Heart Failure Flashcards
Explain heart failure to a patient
Heart failure is an inability of the heart to supply adequate blood flow and therefore oxygen to tissues and organs. This results in reduced exercise tolerance, tiredness and shortness of breath.
Causes of acute heart failure
Acute heart failure develops rapidly and can be life threatening as the heart has no time to undergo compensation. Acute failure (hours - days) is caused by
- cardiopulmonary bypass surgery
- Acute MI
- Severe arrhythmia
- Valve dysfunction
Acute failure can be managed pharmacologically or surgically.
Causes of Chronic heart failure
Chronic heart failure is a long-term condition (month-years) that is associated with adaptive responses (e.g. hypertrophy) to an underlying cause.
What causes Systolic dysfunction associated with heart failure?
Impaired contractility
- Coronary artery disease e.g. MI, ischaemia
- Chronic volume overload e.g. MR/AR murmur
- Dilated cardiomyopathies
Increased afterload
- Advanced aortic stenosis
- Uncontrolled severe hypertension
Systolic dysfunction causes a REDUCED EJECTION FRACTION
What causes diastolic dysfunction associated with heart failure?
Left ventricular hypertrophy Restrictive cardiomyopathy Myocardial fibrosis Transient myocardial ischaemia Pericardial constriction/tamponade Tricuspid regurgitation
Diastolic dysfunction causes a PRESERVE EJECTION FRACTION
How does left heart failure present?
Decreased cardiac output
- Activity intolerance
- Reduced tissue perfusion
- Cyanosis + Hypoxia
Pulmonary congestion
- Orthopnoea
- Proxysmal nocturnal dyspnoea
- Cough + frothy sputum
How does right heart failure present?
Congested peripheral tissues
- Ankle Oedema
- Ascites
- GI tract congestion (anorexia, GI distress)
- Liver congestion (impaired function)
How do we classify heart failure?
New York Heart Association (NYHA) classification
- No limitation of physical activity (PA)
- No fatigue, palpitations, dyspnoea
- Slight limitation of PA. Comfortable at rest.
- Fatigue, palpitations + dyspnoea after ordinary PA - Marked limitation of PA. Comfortable at rest.
- Fatigue, palpitations and dyspnoea after
List the 10 causes of heart failure
- Coronary heart disease
- Hypertension
3, Ischaemic heart disease
- Valvular disease = AS, AR, MR, MS
- Congenital = ASD, VSD, cardiomyopathies
- Rate-related = uncontrolled AF, thyrotoxicosis, anaemia, heart block
- Pulmonary = COPD (COR PULMONALE), fibrosis, PE,
- Alcohol + drugs
- Autoimmune = Amyloidosis, sarcoidosis
- Miscellaneous = Pregnancy, acute viral myocarditis
Symptoms of heart failure
Respiratory:
- Exertional Dyspnoea
- PND
- Orthopnoea
- Pulmonary oedema
- Crackles
- Wheezing
Cardiovascular:
- Chest pain/pressure
- Palpitaitons
- Tachycardia
- Weak-rapid-thready pulse
- S3 gallop
- Ankle oedema
General:
- Fatigue + weakness
Genito-urinary:
- Nocturia + oligouria
Gastrointestinal:
- Anorexia/weigh loss
- Nausea,
- Ascites
- Heptojugular reflux
- Hepatomegaly
Facial features:
- Exophthalmos
- Visble eye pulsations
- Distended neck veisn
- Cyanosis
- Pallor
How to diagnose heart failure (*which criteria?)?
Framingham’s criteria (2 major/ 1 major + 2 minor)
Major criteria:
- PND
- Weight loss (4.5kg in 5 days)
- Neck vein distention
- Rales/crakcles
- Acute pulmonary oedema
- Hepatojugular reflux
- S3 gallop
- Central venous pressure >16cm water
- Circulation time = >25 seconds
- Radio graphic cardiomegaly
- Visceral congestion, cardiomegaly
Minor criteria:
- Nocturnal cough
- Dyspnoea on ordinary exertion
- Decreased vital capacity by a third
- Pleural effusion
- Tachycardia
- Hepatomegaly
- Bilateral ankle oedema
How to clinically diagnose/investigate heart failure?
- Bloods (FBC, U+E, LFT’s, NTproBNP)
- Hepatic congestion = bilirubin and ALT
- Raised BNP = heart failure present
- Hyponatraemia, hypo/hyperkalaemia, proteinuria
- decreased renal blood flow, decreased eGFR
- Chest X-ray
- Cardiomegaly
- Pleural effusion
- Pulmonary venous congestion [upper zone]
- Valve calcification
- Alveolar shadowing/oedema [Bat wing]
- Interstitial oedema [Septal (kerley B) line]
- Echocardiogram
- LV dilatation and impaired contraction
- Valve disease
- LV aneurysm
- Intracardial thrombus
- Mitral incompetence
- ECG
- LV hypertrophy
- BBB
- Atrial fibrillation
What non-pharmacological treatment is used for heart failure?
Oxygen
Non-invasive pressure ventilation
Sodium and fluid restriction
Valve replacement / repair Ventricular restoration Heart transplant Revascualrisation treatment Electrophysiologic interventions Defibrillators
What pharmacological treatment is used for heart failure?
IV diuretics
IV nitrates
Once stable…… Beta blockers, ACEi/ARB’s, K+ sparing diuretics
Generally
- Diuretics: Furosemide (80mg twice daily)
- ACEi: not used in renal failure, increase dose slowly
- Beta blockers: Bisoprolol (once daily)
- Aldosterone antagonists: Spironolactone
- Ivabradine: used to slow SAN rate if beta blockers are contraindicated. Cannot be used in arrhythmias
- Enestro: increases exercise tolerance
What is NTproBNP and what does it show?
NTproBNP is a blood test to look at a specific peptide in the atria. This peptide increases frequency when the atria and ventricles become stretched (cardiomegaly)
Normal = <300
Heart failure = 300-1000
