduced EF mean? And what does a normal EF mean but patient still has symptoms of heart failure?
50-80% - normal
40-50% - mild
30-40% moderate
<30% - severe
A reduced EF means the heart is in systolic failure
A normal EF but patient shows symptoms means it is in diastolic failure
Describe the New York heart association classification for stages of heart failure.
1 - no limitation and no symptoms
2 - mild limitation but comfortable on mild exertion
3 - moderate limitation, comfortable at rest
4 - severe limitation - any activity brings on symptoms
What treatment can be given?
Diuretics ACE Inhibitors ARBs - for ACE. I intolerance ARB(Valsartan)/Sacubitril combination drug Beta blockers Ivabradine Digoxin - pos inotrope Anticoagulants
What main type of diuretic is used?
Loop diuretic - furosemide
How do loop diuretics work?
Remove excess salt and water by inhibiting the Na-Cl-K transporter in loop of henle
Work at very low GFRs
What would you do in a diuretic resistant patient?
Combine with a thiazide like diuretic - metolazone
Adverese drug reactions of diuretics?
Dehydration Hypotension Hypokalaemia Hyponatraemia Gout Impaired glucose tolerance/diabetes
Drug-drug interactions of diuretics?
Antihypertensives - hypotension
These cause renal toxicity: NSAIDs Lithium Vancomycin Aminoglycosides Frusemide
What diuretic would be used in a resistant oedema if patient has hypokalaemia?
Where does this drug work?
Potassium sparing diuretic - spironolactone
Works in distal tubule
When are ACE inhibitors given? Name a ACE inhibitor
In patients with LV systolic dysfunction as it improves symptoms by reducing preload and afterload
Ramapril
Adverse drug reactions of ACEIs?
Hypotension Cough Hyper-kalaemia Angioedema Renal imparment
Drug-drug interactions of ACEIs?
Potassium supplements or spironolactone causes hyperkalaemia
NSAIDS cause acute renal failure
What can be given instead if patient is ACE inhibitor intolerable or a cough is a problem?
ARBs - candesartan
How do ARBs work?
Block AT1 receptor - stops vasoconstriction and aldosterone secretion
What it the ARB/Neprilysin inhibitor called and how does it work?
Valsartal/Sacubitril
ARB Valsartan blocks AT1
Sacubitirl stops breaksown of ANP (atrial) and BNP so they can stay and increase vasodilation and water and sodium discharge
What beta blocker is given and why?
Carvedilol
Blocks sympathetic system so NA and adrenaline can’t cause increased HR and vasoconstriction anymore - this increases afterload
Are beta blockers routinely given?
No - can be harmful and patients must be selected carefully
How does Ivabradine work?
Inhibits SA node, limiting HR
Doesn’t affect FoC or intracardiac conduction between myocytes
How does digoxin work?
Positive inotrope -
increases the availability of Ca in a myocyte
What can digoxin toxicity cause?
Arrhythmias
Nausea
Confusion
Why are anticoagulants given/considered? What anticoagulant is given?
Dilated ventricle makes it easier for thrombosis or thromboembolisms to happen
Warfarin
Summarise the treatment plan
Diruetic treatment Furosemide +/- thiazide metolazone
ACEIs/ARBs
Valsartan/Sacubitril
B.Blockers +/- Ivabardine
MRA-Spironolactone
Digoxin
Warfarin
