Heart Failure Flashcards
Define Heart Failure
It is when the heart is not capable of providing sufficient cardiac output or can only do so at the expense of elevated filling pressure
Epidemiology of HF
1% of 50-59
5-10% of 80-89
1-3% of general population
Prognosis of HF
25-50% within 5 years
Poor
Whats is congestive cardiac failure
It is when there is both L and R ventricular failure
Symptoms of L ventricular failure
PND
Orthopnoea
Dyspnoea
Poor exercise tolerance
Fatigue
Nocturnal cough - +/- pink frothy sputum
Wheeze “cardiac asthma”
Nocturia
Muscle waisting
Weight loss
Causes of R ventricular failure
LVF
Pulmonary stenosis
Lung disease
Symptoms of R ventricular failure
Peripheral oedema - up to thighs, sacrum, abdominal wall
Ascites
Nausea
Anorexia
Pulsation in neck and face (tricuspid regurgitation)
Epistaxis
Investigating HF
NICE:
If ECG and BNP both normal then unlikely to be HF and other causes must be considered.
If either abnormal perform Echo
When is heart failure considered acute
It is either for a new onset acute HF or a decompensated chronic heart failure characterized by pulmonary and or peripheral oedema with or without signs of peripheral hypoperfusion
What is chronic heart failure
It is when HF is always present but develops or progresses very slowly. venous congestion is common but arterial pressure is affected later on.
What is low-output HF
It is when there is reduced cardiac output and fails to increase with exertion
What is systolic HF
It is the inability for the ventricles to contract normally resulting in reduced cardiac output
Ejection fraction is <40%
Causes of systolic HF
cardiomyopathy
MI
IHD
what is diastolic HF
it is when the ventricles are unable to relax and fill normally resulting in increased filling pressure
Ejection fraction is >50%
Causes of diastolic HF
Tamponade
constrictive pericarditis
restrictive cardiomyopathy
hypertension
Something to remember about Systolic and diastolic HF
They usually co-exist
Causes of low-output HF
Pump failure:
Systolic/diastolic HF
Reduced heart rate (B-blockers, heart block, post MI)
Negatively Inotropic drugs (most antiarythmatic agents)
Excessive preload;
mitral regurgitation
fluid overload (NSAID causing fluid retention)
Chronic excessive afterload
aortic stenosis, hypertension
High output heart failure
Rare
Here output is normal or increased with increased demand
Failure occurs when the cardiac output fails to meet these demands
consequences are this could develop to RF and ultimately LVF
High output heart failure causes
Anaemia
pregnancy
hyperthyroidism
pagets
arteriovenous malformation
beri beri
what is beri beri
thiamine (vit B1) deficiency with symptoms
What is tamponade
compression of the heart because of fluid in the pericardial sac
Other investigations of HF
FBC
U and E
BNP
CXR
ECG - look MI ventricular hypertrophy ischaemia
Echocardiography
endomyocardial biopsy - rarely needed
Tell me about the CXR of LVF
Alveolar oedema (bat wings)
B kerley lines (interstial oedema)
Cardiomegaly
Dilated prominent upper lobe vessels
pleural effusion (blunted costophrenic angles)#
http://epomedicine.com/wp-content/uploads/2016/02/pulmonary-edema-mnemonics.jpg
What is the Framingham criteria
It is used for diagnosis of congestive cardiac failure
conservative management of Chronic HF
Low salt diet
stop smoking
weight and diet control
treat cause
treat exacebrating factors (HTN, anaemia, thyroid)
avoid exacebrating factors (NSAIDs/Verapamil, etc)
Medical Management of chronic HF
Diuretics - reduce risk of death and worsening HF, Loop for Sx relief
ACE - consider in all with L ventricular and systolic failure, improves Sx and prolong life
B-blockers, decrease mortality in HF. Benefits are additional to those of ACE. Give after ACE and diuretics
Spironolactone - reduces mortality by 30% when given with above treatment. use when Sx persist despite above Rx
Digoxin - helps Sx even when sinus rythm
Vasodilators
What is an alternative if ACE gives Pts cough
Angotensin receptor blocker
Tell me about B-blockers and HF
give after ACE-i, be cautious, start slow and go slow
Whats the problem with spironolactone in HF
small risk of significant hyperkalaemia even with ACE-i
Tell me about the vasodilator therapy for HF
the use of hydralazine (SE drug induced lupus) and isorbide dinitrate should be used if intolert to ACE or ARB
in black patients with HF it reduces mortality when added to standard therapy
Treatment of acute HF
Medical emergency
start treatment before investigations
sit patient upright
Oxygen - 100% if no prexisting lung disease
IV access and monitor ECG - Rx any arrythmias
Diamorphine IV - slowly caution with COPD and Liver F
Furosemide IV - slowly, larger dosses required in renal failure
GTN - dont give if systolic BP <90
Review notes, investigate, examine, HX
If BP systolic >100 start nitrate IV
If still worsening -
addition furosemide
consider CPAP
increase nitrate infusion
If systolic BP <100 treat as cardiogenic shock and refer to ICU
What is the normal cardiac output
4 to 8 L/min
so why do we use ACE-i to treat CHF
because it stops Angiotensin I converting to Angiotensin II, therefore, stop renin from water retention hence reduced BP.
Reduce BP helpfull because vascular resistance against heart pump will be less, thus less work for hear.
Also because aldosterone is blocked as well it cant stimulate NaCl reabsortion and K excretion hence no water retention heeence reduced circulating volume heence reducing preload aswell
Why do we use B-blockers then
B1 receptors are found in the heart.
they reduce force of contraction and speed of conduction.
this helps in reducing cardiac work and oxygen demand which therefore stops heart for dialating.
