heart failure Flashcards
define heart failure
Inability of the heart to adequately pump supply in relation to the bodies demands
explain the different types of heart failure
Systolic vs Diastolic
- systolic = impaired contraction
- diastolic = impaired filling
left vs right
low output vs high output
- low output = pump failure, diastolic failure, arrhythmias
- high output = pregnancy, anaemia, thyrotoxicosis
what are the causes of systolic heart failure?
MI/ischaemia (commonest)
dilated cardiomyopathy
HTN
myocarditis
what are the causes of diastolic HF?
pericardial effusion
Tamponade
restrictive/hypertrophic cardiomyopathy
how do the causes of right heart failure and left heart failure differ?
…
what is the difference between low vs high output heart failure?
In low output CO falls and the heart fails to increase exertion - LVF
In high output there is an increased demand on the heart - RVF first then LVF
how do arrhythmias cause heart failure?
uncoordinated contraction leads to decreased CO to supply the bodies demands
describe the physiological responses to heart failure
Baroreceptors detect low CO and stimulate sympathetic drive to vasoconstrict, increase HR and activate RAAS
decreased CO leads to decreased renal perfusion and RAAS activation
BNP released due to stretch causes naturesis to reduce fluid and strain on heart by relaxing smooth muscle
Myocyte hypertrophy - match demand
explain starlings curve in heart failure
Normally increase in preload increases CO but in heart failure the peak is reached earlier. In mild heart failure this reduced CO will be compensated for by increased HR.
However, later the heart cannot keep up with the bodies demands and the curve shifts
what is the NYHA classification for HF?
Class I – no limitation / breathless on physical activity. But heart disease present
Class II – some limitation
Class III – marked limitation
Class IV – symptoms at rest
what are the symptoms of heart failure (Split up into left and right sided)
left = fatigue, exertional dyspnoea, orthopnoea, PND
right = fatigue, dyspnoea, anorexia/nausea, peripheral oedema, ascites
what are the signs of heart failure
left = cardiomegaly and shifted apex, crackles, 3rd/4th heart sounds, murmur, cool peripheries, low BP, tachycardia
right = hepatomegaly, ascites, raised JVP, cardiomegaly
Kussmaul sign – seen in diastolic HF whereby there is a paradoxical rise in JVP with inspiration or failure of JVP to drop with inspiration
what are the complications of heart failure?
Low CO
Muscle underpurfusion – weakness, exercise intolerance, fatigue
Poor renal perfusion can lead to CKD
Pulmonary oedema
Arrhythmias – due to tissue remodelling
Risk of VTE and stroke due to stasis and arrhythmias
What crtieria is used to diagnose heart failure?
Framingham criteria - need 2major or 1major + 2minor
MAJOR: (3 lung, 3 heart, 3 peripheral) PND Lung crepitations Acute pulmonary oedema Cardiomegaly S3 gallop rhythm Increased central venous pressure Neck vein distension Hepatojugular reflux Weight loss in response to treatment
MINOR: (3 lung, 1 heart, 2 enlargements) Dyspnoea Nocturnal cough Plural effusion Tachycardia Bilateral ankle oedema Hepatomegaly
what investigations would you want to carry out in someone presenting with HF?
bloods: FBC (anaemia), U&E (kidney function), BNP, TFT
CXR
ECG - axis deviation, ischaemia
ECHO - assess LV function, heart structure, valve disease, ejection fraction
what can an ECHO tell you in HF?
Assess LV function
LV wall thickness
ejection fraction
valve disease
what does NICE suggest about diagnosis of HF based on ECG, ECHO and BNP?
If ECG and BNP both normal – HF is unlikely
If abnormal then ECHO required to confirm diagnosis
If very high BNP – 2 week referral for ECHO
If moderately high – 6 week referral for ECHO
what are the classical CXR seen in HF
Alveolar shadowing – bat wings Kerley B lines Cardiomegaly Upper lobe Diversion Effusions
Discuss the steps in managing heart failure
- conservative
- manage risks e.g. smoking, BMI, salt intake
- exercise rehab
- vaccinations
- avoid certain drugs e.g. NSAIDs, verapamil - correct any underlying cause
- Pharma
- protective = aspirin and statins
- 1st line = ACEi/ARB (Lisinopril/Candesartan), b-blocker, loop diuretic
- 2nd line - get specialist help (spironolactone etc)
- 3rd line = digoxin
- anticoag also should be considered - Surgery
- cardiac resync (pacemaker)
- implantable cardioverter defib
- CABG/angioplasty
- LV assist device
- transplant
which medications actually improve prognosis for HF (rather than just symptom control) ?
ACEi
B blockers
Spironolactone
what are the causes of pulmonary oedema?
Cardiogenic:
- MI, arrhythmia, fluid overload
non-cardio:
- ARDS, airway obstruction, neurogenic
how can acute HF / pulmonary oedema occur?
New onset OR decompensation of chronic HF
Anything which makes the HF situation worse
Causes of acute HF – CHAMP Coronary syndrome Hypertensive emergency Arrhythmias Mechanical – VSD, valve leak, LV aneurysm P.E
what are the symptoms of acute HF/ pulmonary oedema ?
acute breathlessness
cough/pink frothy sputum
collapse/arrest
what are the signs of acute HF/ pulmonary oedema?
distressed, sweaty, cyanosed anxiety increased HR + RR increased JVP S3 gallop rhythm bibasal creps pleural effusions wheeze (cardiac asthma)
Discuss step wise management of pulmonary oedema / Acute HF
- sit patient upright
- O2 high flow (94-98%)
- IV access and ECG
- diamorphine 5mg IV + metoclopramide 10mg IV (calm patient + venodilator)
- Furosemide 40-80mg IV
- GTN
7 if worsening consider CPAP, ITU, dialysis, more furosemide
what are the causes of a raised BNP?
HF MI Athletes P.E CKD or AKI Sepsis COPD with cor pulmonale Hyperthyroidism
what is restrictive cardiomyopathy?
Ventricular walls become rigid
diastolic dysfunction
least common type of cardiomyopathy
what is hypertrophic cardiomyopathy?
thickened left ventricular wall, with reduced ventricular lumen size
diastolic dysfunction
risk of sudden cardiac death in the young
what is congestive cardiomyopathy?
enlargement of all 4 heart chambers of the heart
most common type
systolic dysfunction
how can we distinguish between COPD exacerbation and pulmonary oedema?
Both have breathlessness but:
COPD – red due to vasodilation
Acute HF – cold, clammy and pale
what are the causes of acute HF?
Causes of acute HF – CHAMP
- Coronary syndrome
- Hypertensive emergency
- Arrhythmias
- Mechanical – VSD, valve leak, LV aneurysm
- P.E
