Heart Failure Flashcards
Another name for heart failure? What is it? Why?
- Congestive cardiac failure (CCF)
- Syndrome - not one disease
- Occurs due to low CO and a lot of cardiac diseases cause this
Types of heart failure? (2)
- Left, right, mixed
* Acute, chronic
What do signs and symptoms of heart failure occur because of? Explain how this occurs
- Due to fluid retention
* Low CO means kidneys are hypo-perfused and respond by retaining Na+ and H2O
Causes of left-sided CCF? (3)
What are they?
- Ischaemic heart disease e.g. MI (commonest cause of LCCF)
- Cardiomyopathy - does not contract properly
- Valvular disease - valve regurgitation, forward CO is reduced
Causes of right-sided CCF? (3)
What are they?
- Secondary to left heart failure (most commonly)
- Cor pulmonale - lung disease puts strain on heart causing HF
- Congenital heart disease
Symptoms of left heart failure (LVF)? (5)
What is another cause of night-time breathlessness?
- Fatigue
- Dyspnoea
- Orthopneoa (when lie flat, fluid gathers in lungs)
- Paroxysmal nocturnal dyspnoea (patient wakes up breathless, gets fresh air and feels better)
- Pulmonary oedema (sudden dyspnoea and pink, frothy sputum)
Asthma
Clinical signs of LVF? (4)
LVF on CXR? (3)
- Tachycardia
- Fine crepitations
- Pleural effusion – fluid underneath the lung
- S3 (gallop rhythm = S3 + Tachycardia)
CXR
- Cardiomegaly
- Bats wing shadows esp. lower zones
- Interstitial fluid
What are 2 possible causes of pleural effusion?
Lung cancer and LVF
Where does fluid gather in LVF? RVF?
- LVF - lungs
* RVF - produces signs in ankles, stomach (ascites), liver (hepatomegaly) and neck (JVP)
Symptoms of right heart failure? Clinical signs? (4) CXR?
- Oedema
Signs
- Oedema (ankle/sacral)
- JVP elevated (>4cm above sternal angle)
- Hepatomegaly
- Ascites
CXR
* Normal
What does treatment of CCF depend on? Examples of treatments? (4)
- Underlying cause
Treatments
- Previous MIs, cardiomyopathies - standard medical therapy for CCF
- Cor Pulmonale - Diuretics and oxygen only
- Valvular disease - valve replacement surgery
- Fast AF - digoxin or DC shock
Why is fast atrial fibrillation a problem? What drug is used to treat this? What is its effect?
- Makes ventricle beat too quickly, so does not have time to fill before it empties - reduced CO
- Digoxin
- Blocks transmission between atria and ventricle so ventricle beats at around 80 bpm
Standard medical treatment for CCF? (9)
- Diuretics to excrete retained fluid
- ACEIs
- Beta Blockers
- Spironolactone (severe cases only)
……………………………………………………………
(less commonly used) - Digoxin
- Other vasodilators (nitrates, hydralazine)
……………………………………………………………
(unique devices and treatments used in rare cases) - Implantable Cardiac Defibrillators
- Cardiac Resynchronisation Therapy
- Transplantation
What diuretics are used for CCF? (2) Example? Complication of diuretics? Solution?
- Thiazide diuretics for mild CCF only
- Loop diuretics commoner
- e.g. Furosemide
- Lose K+ along with Na+ and H2O
- Often used alongside ACEIs and spironolactone which help retain and normalise K+
Side effects of ACEIs? (4)
Alternative to ACEIs?
- IMPORTANT - angioneurotic oedema (life-threatening but rare)
- Hypotension esp. if serum Na low
- Renal Impairment – UE must be monitored after AECI begun
- Dry cough
- Angiotensin II receptor blockers (ARBs) - used if cough is intolerable
How are B-blockers used in CCF? (2) Short term risks of B-blcokers? (2)
Examples of B-blockers? (2)
- Good in long term CCF
- Can worsen CCF in short term so start with low lose and increase slowly (start low, go slow)
Short-term Risks
- Hypotension
- Worsening dyspnoea
E.g.
- Bisoprolol (B1 selective)
- Carvedilol (non-selective plus alpha blockade)
What is spironolactone? When/how is it used?
- Aldosterone receptor antagonist
* Use in moderate/severe CCF alongside ACEI
Side effects of sprionolactone?
- Hyperkalaemia – increases K+ (K+ may go too high as used alongside ACEIs which also increase K+)
- Renal Dysfunction
- Gynaecomastia
How is hyperkalaemia caused by sprionolactone avoided? What is gynaecomastia? How does this occur?
- Often use spironolactone, ACEI and furosemide together (furosemide decreases K+ so often balances out)
- Male breast growth
- Spironolactone not only blocks aldosterone receptor but also has anti-androgen effect, and so blocks male hormones
What is ivabradine used for? What is its effect? When is it used?
- Used for CCF and angina
- Slows HR (in sinus rhythm only)
- Only used if HR fast despite B-blockers
What is Sacubitril-Valsartan? What is its effect? Is it effective? What must it never be used alongside and why?
- Combination of ARB and Neprilysin Inhibitor
- Neprilysin Inhibitor blocks natriuretic peptide breakdown and boosts natriuretic peptide (BNP) levels (opposite effect to RAAS)
- Will replace ACEIs in moderate to severe heart failure
- MUST NEVER USE WITH ACEI - both have possibility of angioneurotic oedema
What are implantable cardiac defibrillators (ICDs)?
Sense rhythm all the time – so if abnormal, patient receives shock to bring rhythm back to normal
What is cardiac resynchronisation therapy (CRT) used for? What is this? Explain process of CRT?
- Only used for bundle branch block (prolonged QRS)
- BBB - right and left ventricle do not contract at exactly the same time so flow of blood through heart is impeded
- Complicated pacemaker system using 3 different pacemakers to cause RV and LV to contract at same time - CO improves
What is Digoxin used for? (2) Why must Digoxin levels be measured in bloodstream regularly?
- Excellent therapy for AF
- Mediocre therapy for CCF in sinus rhythm
- Has a very narrow therapeutic window
Why is it easy for toxic levels of Digoxin to build up in body? When would reduced doses be required?
- Builds up slowly in body and is excreted slowly by kidneys (1/3rd each day)
- Patients with renal impairment e.g. elderly
Side effects of Digoxin? (3)
- Nausea, vomiting
- Bradycardia, Heart Block
- Any arrhythmia e.g. ventricular tachycardia or paroxysmal atrial tachycardia with block
What are clinical effects of A-V block by Digoxin? (2)
Clinical effects of irritable ventricles due to Digoxin?
Good
* Slows fast AF
Bad
* Bradycardia, heart block
Always bad
* Ventricular arrhythmias
What is treatment for ACUTE LVF? (5)
- Sit up (removed fluid from lungs)
- Oxygen (caution in COPD)
- Intravenous Furosemide – fast onset (feel better in 20 mins)
- Intravenous Diamorphine (not in COPD – will stop breathing)
- Intravenous nitrates
