Heart failure Flashcards
what are the 8 phases of heart failure?
1) risk factors = diabetes & hypertension
2) atherosclerosis & LVH
3) MI
4) remodelling
5) ventricular dilation
6) congestive heart failure
7) end stage heart disease & death
8) death
what is heart failure?
state in which the heart is unable to pump blood at a rate commensurate with the requirements of the tissues or can do so only at high pressure
what 2 impairments to the heart cause heart failure?
1) impairment of left ventricular filling
2) impaired ejection of blood
what happens in impaired left ventricular filling?
= in diastole, left ventricle walls relax allowing for filling of LV cavity
= without proper LV relaxation, the volume of blood filling the cavity is reduced, thus reducing SV, the volume of blood ejected with each contraction
what happens in impaired ejection of blood?
= due to LV wall damage, LV has reduced ability to pump or eject blood
what are some possible causes of heart failure?
- coronary heart disease
- hypertension/diabetes
- dilated cardiomyopathy
- valve disease
- tachycardia arrhythmias
- heart failure with preserved ejection fraction, HFpEF
what are the symptoms of heart failure?
- shortness of breath
- difficult of breathing at night when recumbent;
= orthopnoea
= paroxysmal nocturnal dyspnoea - reduced exercise tolerance
- fatigue / tiredness
- ankle swelling
in a volume overload scenario in heart failure, what common findings would you find in a physical examination?
1) neck exam
= elevated jugular venous pressure
2) auscultation of lungs
= rales or crackles
3) auscultation of heart
= 3rd or 4th heart sounds sometimes called gallop rhythm
= murmur
4) oedema in dependent areas
= sacrum
= feet/ankles/lower legs
what 2 diagnostic tests can be used to diagnose heart failure?
and what can these tests determine?
1) ECG
- can identify causes of HF such as;
= arrhythmias
= post MI
= left ventricular hypertrophy
2) chest X-ray
= size & shape of cardiac silhouette
= evidence of fluid accumulation in lungs
what is the single most useful diagnostic test?
= trans-thoracic echo-cardiography(TTE)
what does an echocardiogram reveal?
- chamber size
- right & left ventricular function
- regional wall motion abnormalities
- evidence of impaired LV filling (feature of diastolic dysfunction)
- valvular heart disease
- diseases of pericardium
- ejection fraction
what does EF represent?
and what is a normal EF?
= % of blood that is pumped out of hart during each beat
= > 50%
what is heart failure with an EF < 40% known as?
= heart failure with reduced ejection fraction (HFrEF)
what is heart failure with a normal EF known as?
= heart failure with preserved ejection fraction (HFpEF)
what is the difference between HFrEF and HFpEF?
HFrEF (reduced)
= LV is unable to eject an adequate amount of blood during systole
HFpEF (preserved)
= less blood is able to fill LV in diastole, due to myocardial stiffness.
= so, LV has less blood to eject during systole
why is echocardiogram the gold standard?
for looking at;
1) structure & function
2) LVEF
- systolic dysfunction
- diastolic dysfunction (TDI)
3) may help define cause; valve, previous AMI
what is BNP?
if ANP is an atrial hormone, what is BNP?
B-type natriuretic peptide which is a cardiac hormone
BNP = ventricular hormone
what is the normal range for BNP?
= Less than 125 pg/mL for patients aged 0-74 years
= Less than 450 pg/mL for patients aged 75-99 years.
what lifestyle measures should you do to avoid heart failure?
1) water salt restriction
2) continued exercise
3) vaccinations up to date
4) management of mental health
what drugs prolong survival in heart failure?
1) RAS inhibitors
= ACE inhibitors & ARI antagonists
= push to maximum dose tolerated
2) B-blockers
3) aldosterone antagonists
e. g. spironolactone & eplerennone
4) vasodilators
e. g. hydralazine & nitrates combined (for this who can’t tolerated ACEI/ARB)
5) sinus node blocker
e. g. ivabradine
what drugs improve symptoms in heart failure?
e.g.
digoxin
frusemide
what is the first line treatment in people with LVSD (left ventricular systolic dysfunction?
= ACE inhibitors and beta-blockers licensed for heart failure to all patients with LVSD
= offer beta-blockers licensed for heart failure to all patients with LVSD, including; - older adults - patients with = peripheral vascular disease = erectile dysfunction = diabetes mellitus = interstitial pulmonary disease = COPD without reversibility
what is cardiac resynchronisation therapy (CRT)?
it co-ordinates the function of the left and right ventricles.
what does the presence of LBBB in heart failure cause?
causes
- abnormal contractile waves frown across the LV
- LV doesn’t contract efficiently = dysnchronous contraction
- worsening LV systolic dysfunction
what does pacing the LV from left lateral wall do?
= increases synchronous contraction
= improves LV haemodynamics
what are 3 new treatments for heart failure?
1) eplerenone in mild heart failure
2) ivabradine addition when beta-blockers aren’t enough
3) LCZ-696. Pradigm
what is ivabradine?
If channel modulator
what does ivabradine do?
= specifically binds the funny channel;
- slowing heart rate
- doesn’t work in AF
= doesn’t alter;
- ventricular depolarisation
- myocardial contractility
- blood pressure
describe the doses of entresto that should be given?
- Entresto 24 mg/26 mg TWICE DAILY (for ACEI naïve patients or those on low dose ACEI (ramipril 2.5 mg) /ARB (losartan 50 mg)
- Entresto 49 mg/51 mg TWICE DAILY (from high dose ACEI (Ramipril 10 mg) or ARB (losartan 150 mg)
- Target dose Entresto 97 mg/103 mg TWICE DAILY
what 3 things do you need to be wary of in risk management?
1) BP;
- startin BP (SBP > 100mmHg)
- symptomatic hypotension (adjust other medications or temporary down titration)
2) hyperkalaemia
3) renal dysfunction
what things should you manage in HfpEF?
1) AF.
- Loss of atrial contraction reduce left atrial
emptying
2) Tachycardia.
- Shortens the duration of diastole
3) Elevations in BP (abrupt, severe,
refractory)
4) Ischaemia.
- Acute induction or worsening of diastolic dysfunction by ischemia raises left atrial and therefore pulmonary venous pressure.
how would you manage refractory end-stage HF?
- Review etiology, treatment & aggrav. factors”
- Control fluid retention”
• Resistance to diuretics”
• Ultrafiltration ?” - iiv inotropics / vasodilators during decompensation”
- Consider resynchronization”
- Consider mechanical assist devices”
- Consider heart transplantation”
who are potential candidates for LVAD, from bridge to destination therapy?
- not currently Tx eligible
- no end stage kidney disease, liver disease or lung disease
- chronic refractory HF & life expectancy <2years without LVAD
who is eligible for heart transplant?
- Refractory cardiogenic shock”
- Documented dependence on IV inotropic support
to maintain adequate organ perfusion” - Peak VO2 < 10 ml / kg / min “
- Severe symptoms of ischemia not amenable to revascularization”
- Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities”
= Contraindications: age, severe comorbidity”
