Heart Failure Flashcards
Heart Failure
CO is inadequate for the body’s requirements.
two types of HF:
low output and high output HF
- definition of each
- causes of each?
Low output = CO is down and fails to increase normally with exertion.
High output = Rare.
CO is normal or increased due to increased demand.
Failure occurs when CO fails to meet these needs.
Causes:
High output HF:
1) Anaemia
2) Pregnancy
3) Hyperthyroidism
Low output HF:
- mitral regurgitation (LV dilatation)
- aortic stenosis (LV thickening)
- HTN
high output HF - features of Left HF or Right HF?
Intially features of RHF then LVF becomes evident later.
SYSTOLIC FAILURE
ejection fraction?
heart abnormality?
Causes?
- Inability of the ventricle to contract normally, resulting in reduced CO.
- Ejection fraction is <40%.
- Dilated heart
= MI, IHD, cardiomyopathy
DIASTOLIC FAILURE
ejection fraction?
heart abnormality?
causes?
- Inability of the ventricle to relax and fill normally, causing increasing filling pressures, typically Ejection fraction >50%.
- Hypertrophied heart.
- Typically HF with preserved EF.
ventricular hypertrophy, constrictive pericarditis, tamponade
bilateral or unilateral leg swelling ?
Bilateral leg swelling (suggests cardiac failure) whereas unilateral swelling suggest venous disease and trauma.
LV FAILURE:
features?
CXR - FOR LV failure?
ABCDE
- dyspnoea
- orthopnoea
- PND
- pulmonary oedema
- nocturnal cough (+/- pink sputum)
A – alveolar oedema ‘bat’s wings’ B – kerley b lines C – cardiomegaly D – dilated upper lobe vessels E – pleural effusion
RV FAILURE:
features?
- peripheral oedema (upto thighs)
- ascites
- anorexia
- epistaxis
- facial engorgement
- raised JVP
LVF and RVF may occur independently or together as ?
CCF (congestive cardiac failure)
long term LVF leading to RVF
what is the criteria for CCF?
Framingham criteria
presence of 2 major or 1 minor criteria
Refer someone with suspected HF for a transthoracic Doppler 2D echo within?
why do you do echo?
2 weeks
TO determine if there is LV dysfunction
chronic HF
- ECG changes?
bloods: - BNP - when is it released?
- if BNP >100?
- if BNP <100?
- BNP and ECG normal?
- LVH, Q waves
BNP is secreted from ventricular myocardium and is released in LV dysfunction
– diagnoses HF better than any other clinical marker.
- exclude HF or LV failure
If ECG and BNP are normal = HF is highly unlikely.
classification of HF?
NEW YORK CLASSIFICATION OF HF
- Grade I = heart disease present but no dyspnoea.
- Grade II = comfy at rest and dyspnoea during activity.
- Grade III = ordinary activity causes dyspnoea, limiting,
- Grade IV = dyspnoea at rest.
CHRONIC HF - Mx
1st line?
2nd line?
3rd line?
1st line = ACE-i + b-blocker + furosemide
2nd line = spironolactone + valsartan + hydralazine/isosorbide mononitrate
3rd line = Digoxin = cardiac glycoside that increases myocardial contraction and reduces conductivity in AV node – helps symptoms even in those with sinus rhythm.
acute HF - usually LV OR RV?
Usually LV failure,
Signs of Acute HF?
characteristic sign of Acute HF: pulsus alterans - what is it?
- indicative of what impairment?
- Dyspnoea
- Orthopnoea
- Pink frothy sputum
- Distressed, pale, sweaty,
- Lung crackles
Resulting in severe pulmonary oedema.
pulsus alterans = alternating between strong and weak beats
LV systolic impairment
Acute HF - Mx
high flow oxygen
Diamorphine IV
Furosemide IV
GTN spray
if systolic BP >100 : give isosorbide dinitrate
A 78-year-old man is recovering after an ST elevation myocardial infarction (STEMI). In the past hour, his pulse rate has increased from 100 to 130bpm and his respiratory rate from 20 to 30/min. The junior doctor is called. The patient has a productive cough and is sitting forward with his hands on his knees. Which single treatment is most likely to reverse this man’s deterioration?
Bendroflumethiazide 2.5 mg PO Bumetanide 1 mg PO Furosemide 80 mg IV Heparin 5000U IV Metoprolol 50 mg IV
Furosemide 80 mg IV
This man is displaying the signs of severe acute heart failure, common after an MI, and requires intravenous diuresis
A 36-year-old woman has been lethargic and felt increasingly dizzy over the last 2 months. She is usually well but does report long and very heavy periods, especially in the last 6 months.
T 36.6°C, HR 110bpm, BP 95/65mmHg.
Her JVP is visible 5cm above the sternal angle and she has bilateral ankle oedema pitting to the mid-calf. In her chest there are fine end-inspiratory crepitations heard at both bases. Which is the single most appropriate next step?
Furosemide 40mg IV Human albumin solution 20% 200 mL IV Iron sucrose 200 mg IV Packed red cells 2U IV Vitamin K 10 mg IV
Packed red cells 2U IV
This is symptomatic anaemia (Hb usually <50g/L) causing heart failure. In treating the low Hb, it is important to transfuse slowly in conjunction with a diuretic, e.g. furosemide 10–40mg IV with alternate units.
A 78-year old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. Which sign is most likely to be present?
Pleural effusion on CXR Raised JVP Bilateral pedal oedema Bibasal crepitation Atrial fibrillation
Bibasal crepitation
A 78-year old woman is admitted to your ward following a 3-day history of shortness of breath and a productive cough of white frothy sputum. On auscultation of the lungs, you hear bilateral basal coarse inspiratory crackles. You suspect that the patient is in congestive heart failure. You request a CXR. Which of the following signs is not typically seen on CXR in patients with congestive cardiac failure?
Lower lobe diversion Cardiomegaly Pleural effusions Alveolar oedema Kerley B lines
Lower lobe diversion
A patient with known heart failure is unable to carry out any physical activity without discomfort. Symptoms of heart failure are present even at rest with increased discomfort with any physical activity. What New York Heart Association class best describes the severity of their disease?
NYHA Class I
NYHA Class II
NYHA Class III
NYHA Class IV
NYHA Class IV
An 82-year-old lady is found to have heart failure with a left ventricular ejection fraction (LVEF) of 30%. Her renal function is normal and BP is 165/102mmHg. She is not taking any other medication. What combination of drugs would be the best initial treatment for her?
Amlodipine + Spironolactone
Bisoprolol + Lercanidipine
Furosemide + digoxin
Ramipril + Bisoprolol
Ramipril + Bisoprolol
Patients with heart failure with reduced LVEF should be given a beta blocker and an ACE inhibitor as first-line treatment
Should be offered annually for all patients with heart failure
A. Pneumococcal vaccine B. Influenza vaccine C. Calcium channel blocker D. Spironolactone E. ACE inhibitor + beta-blocker F. Hydralazine + nitrates G. ACE inhibitor + frusemide H. Digoxin I. Echocardiogram J. Electrocardiogram
Influenza vaccine
Should be introduced first-line in patients with stable impaired left ventricular function
A. Pneumococcal vaccine B. Influenza vaccine C. Calcium channel blocker D. Spironolactone E. ACE inhibitor + beta-blocker F. Hydralazine + nitrates G. ACE inhibitor + frusemide H. Digoxin I. Echocardiogram J. Electrocardiogram
ACE inhibitor + beta-blokcer
A 73 year old woman presents to the Emergency Department with progressive shortness of breath. On examination the patient has an S3 gallop rhythm, bibasal crepitations and pitting oedema up to both knees. An ECG shows signs of left ventricular hypertrophy and a chest X-ray shows small bilateral pleural effusions, cardiomegaly and upper lobe diversion.
Given the likely diagnosis, which of the following drugs has been shown to improve long-term survival?
digoxin
furosemide
ramipril
bumetanide
ramipril
While loop diuretics (furosemide, bumetanide) and nitrates are important in the management of acute or decompensated cardiac failure, they have no effect on long-term survival.
Which one of the following treatments have not been shown to improve mortality in patients with chronic heart failure?
beta blockers spironolactone furosemide enalapril nitrates
furosemide
A combination of isosorbide dinitrate with hydralazine has been tried recently but had to be stopped due to side-effects. What additional medication would best help her symptoms?
bosentan
isosorbide mononitrate
losartan
digoxin
digoxin
An 89 year old lady presents acutely short of breath and distressed. She has a background of previous myocardial infarction (MI) and hypertension. She is now coughing up white sputum. Examination reveals bilateral course crepitations throughout the lung fields. She has a raised jugular venous pressure and peripheral oedema. Observations are a respiratory rate of 35/min, oxygen saturations of 92% on 15 litres of oxygen per minute, blood pressure 135/90 mmHg, heart rate 100/min. Chest X-ray reveals widespread interstitial shadowing. Intravenous furosemide has been given but the patient fails to improve. Which of the following would be useful in treating this patient?
IV abx
oral furosemide
bilevel +ve airway pressure
continuous +ve airway pressure
continuous +ve airway pressure
The patient is suffering from severe pulmonary oedema with bilateral course crackles and cough productive of white sputum. The patient has signs of right sided heart failure with raised JVP and peripheral oedema.
A 65-year-old man comes to see you as he has noticed that he has become increasingly short of breath and has to sleep with 3 or 4 pillows to help him breathe at night. He also reports feeling more breathless after climbing 1 flight of stairs. His past medical history includes high cholesterol and myocardial infarction.
On examination, you auscultate bibasal crepitations and note that his ankles appear swollen.
Which one of the following is the most appropriate next investigation?
ct CHEST 24 hour ECG ECHO BNP Cardiac exercise test
ECHO
You review a 62-year-old man who has recently been discharged from hospital in Hungary following a myocardial infarction. He brings a copy of an echocardiogram report which shows his left ventricular ejection fraction is 38%. On examination his pulse is 78 / min and regular, blood pressure is 124 / 72 mmHg and his chest is clear. His current medications include aspirin, simvastatin and lisinopril. What is the most appropriate next step in terms of his medication
add atenolol
add furosemide
add bisoprolol
add isosorbide mononitrate
add bisoprolol
Both carvedilol and bisoprolol have been shown to reduce mortality in stable heart failure. The other beta-blockers have no evidence base to support their use.
NICE recommend that all heart failure patients should take both an ACE-inhibitor and a beta-blocker.
if someone has had a previous MI and suspect HF - what test do you do?
if someone has not had previous MI and suspect HF what test do you do?
ECHO - (BNP reading will be inaccurate as it is raised by MI as well)
BNP
