Heart Failure Flashcards
What is the prognosis for heart failure?
High mortality shortly after diagnosis – 30-40% die within a year
Mortality following is 10%
Admission required – 5yr mortality = 75%
What are community support programmes for chronic disease?
Expert patient programmes:
6 week course led by a ‘lay’ patient that has experience living with the specific chronic disease
Better lifestyle, communication, pain management, mental health, problem solving and planning
Specialised nurses:
1-2x/yr regular; more frequent if poorly controlled disease
Work closely with patients to improve care
DAFNE + DESMOND:
Diabetes specific courses
What are examples of levels of prevention of disease in heart failure?
Primary:
NHS health check
Education and doing re lifestyle factors
Secondary: Regular monitoring – BP, Echos etc Daily low dose aspirin BP meds Statin DM/renal management Diet/exercise programmes
Tertiary:
Cardiac rehab
Community support
Population: Salt and sat fats guidance/labelling Physical activity encouragement – change4life, cycle lanes etc Sugar and alcohol taxes Collection of population health data
What is the definition of heart failure?
Inability of the heart to pump adequate amounts of blood to meet the body’s metabolic demands → the end stage of all heart disease
What are the different types of heart failure?
Systolic - inability of heart to contract efficiently to eject adequate volumes of blood to meet metabolic demands (most common)
Diastolic - reduction of heart compliance → reducing in ventricular filling and ejection
Left - leads to pulmonary oedema and usually results in right sided heart failure due to pulmonary hypertension (cor pulmonale)
Right - leads to peripheral oedema, hepatic congestion and tenderness
Congestive = L+R heart failure
Low-output - HF from low CO
High-output - due to metabolic demand-
supply mismatch i.e. reduced blood O2 carry-
ing capacity or increased body metabolism
Acute - usually the result of acute event - MI
Chronic - slow symptom progression due to
underlying disease
Acute-on-chronic - acute degeneration of a
chronic cause i.e. caused by infection
What is the pathophysiology of heart failure?
NEEDS BETTER CLARITY:
HR and contractility increase to maintain cardiac output - over time this causes hypertrophic changes to the cardiac tissue - with too much growth this tissue becomes under perfused, unable to deal with the increased demand and undergoes ischemic injury
Also stimulation of RAAS due to reduced renal perfusion:
Angiotensin II creation leads to vasoconstriction + aldosterone + ADH release - increase in Na and H2O retention, increasing stroke volume and total peripheral resistance, but also more fluid stretches the heart = reduced contractile ability + pulmonary and peripheral oedema
How does heart failure present?
The Framingham criteria:
SAW PANIC HEART ViNo
Major:
S3 heart sound present (‘gallop’ sound)
Acute pulmonary oedema (left side of heart is unable to clear fluid from lungs)
Weight loss of more than 4.5kg in 5 days when treated (patients lose their retained fluids)
Paroxysmal nocturnal dyspnoea
Abdominojugular reflux (JVP waveform rises when pressure applied over liver area)
Neck vein distended (i.e. JVP elevated at rest)
Increased cardiac shadow on X-ray (cardiomegaly = cardiothoracic ratio of >0.5; double density sign = enlarged L atrium)
Crackles heard in lungs
Minor: Hepatomegaly Effusion, pleural Ankle oedema bilaterally exeRtional dyspnoea Tachycardia Vital capacity decreased by a third of maximum value Nocturnal cough
How do you investigate heart failure?
CXR:
- Cardiomegaly, pulmonary oedema
ECG:
- Can help confirm HF, define underlying cause - MI, BBB, arrhythmias
Echo:
- Look at ejection fraction, wall thickness, cardiac kinetics etc
Bloods:
- Causes and severity: anaemia, hypernatraemia, hypo/hyperkalaemia
Brain natriuretic peptide (BNPs):
- Peptides that cause natriuresis, diuresis and vasodilation (body’s “natural defence” against hypervolaemia)
- Levels correlated with cardiac filling pressures
- Recommended in all patients with suspected HF
Renal function/U+E:
- Cardio-renal axis dysfunction will often occur with long term CCF patients due to the relationship between the two axes and the effects/side effects of medications (e.g. ACEis, diuretics etc)
Liver function/LFTs:
- Can become deranged in biventricular failure due to systemic hypervolaemia and increased back pressures in liver
- Should settle with cardiac management and diuresis
Angiography
Thyroid function - rule out thyrotoxicosis
PFTs - to discount lung disease
What non-pharmacological management options are there for heart failure?
Exercise Diet control - plant based whole-food diet, reduce salt intake Monitor weight, lose weight if obese Fluid restriction Reduce alcohol intake Quit smoking Flu vaccination Watch for depression and act accordingly
What is the pharmacological management of heart failure?
ABCD = ACE-I, B-blocker, Ca blocker + nitrates, Diuretics + Digoxin
Stepwise approach: ACE inhibitors or ARB ADD diuretic ADD beta-blocker ADD aldosterone antagonist ADD digoxin Consider another vasodilator, e.g. isosorbide dinitrate or hydralazine Drugs to avoid
What ACE-Is are used in HF?
Enalapril, lisinopril etc
Reduce afterload and fluid retention → slows LV disease progression
Strong vasodilators
SE: dry cough - if intolerable = angiotensin II inhibitors (candesartan)
Caution: concomitant use with spironolactone (can cause hyperkalaemia)
What Diuretics are used in HF?
Promote renal Na excretion and thus water excretion; decrease ventricular filling pressures, decreasing pulmonary and systemic congestion - if congestion controlled, can cease diuretics and maintain strict fluid/salt balance with diet
Furosemide (loop, moderate/severe HF) (1st line)
SE: gout, electrolyte imbalance, postural drop (elderly)
Bendroflumethiazide (thiazide, first line in mild HF)
SE: gout, electrolyte imbalance, postural drop (elderly)
Spironolactone (potassium sparing)
SE: gynaecomastia
DONT use as monotherapy, always with ACE-I
What B-blockers are used in HF?
Beta blockers:
Bisoprolol, cavedilol etc (cardioselective options)
Reduce afterload and HR to prevent arrhythmias
SE: dizziness, nausea, headache, change in sex drive/performance
Contraindications: asthma, heart block, bradycardia
What Ca-blockers and vasodilators are used in HF? What should be avoided?
CaB:
Amlodipine
Hydralazine + nitrates
-ve chrono/inotrophic
Used if intolerant to ACE-I/ARB
AVOID:
Diltiazem, Verapamil
When is Digoxin indicated in HF?
Sinus rhythm patients that remain symptomatic even after other pharmacological interventions (third line after ACE-i and diuretics)
Patients with severely impaired left ventricular function
Recurrent hospital admissions
Treating AF in CHF
