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Cardiovascular > Heart FAilure > Flashcards

Heart FAilure Flashcards

1
Q

What is heart failure?

A

Cardiac output is inadequate for the body’s requirements

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2
Q

What is systolic failure vs diastolic failure

A

Systolic failure - inability of the ventricle to contract normally resulting in reduced cardiac output. Ejection fraction is <40%

Diastolic failure - inability of ventricles to relax and fill normally causing increased filling pressures. Ejection fraction is >50% - heart failure with preserved ejection fraction.

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3
Q

What are causes of systolic failure?

A

Ischaemic heart disease
MI
Cardiomyopathy

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4
Q

What are causes of diastolic failure?

A 
Ventricular hypertrophy
Constrictive pericaridtis
Tamponade
Restrictive cardiomyopathy 
Obesity
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5
Q

What are symptoms of left ventricular failure?

A

Dyspnoea, poor exercise tolerance, fatigue, orthopnoea (SOB when lying flat), paroxysmal nocturnal dyspnoea (SOB attack and coughing at night that wakes pt up), nocturnal cough, wheeze, nocturne, cold peripheries, weight loss

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6
Q

What are causes of RVF?

A

LVF, pulmonary stenosis, lung disease (cor pulmonale)

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7
Q

What are symptoms of RVF?

A

Peripheral oedema (up to thighs, sacrum, abdominal wall) ascites, nausea, anorexia, facial engorgement, epistaxis

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8
Q

What is cor pulmonale?

A

Enlargemetn and failure of the right ventricle in response to increased vascular resistance such as from pulmonic stenosis or high BP in the lungs

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9
Q

What is acute heart failure?

A

New onset acute or decompensation of chronic HF characterised by pulmonary and/or peripheral oedema with or without signs of peripheral hypoperfusion

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10
Q

What are features of acute heart failure?

A 
Dyspnoea
Cough with pink frothy sputum
Bibasal crackles
Low SaO2
S3 - gallop rhythm
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11
Q

What are pathophysiological causes for HF?

A

Excessive preload - mitral regurgitation or fluid overload (e.g. renal failure or IV infusion too rapid)

Pump failure: systolic and/or diastolic HF, bradycardia (due to betablockers, heart block, post MI), negatively inotropic drugs (e.g. most antiarrhythmics)

Chronic excessive after load (aortic stenosis, hypertension)

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12
Q

What physical difference in the ventricles do you see between excessive preload and excessive after load?

A

Excessive preload can cause ventricular dilatation, exacerbating pump failure

Excessive after load prompts ventricular muscle thickening (hypertrophy) resulting in stiff walls and diastolic dysfunction.

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13
Q

How is HF diagnosed if there is previous MI vs no previous MI?

A

Previous MI - arrange echocardiogram within 2 weeks

No previous MI

  • Measure serum natriuretic peptide BNP
  • If high echo within 2 weeks
  • If raised, echo within 6 weeks
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14
Q

What is BNP? What are high, raised and normal levels?

A

Hormone produced mainly by left ventricular myocardium in response to strain.
High > 400pg/ml (116pmol/L)
Raised 100-400pg/ml (29-116pmol/L)
Normal <100pg/ml (<29pmol/L

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15
Q

What factors increase BNP level?

A 
LVH
Ischaemia
tachycardia
RVF
Hypoxaemia
GFR < 60
Sepsis
COPD
Diabetes
Age >70
Liver cirrhosis
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16
Q

What factors decrease BNP?

A 
Obesity
Diuretics
ACEi
Beta blockers
ARB
Aldosterone antagonists
17
Q

What are signs of HF?

A 
Cyanosis
Hypotension
Narrow pulse pressure
Displaced apex beat due to LV dilatation
RV heave due to pulmonary hypertension
Signs of valve disease
18
Q

How can HF be graded?

A

New York Heart Association classification

I no symptoms, no limitation of ordinary activity - no undue dyspnoea, fatigue, palpitations

II - comfortable at rest, dyspnoea, fatigue, palpitations during ordinary activity

III - Less than ordinary activity causes dyspnoea which is limiting

IV - dyspnoea at rest with increased discomfort on any activity.

19
Q

What investigations for HF?

A 
Bedside:
SaO2
BP
ECG (look for ischaemia, MI, ventricular hypertrophy)
Peak Flow

Bloods
FBC
U&E
BNP

Imaging:
CXR Echo

Other:

20
Q

definitive investigation

A

echocardiography

21
Q

What features are seen on x-ray in HF?

A

Alveolar oedema - perihilar batwing shadowing
Kerley B lines (septal lines) - interstitial oedema and engorged perilymphatic
Cardiomegaly (cardiothoracic ratio >50% on PA film)
Dilated upper lobe vessels - upper lobe diversion due to pulmonary venous HTN
Effusion (pleural) - blunt costophrenia/cardiophrenic angles

22
Q

What advice would you give to someone with chronic heart failure?

A

Stop smoking, stop drinking alcohol, eat less salt, optimise weight and nutrition

23
Q

what drugs are used in chronic heart failure?

A

Diuretics - loop diuretics (furosemide) to relieve symptoms of fluid overload. Add K sparing diuretic (spironolactone if K<3.2.

1st line:
ACEi - left ventricular systolic dysfunction - ARB if cough is problem
Beta- blockers (bisoprolol, carvediol, nebivolol)

2nd line
Aldosterone antagonist - spironolactone - monitor U&E as K sparing
ARB
Hydralazine (vasodilator) + nitrate - used if intolerant of ACEi and ARB

Digoxin tif symptoms persist of AF present.

24
Q

What other management of chronic heart failure?

A 
Treat cause - arrhythmia, valve disease
Treat exacerbating factors - anaemia, thyroid disease, infection, hypertension
Avoid exacerbating factors
Annual flu vaccine
One off pneumococcal vaccine
25
Q

What do you give a chronic HF patient who also has AF?

A

Digoxin

26
Q

What are the roles of natriuretic peptides?

A

ANP and BNP assist the stretched atria and ventricles by increasing GFR and decreasing renal Na resorption thereby reducing fluid load, ad be relaxing smooth muscle, decreasing preload.

27
Q

What are symptoms/signs of severe pulmonary oedema?

A

Dyspnoea, orthpnoea, pink frothy sputum

Distressed, pale. sweaty, tachycardia, tachypnoea, pink frothy sputum, raised JVP, fine bibasal crackles, triple/gallop rhythm, wheeze
Sitting up, leaning forward

28
Q

What is the management for acute heart failure?

A 
Sit upright
High flow O2 if SaO2 low
Treat arrhythmias
Diamorphine IV
Furosemide (loop diuretics) IV slowly
GTN spray - vasodilators
Inotropic agents
Nitrate infusion to maintain BP
Consider COAO - improves ventilation by recruiting more alveoli,d riving fluid out of alveolar space and into vasculature

Discontinue beta-blockers in short term

Cardiovascular (16 decks)

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