Heart Failure Flashcards
What is the mechanism behind systolic HF?
Ventricles enlarged
Unable to contract fully
↓CO + ejection fraction < 40%
What are the causes of systolic HF?
IHD
MI
Cardiomyopathy
What is the mechanism behind diastolic HF?
Stiff ventricles cannot relax fully
↑filling pressure
Ejection fraction > 50%
What are the causes of diastolic HF?
Constrictive pericarditis
HTN
Cardiomyopathy
How are HF causes divided?
LOW OUTPUT = reduced heart function
HIGH OUTPUT = Heart working at normal/inc rate but body has greater demand
What are the causes of low output HF?
Inc pre-load: MR, fluid overload
Pump failure: IHD, MI, (restrictive) Cardiomyopathy, AF, tamponade
Chronic excessive overload: AS, HTN
What are the causes of high output HF?
Hyperthyroid
Anaemia
Paget’s
AV malformation
What are the Sx of LVF?
Dyspnoea → Orthopnoea → PND Nocturnal cough- pink frothy sputum ↓weight Muscle wasting Fatigue/lethargy Cyanosis Basal creps Displaced Apex beat Pulsus alternans
What are the Sx of RVF?
Peripheral oedema (calfs & ascites) N&V (pressure on stomach) Dyspnoea ↑JVP ↑Weight Poor exercise tolerance Confusion
How is HF investigated?
ECG BNP CXR Bloods: FBC, U&E, LFT, TFT, Lipids, Glucose Urine dip: Check for proteins
What is seen on an ECG in HF?
Exaggerated R waves V1-6 = LVH
Inverted R waves V1-6 = RVH
Axis deviation
What do the different BNP levels correlate to?
> 400/Prev MI: 2w referral for doppler ECHO
100-400: 6w referral for doppler ECHO
<100: likely not HF
How is acute HF treated?
LMNOP's: L: Loop diuretics 40-80mg Slow IV M: Morphine & Metoclopramide N: Nitrates- 2sprays GTN O: O2 15L/min P: Position- sit up S: SHIT!- CPAP
What needs to be monitored in acute HF in someone on loop diuretics?
U&E eGFR ACR Weight Urine output
How is stable HF initially managed?
1) ACEi: Ramipril → ARB if not tolerated
2) BB: Bisoprolol
FOLLOW-UP in 2w w/HF team
Why are beta-blockers given in HF?
Prevent cardiac remodelling
What surgery can be offered in HF?
AV replacement: Due to severe AS
Implantable cardioverter defibrillator: Prev VT/VF, familial CV condition, surgical repair of congenital HD
What is the NYHA classification of HF?
1: No limitation, normal activity
2: Slight limitation, ordinary activity
3: Marked limitation, less than ordinary activity
4: Unable to carry out activity w/o discomfort, Sx of HF at rest
What additional medications can be given to those of NYHA stage 3-4?
Aldosterone antagonist (Spironolactone)
Hydralazine +/- Nitrate
Valsartan
3rd line: Digoxin
How is cardiomyopathy categorised?
Dilated- MOST COMMON
Hypertrophic- MAIN CAUSE OF DEATH IN YOUNG PTS
Restrictive
What are the causes of dilated cardiomyopathy?
Idiopathic DMD Infection (Coxsackie, Chaga) OH- Drugs (Chemo-Doxorubicin, Cocaine) Peri-partum
What happens in dilated cardiomyopathy?
Dilatation of all 4 chambers Mostly LV = thin walls = weak contractile strength ↓SV (less blood pumped) → systolic HF
What complications can arise from dilated cardiomyopathy?
Arrhythmia: Stretching → pacemaker cell dysfunction
Murmur: Dilated ventricle → Tricuspid & mitral valve fail to close properly = Regurg
What are the causes of hypertrophic cardiomyopathy?
GENETIC: Autosomal Dominant mutation of B-myosin heavy chain or myosin binding protein C
How is dilated cardiomyopathy managed?
LV Assist device
Transplant
What happens in hypertrophic cardiomyopathy?
Enlarged LV Leads to Hypercontractile walls Intraventricular septum enlarges → stiff walls ↓ventricular space for blood → ↓SV DIASTOLIC HF
Why is intraventricular septal growth in hypertrophic cardiomyopathy an issue?
Narrows outflow to aorta
MN leaflet pulled towards septum
VENTURI EFFECT → Ejection systolic murmur
Sound increases w/valsalva manoeuvre
What are the signs of hypertrophic cardiomyopathy?
Dyspnoea, syncope, angina
ECG: Signs of LVH- R wave progression, progressive T wave inversion, Large A waves
Double apex beat
Jerky pulse
How is hypertrophic cardiomyopathy managed?
BB/CCB
Surgery
What are the causes of restrictive cardiomyopathy?
Amyloidosis
Sarcoidosis
Post-RT (Fibrosis)
Haemochromatosis (Fe deposition in myocardium)
How does restrictive cardiomyopathy occur?
Stiffening of muscle +/- hypertrophy
↓ventricular filling
DIASTOLIC HF
How is restrictive cardiomyopathy managed?
Tx cause
Transplant
What is heart block?
Conduction pathway abnormality (scarring, ageing, IHD)
Leads to slow conduction
AV node develops delayed response to SA impulse
Atrio-ventricular conduction abnormality
What are the risk factors for heart block?
Inferior MI Well trained athletes SLE Lyme disease Myocarditis Meds (Flecainide, CCB, BB, Mg, Digoxin)
On an ECG how is each degree of heart block differentiated?
1st: Prolonged PR
2ndT1: Prolonged PR, eventual QRS drop
2ndT2: Prolonged PR, regular QRS drops
3rd/Complete: Regular P waves, complete unconnected wide or narrow QRS rhythm, bradycardia
How does each degree of heart block present?
1st: Asymptomatic
2nd: Dizzy, syncope, fatigue, chest pain, dyspnoea, palpitations (T2)
3rd: Bradycardia, cannon waves in JVP, confusion
What is a Stokes Adam’s attack?
Sudden syncope without warning
LOC 5-20s
Associated w/complete heart block
ECG: Wide inverted T waves
How is complete heart block managed?
Bradycardia → follow bradycardia pathway If adverse features: Shock, syncope, myocardial ischaemia, HF, sBP <90: HELP Defib on & Lay flat w/legs ↑ 500mcg IV Atropine w/large flush ASSESS FOR RESPONSE: YES = Consider risk of Asystole & observe NO = Consider following: Atropine 500mcg IV OR Transcutaneous pacing OR Adrenaline 2-10mcg IV Isoprenaline 5mcg IV
Which types of heart block require pacing?
Mobitz type 2
Complete
If bradycardia is caused by a CCB or BB what medication should be given?
Glucagon
What are the indications for risk of asystole?
Recent asystole
Mobitz type 2 AV block
Complete heart block w/broad QRS
Ventricular pause >3s
What is bifascicular block?
RBBB w/L ant/post hemi-block:
RBBB w/L axis deviation
What is trifascicular block?
Features of bifascicular block + 1st degree heart block
