Heart failure Flashcards
What are symptoms of left heart failure?
- dyspnoea
- PND
- nocturnal cough
- nocturia
- cold peripheries
- weight loss
- poor exercise tolerance
- orthopnoea
- wheeze (cardiac asthma)
- fatigue
- muscle wasting
What are signs of LHF?
- crackles heard over lung bases (due to pulm oedema)
- cardiomegaly (->displaced apex beat)
- S3 gallop rhythm (due to rapid ventricular filling)
- pulsus alternans (alternating weak + strong in severe LVF)
- murmurs of mitral or aortic valve disease
- cyanosis
What are symptoms of right heart failure?
- peripheral oedema (up to thighs, sacrum, abdominal wall)
- ascites
- nausea
- anorexia
- facial engorgement
- epistaxis (nosebleed)
- pulsation in face + neck
What are signs of RHF?
- peripheral oedema
- raised JVP (accentuated by h-j reflux)
- parasternal heave
- ascites
- hepatomegaly + tenderness
What is the NYHA classification for heart failure?
- Class I - no symptoms, no limitation
- Class II - mild symptoms, slight limitation on PA: comfortable at rest, but ordinary activity results in fatigue, palps or dyspnoea
- Class III - moderate symptoms, marked limitation on physical activity: comf at rest, but less than ordinary acitvity results in symptoms
- Class IV - severe symptoms, unable to carry out any physical activity without discomfort: symptoms of HF are present even at rest w/ inc discomfort w/ any physical acitivty
Diagnosis of congestive cardiac failure requires presence of at least 2 major criteria or 1 major criterion + 2 minor criteria (Framingham criteria)
What are these criteria?
How would you quantify the patient’s dyspnoea in history taking - ie. what sort of Qs?
- how far can you walk before you get short of breath?
- problems taking stairs or walking up hills?
- any problems breathing when lying flat?
- how many pillows do you sleep on?
- do you wake up at night trying to catch your breath?
- nocturnal cough? any sputum? colour?
Explain the mechanisms by which cardiac failure causes of shortness of breath
- heart failure causes backlog of blood into pulmonary veins increasing pressure
- increased pulmonary venous pressure -> increases hydrostatic pressure
- -> increases filtration pressure
- causes fluid accumulation in the interstitium + alveoli
- leads to impaired gas exchange at alveoli
- causing dyspnoea
- interstitial oedema occurs >20mmHg
- alveolar oedema occurs at >25mmHg
Which investigations are important for heart failure?
If ECG + BNP are normal, heart failure is unlikely and an alternative diagnosis should be considered; if either is abnormal, then echocardiography required.
- bloods - BNP, FBC (anaemia), U+E
- CXR
- ECG -> underlying arrhythmia? LV hypertrophy (HT)?
- echocardiography -> LV dysfunction
What are the strutural abnormalities on CXR for heart failure?
- Alveolar bat wings
- Kerley B lines
- Cardiomegaly
- Dilated prominent upper lobe vessels
- Pleural Effusion
What is the acute/emergency management of a patient with cardiac failure?
The immediate goal in acute decompensated heart failure is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that airway, breathing + circulation (ABC) are adequate.
- sit pt upright
- oxygen (100% if no lung disease)
- IV access + monitor ECG, treat any arrhythmias
- investigations while continuing tx
- diamorphine 1.25-5mg IV slowly
- furesomide 40-80mg IV slowly
- GTN 2 puffs
- necessary investigations, examination + history
- if systolic >= 100 mmHg -> start nitrate infusion
- if pt worsening: more furosemide, consider CPAP
- if systolic <100mmHg -> treat as cardiogenic shock + refer to ICU
LMNOPP = loop diuretics, (morphine), nitrates, oxygen, positioning, positive airway pressure
What is the non-pharmacological management of cardiac failure?
- treat underlying cause if possible
- treat exacerbating factors (anaemia, thyroid disease, infection, bp)
- avoid exacerbating factors (NSAIDs, negative inotropes eg. Verapamil)
- annual flu vaccine, one-off pneumococcal vaccine
-
lifestyle changes
- smoking + alcohol cessation
- decrease salt intake
- maintain optimal weight + nutrition
What is the pharmacological treatment for heart failure?
- first-line: ACEi and a beta-blocker
- second-line: either
- aldosterone antagonist
- ARB
- or a hydralazine in combo w/ nitrate (in black pts)
- if symptoms persist: digoxin or ivabradine
- diuretics for fluid overload
How do diuretics help in heart failure?
- loop diuretics to relieve symptoms
- promote renal salt + water excretion by inhibiting Na/K/Cl reabsorption at ascending limb of LoH -> loss of fluid -> reduces preload -> reduces congestion
- eg. furosemide or bumetanide
- increase dose as necessary
- SE: low K+, renal impairment
- monitor U+E and add K+-sparing diuretic (spironalactone) if hypokalaemic, predisposition to arrhythmias, concurrent digoxin therapy, or pre-existing K+-losing conditions
- if refractory oedema, consider adding thiazide
How do ACE inhibitors help in heart failure?
- consider in all those w/ left ventricular systolic dysfunction
- improves symptoms and reduces mortality
- increase renal salt + water excretion + reduce afterload
- if cough is a problem, an ARB may be substituted
- SE: hyperkalaemia (as it counters aldosterone), angioedema, cough, first-dose hypotension
