Heart FAilure Flashcards
What is heart failure?
Cardiac output is inadequate for the body’s requirements
What is systolic failure vs diastolic failure
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.
What are causes of systolic failure?
Ischaemic heart disease
MI
Cardiomyopathy
What are causes of diastolic failure?
Ventricular hypertrophy Constrictive pericaridtis Tamponade Restrictive cardiomyopathy Obesity
What are symptoms of left ventricular failure?
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
What are causes of RVF?
LVF, pulmonary stenosis, lung disease (cor pulmonale)
What are symptoms of RVF?
Peripheral oedema (up to thighs, sacrum, abdominal wall) ascites, nausea, anorexia, facial engorgement, epistaxis
What is cor pulmonale?
Enlargemetn and failure of the right ventricle in response to increased vascular resistance such as from pulmonic stenosis or high BP in the lungs
What is acute heart failure?
New onset acute or decompensation of chronic HF characterised by pulmonary and/or peripheral oedema with or without signs of peripheral hypoperfusion
What are features of acute heart failure?
Dyspnoea Cough with pink frothy sputum Bibasal crackles Low SaO2 S3 - gallop rhythm
What are pathophysiological causes for HF?
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)
What physical difference in the ventricles do you see between excessive preload and excessive after load?
Excessive preload can cause ventricular dilatation, exacerbating pump failure
Excessive after load prompts ventricular muscle thickening (hypertrophy) resulting in stiff walls and diastolic dysfunction.
How is HF diagnosed if there is previous MI vs no previous MI?
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
What is BNP? What are high, raised and normal levels?
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
What factors increase BNP level?
LVH Ischaemia tachycardia RVF Hypoxaemia GFR < 60 Sepsis COPD Diabetes Age >70 Liver cirrhosis
What factors decrease BNP?
Obesity Diuretics ACEi Beta blockers ARB Aldosterone antagonists
What are signs of HF?
Cyanosis Hypotension Narrow pulse pressure Displaced apex beat due to LV dilatation RV heave due to pulmonary hypertension Signs of valve disease
How can HF be graded?
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.
What investigations for HF?
Bedside: SaO2 BP ECG (look for ischaemia, MI, ventricular hypertrophy) Peak Flow
Bloods
FBC
U&E
BNP
Imaging:
CXR Echo
Other:
definitive investigation
echocardiography
What features are seen on x-ray in HF?
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
What advice would you give to someone with chronic heart failure?
Stop smoking, stop drinking alcohol, eat less salt, optimise weight and nutrition
what drugs are used in chronic heart failure?
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.
What other management of chronic heart failure?
Treat cause - arrhythmia, valve disease Treat exacerbating factors - anaemia, thyroid disease, infection, hypertension Avoid exacerbating factors Annual flu vaccine One off pneumococcal vaccine
What do you give a chronic HF patient who also has AF?
Digoxin
What are the roles of natriuretic peptides?
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.
What are symptoms/signs of severe pulmonary oedema?
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
What is the management for acute heart failure?
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
