Heart failure Flashcards
Heart failure can also be known as congestive heart failure.
Pathoma has a section on this.
Define heart failure.
Definition:
“Failure of heart to pump blood (=oxygen) at a rate sufficient to meet metabolic requirements of the tissues - caused by abnormal cardiac function.”
Characteristics of heart failure:
- typical haemodynamic changes e.g. _____ _________
- neurohumoral activation (explain what this is)
Characteristics of heart failure:
- typical haemodynamic changes e.g. systemic vasoconstriction
- neurohumoral activation = ‘ increased activity of the sympathetic nervous system, RAAS, ADH and atrial natriuretic peptide (ANP) ‘
Clinical presentation:
think of 3 main ones
Clinical presentation:
- breathlessness
- effort intolerance
- fluid retention (ankle swelling)
Causes of heart failure:
5 common listed, think of the usual
6 less common listed too.
Causes of heart failure:
COMMON:
- hypertension
- coronary artery disease / ischaemic heart disease (same thing), (MI is an example of acute CAD/IHD)
- idiopathic
- toxins (alcohol, chemo)
- genetic
LESS COMMON:
- valve disease
- infections (e.g. Chaga’s)
- Congenital heart disease (abnormalities from birth)
- Metabolic (e.g. haemochromatosis, amyloid, thyroid disease)
- pericardial disease/pericardial effusion (fluid in pericardial cavity) (e.g. TB)
- endocardial disease/endocardial fibroelastosis (defect in which there’s too much supporting connective tissue - collagen, elastic fibres)
Main types of heart failure (HF):
— __-___
> younger
> usually male
> coronary artery aetiology
— __-___
> older
> usually female
> hypertension aetiology
— ______ (‘congestive’)
> present for period of time
— _____ (‘decompensated’)
> a worsening of chronic
or
> new onset
Main types of heart failure (HF):
— HF-REF (reduced ejection fraction)
> younger
> usually male
> coronary artery aetiology
— HF-PEF (preserved ejection fraction)
> older
> usually female
> hypertension aetiology
— Chronic (‘congestive’)
> present for period of time
— Acute (‘decompensated’)
> a worsening of chronic
or
> new onset
Simple pathophysiology steps to heart failure:
- _______ ____
\/\/\/
- ___ ______ ____ ______
\/\/\/
- ______ ______ _ ______ _____ / _____
\/\/\/
- _________ _______ (SNS, RAAS, ADH, ANP)
\/\/\/
- ______ _________ ___ ____ __ ___ ____ _______ (caused by neurohumoral activation)
\/\/\/
_. again, cycle repeats
Simple pathophysiology steps to heart failure:
- Myocardial injury
\/\/\/
- Left ventricular systolic dysfunction
\/\/\/
- Percieved reduction in circulating volume / pressure
\/\/\/
- Neurohumoral activation (SNS, RAAS, ADH, ANP)
\/\/\/
- Systemic vasoconstriction and renal Na and water retention (caused by neurohumoral activation)
\/\/\/
- again, cycle repeats
Signs and symptoms of heart failure
SYMPTOMS (what patient notices)
3 listed
SIGNS (what doctor notices on examination)
6 listed
Signs and symptoms of heart failure
SYMPTOMS (what patient notices)
- dyspnoea (difficult breathing) and cough
- ankle swelling (also legs and abdomen)
- fatigue
SIGNS (what doctor notices on examination)
- peripheral oedema (ankles, legs, sacrum)
- elevated JVP
- third heart sound
- displaced apex (due to cardiomegaly)
- pulmonary oedema (lung crackles, remember because left ventricle can’t pump enough so there is back log)
- pleural effusion
New York Heart Association (NYHA) Functional Classification:
Discuss when symptoms arise and limitations for each.
NYHA class 1 ?
NYHA class 2 (mild) ?
NYHA class 3 (moderate) ?
NYHA class 4 (severe) ?
New York Heart Association (NYHA) Functional Classification:
NYHA class 1 no symptoms or limitation in ordinary activity (such as walking/stairs)
NYHA class 2 (mild) mild symptoms (mild shortness or breath an/or angina) and slight limitation in ordinary activity
NYHA class 3 (moderate) Symptoms with less than ordinary activity (such as walking short distances), comfortable only at rest
NYHA class 4 (severe) Severe limitations and symptoms at rest, bedbound.
General investigations for heart failure.
Think of the reason for doing each of these:
- ECG
- CXR (chest X-ray)
- Echocardiogram
- Blood chemistry
- Haematology
- Natriuretic peptides
General investigations for heart failure.
Think of the reason for doing each of these:
- ECG = check for MI, LVH, rhythm, rate, QRS duration
- CXR (chest X-ray) = exclude lung pathology, assess pulmonary oedema
- Echocardiogram = chamber size, systolic+diastolic function, check valves (CMR/cardiovascular magnetic resonance is alternative)
- Blood chemistry (to assess U&Es, Creatinine, urea, LFTs, urate)
- Haematology ( Hb, RDW [RBC Distribution Width, checks size of RBCs] )
- Natriuretic peptides (BNP, NT-proBNP)
Heart failure diagnosis:
[ say what each looks for ]
Signs and symptoms -
\/\/\/
Examination -
\/\/\/
Natriuretic peptides and ECG -
\/\/\/
Echocardiography
Heart failure diagnosis:
Signs and symptoms - ones suggestive of HF, such as dyspnoea/fatigue/ankle swelling (symptoms) and raised JVP/third heart sound/displaced apex beat/peripheral oedema/pulmonary oedema (signs)
\/\/\/
Examination - full blood count, blood glucose, U&Es, urinalysis, CXR
\/\/\/
Natriuretic peptides and ECG - BNP, NT-proBNP
(if high BNP or high NT-proBNP or abnormal ECG then continue \/\/\/)
\/\/\/
Echocardiography
Selected patient investigations:
- c_____ a_______ (X-ray with radioactive dye in vessels)
- e_____ t___
- m______ b____
- g_____ t_____
Selected patient investigations:
- coronary angiography (X-ray with radioactive dye in vessels)
- exercise tests
- myocardial biopsy
- genetic testing
SIGN GUIDELINES
- ____ ______ (slows heart) and ___ _______ (reduces BP) [if intolerant to ___ _____ then ARB]
\/\/\/ ongoing symptoms (NYHA II-IV)
- Add _______ _______ _______ (___) (antagonist to aldosterone, so reduces fluid, aka acts a diuretic)
\/\/\/ ongoing symptoms (NYHA II-IV)
- Give ______ (inhibits breakdown of natriuretic peptides [e.g. ANP+BNP] ) and ______ (an ARB).
STOP the ___ ______ and ___.
CONTINUE ___ _____ and ___.
\/\/\/ ongoing symptoms (NYHA II-IV)
- Other shiz:
- ___ (inserted defib, pacemaker action too) or ___-/___- (inserted pacemaker)
- ________ (inhibits sinus node, so slows pace)
then
- digoxin
- hydralazine + isosorbide dinitrate
then
transplant
SIGN GUIDELINES
- Beta blocker (slows heart) and ACE inhibitor (reduces BP) [if intolerant to ACE inhibitor then ARB]
\/\/\/ ongoing symptoms (NYHA II-IV)
- Add Mineralocorticoid Receptor Antagonist (MRA) (antagonist to aldosterone, so reduces fluid, aka acts a diuretic)
\/\/\/ ongoing symptoms (NYHA II-IV)
- Give Sacubitril (inhibits breakdown of natriuretic peptides [e.g. ANP+BNP] ) and Valsartan (an ARB).
STOP the ACE inhibitors and other ARB.
CONTINUE beta blocker and MRA.
\/\/\/ ongoing symptoms (NYHA II-IV)
- Other shiz:
- ICD (inserted defib) or CRT-P/CRT-D (inserted pacemaker)
- ivabradine (slows pacemaker current)
- digoxin
then
- digoxin
- hydralazine + isosorbide dinitrate
then
transplant
Diuretics important in heart failure patients to reduce their fluid retention.
Will help the peripheral oedema and pulmonary oedema.
Name examples of a diuretic (3 listed).
Examples of diuretics include:
- furosemide (loop diuretic, inhibits Na-K-
Cl transporter) - bumetanide (loop diuretic too)
- spironolactone (blocks aldosterone receptors)
What type of medication is Enalapril?
ACE inhibitor
What is the most evidence based medication in heart failure?
Beta blockers
