Heart Failure Flashcards
What is the equation for Cardiac Output (CO)?
Heart Rate (HR) x Stroke Volume (SV)
What is the equation for Stroke Volume (SV)?
End diastolic volume (EDV) - End systolic volume (ESV)
What is the equation for Ejection Fraction (EF)?
Stroke volume (SV) / End diastolic volume (EDV)
What is approximately defined as normal Ejection Fraction? What is borderline? What is HFREF?
Normal EF: 50-70%
Borderline EF: 40-50%
HFREF: <40%
What is the basic definition of Systolic / HFREF and Diastolic / HFPEF?
Systolic: When the heart can’t pump hard enough (increased end-systolic volume), leading to a reduced ejection fraction
Diastolic: When the heart can’t fill enough (decreased end-diastolic volume), leading to a preserved ejection fraction
What is the Frank-Starling law?
Refers to when stroke volume of the heart increases in response to an increase in volume of the blood in the ventricles before contraction
Left-sided heart failure is usually which, systolic, or diastolic in cause? What underlying causes are there for this type of heart failure?
Left sided heart failure is usually systolic, whereby the heart cannot generate a forceful contraction leading to increased end-systolic volume. There are three main causes:
- Ischaemic heart disease (myocardial damage)
- Chronic hypertension (myocardium struggles to pump against a hypertensive systemic circulation)
- Dilated cardiomyopathy (thinning of myocardium wall to increase LV size and filling and thus stronger contraction by Frank-Starling Law)
Left-sided heart failure can be diastolic in nature. What are some causes to this?
- Concentric hypertrophy (caused by 1. Chronic Hypertension, 2. Aortic Stenosis, 3. HOCM)
- Restrictive cardiomyopathy (stiffening of myocardial walls, not enlargement)
What are the three subtypes of Cardiomyopathy? What heart failures are they associated with?
- Dilated (systolic)
- Hypertrophic (diastolic)
- Restrictive (diastolic)
How does left-sided heart failure cause fluid retention and why?
If the heart does not pump adequate blood, there is reduced perfusion to the kidneys which in turn activates RAAS. RAAS causes fluid retention to increase filling and pre-load which in turn theoretically increases contraction strength (Frank-Starling)
In left sided failure, where does blood typically become congested? What symptoms are thus associated with this heart failure?
In left-sided heart failure: Blood congests to lungs, causing PND, Orthopnoea, Dyspnoea, Elevated pulmonary wedge pressure, Cough, Crackles, Wheeze, Haemoptysis, Tachypnoea
Give examples of causes of Right-sided heart failure
- Left-sided heart failure (Biventricular HF)
- Left-to-right cardiac shunt (ASD, VSD)
- Chronic Lung Disease
What are the six CXR findings in patients with heart failure?
- Kerley B lines
- Upper lobe venous distension
- Perihilar (batwing) shadowing
- Fluid in oblique / horizontal fissures
- Pleural effusions
- Increased cardiothoracic ratio >50% (cardiomegaly)
What vaccinations are offered to patients with heart failure?
Annual influenza vaccine
One-off pneumococcal vaccine
What are the treatment options for patients with HFPEF (diastolic)?
- No treatments have been shown to improve prognosis
- Management of HTN, diabetes, weight reduction, lipid control, diuretics, beta blockers
What are the two categories of Acute Heart Failure?
- De novo heart failure
- Acute-on-chronic heart failure (decompensated)
On auscultation, what finding particularly corresponds to Acute Heart Failure?
S3 gallop sound or S4 sound
S3 - systolic
S4 - diastolic
What is cardiogenic shock defined as?
Systolic BP <90 mmHg plus one of the following:
- Low urine output
- Poor peripheral perfusion
- Confusion
- Serum lactate >2 mmol/L
What is “cardiac asthma”
A polyphonic expiratory wheeze associated with heart failure
What are causes of acute-on-chronic (decompensated) heart failure?
- Iatrogenic (aggressive IV fluids in frail, elderly patients)
- Sepsis
- Myocardial Infarction
- Arrhythmias
What are symptoms of acute heart failure?
- Acute SOB
- Looking / feeling unwell
- Cough (frothy white / pink sputum)
- May have chest pain (?ACS), fever (?sepsis), palpitations (?arrhythmias)
What signs may be seen in patient with acute heart failure?
- Tachypnoea
- Tachycardia
- Hypoxia
- Bibasal crackles bilaterally
- Cyanosis
- Increased JVP
- Oedema (ankle, leg, sacral)
- 3rd heart sound
What baseline investigations which you request for a patient with acute heart failure?
- Baseline observations
- 12-lead ECG
- FBC, CRP, U&E, BNP, Troponin
- Blood cultures (if ?sepsis)
- ABG
- CXR
- Echo (later)
What is the initial management of acute heart failure?
Once the patient is stable, how can you manage the patient?
Pour SOD
- Stop patient’s fluids
- Sit the patient up
- High flow oxygen (if below <94%)
- IV access
- Perform ECG, treat any underlying arrhythmias
- IV Furosemide 40mg STAT
- Diamorphine 1.25-5mg IV STAT
- GTN spray 2 puffs, 5L
- Daily weights, monitor fluid balances, U&E bloods and repeat CXR
How can heart failure be classified?
Acute vs. Chronic
Left vs. Right
Systolic vs. Diastolic
What are the management options of patients with heart failure?
- Refer to cardiology
- Advice and guidance to patient
- Medical management (ACEI, BBs first line, Aldosterone antagonist if not controlled i.e. Spironolactone, Eplerenone. Loop diuretics improve symptoms i..e Furosemide)
- Surgical management (correct underlying arrhythmias?)
Where does blood collect in right sided heart failure, and what are the signs of it?
In right-sided heart failure: Blood congests to body, causing hypoxia, cyanosis, increased JVP, periperal oedema, S3 sound, murmurs (pansystolic, tricuspid regurgitation), hepatosplenomegaly
What is the pathophysiology of Cor Pulmonale?
It is a R sided heart failure, caused by respiratory diseases. The increased pressure in pulmonary arteries results in RV being unable to pump blood, leading to a back pressure into RA, vena cava and venous system
What are the causes of Cor Pulmonale?
Respiratory diseases, such as:
COPD (most common) Pulmonary Embolism Interstitial Lung Disease Cystic Fibrosis Primary Pulmonary Hypertension
DILATED CARDIOMYOPATHY
- What are the many causes of Dilated Cardiomyopathy?
- How does the heart dilate?
- What type of dysfunction is associated with DCM? What murmurs?
- What is seen on CXR?
- Causes
- Ischaemic Heart Disease
- Idiopathic
- Inherited: DMD
- Drugs: Alcohol, Cocaine, Doxorubicin
- Myocarditis: Coksackie B, HIV, Chagas
- Peripartum
- Thiamine deficiency
- Haemochromatosis
- Sarcoidosis - All chambers dilate, however the Left side more than the Right
- Systolic dysfunction, thus tricuspid and mitral regurgitation
- Balloon shaped appearance
