Heart Failure Flashcards
What is heart failure?
Syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction in which the heart is unable to pump blood at a rate required by metabolizing tissues
What is the difference between left and right side heart failure?
Left
- Back up in lungs
Right
- Back up in body
What are the causes of left sided heart failure?
IHD/CAD/MI
Valvular disease
Respiratory disease/COPD
HTN crisis
Congenital
Cardiomyopathy
Arrythmia
What are the causes of right sided heart failure?
Left
Pulmonary stenosis
Cor-Pulmonale
What is the name for heart failure that affects both sides?
Congestive heart failure
Describe the presentation of left sided heart failure?
Dyspnoea/Orthopnoea
Fatigue
Bibasal crackles
Cyanosis
Displaced apex beat
Cardiac wheeze
Productive cough with pink frothy sputum, suggesting end stage heart failure
Cardiac cachexia/weight loss
Pulsus alternans
Describe the presentation of right sided heart failure?
Ascites and Abdominal distention
Peripheral oedema
Hepatomegaly
Raised JVP
Right ventricular heave
What are signs of severe heart failure?
Hypotension
Cool peripheries
3rd and 4th heart sounds
Gallop rhythm
What investigations are used in the diagnosis and monitoring of heart failure?
>Brain B Natriuretic Peptide
- If high levels, arrange specialist investigation within 2 weeks
- If low levels, arrange specialist investigation within 6 weeks
ECG
- Left ventricular hypertrophy/long QRS
ECHO
CXR
FBC
- Anaemia
LFTs
- Low albumin
U&E
Cardiac enzymes/troponin
- Rule out MI
What is first line investigation for HF?
BNP
What is BNP and why is it used in HF diagnosis/monitoring?
B-type natriuretic peptide is a hormone produced mainly by the left ventricular myocardium in response to strain/stretching
High values associated with poor prognosis
Low values suggests effective treatment
What factors increase BNP levels?
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia, including PE
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
What factors decrease BNP levels?
Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists
What is a low level of BNP?
<100 pg/ml
What is a raised level of BNP?
100-400 pg/ml
What is a high level of BNP?
>400 pg/ml
What is looked at in an ECHO when assessing HF?
Left ventricular ejection fraction
What value is a normal left ventricular ejection fraction?
50-80%
What left ventricular ejection fraction suggests mild HF?
40-50%
What left ventricular ejection fraction suggests moderate HF?
30-40%
What left ventricular ejection fraction suggests severe HF?
<30%
What CXR signs are seen in HF?
A: Alveolar oedema, bat wings
B: Kerley B Lines, interstitial oedema
C: Cardiomegaly
D: Dilated veins
What is the non-pharmacological management of HF?
Lifestyle modifications
Annual influenza vaccine
Once off pneumococcal vaccine
What are the steps in HF management?
1st line
- ACEI or B blockers
- One should be started at a time, use clinical judgement to determine which one
- Use both if reduced LVEF
2nd line
- Aldosterone antagonists
3rd line
- Digoxin
If pharmacological methods fail, cardiac resynchronisation therapy
What is the iconic duo in initial HF management?
Bisoprolol and Ramipril
What is the mechanism of action of loop diuretics?
Increase the excretion of sodium and water from the kidney
Give an example of a loop diuretic
Furosemide
Bumetanide
Give side effects of loop diuretics
Hypotension
Hyponatraemia
Hypokalaemia, Hypomagnesaemia
Hypochloraemic alkalosis
Ototoxicity
Hypocalcaemia and osteoporosis
Renal impairment (from dehydration + direct toxic effect)
Hyperglycaemia (less common than with thiazides)
Gout
Give an example of a K+ sparing diuretic
Spironolactone
Give features of digoxin toxicity
N&V
Confusion
Yellow-green vision
Bradycardia, AV block
Gynaecomastia
When should digoxin concentrations be measured if toxicity is suspected?
8-12 hours of last dose
How is digoxin toxicity managed?
Digibind
Correct arrhythmias
Monitor potassium
What B Blockers are most suitable in HF?
Bisoprolol
Carvedilol
What medications should be avoided in HF?
NSAIDS
Verapamil
Give the management for acute HF exacerbations
Sit patient upright
Oxygen
Opiates, reduce dyspnoea and anxiety
IV Loop diuretics/furosemide
CPAP, used if not responding to furosemide
Inotropic agents/IV dobutamine, if above fails
Mechanical circulatory assistance
What scale is used to classify stages of HF?
New York Association Scale Classification
Describe stage 1 HF
Asymptomatic, no dyspnoea
Desribe stage 2 HF
Mild dyspnoea and slight limitations during ordinary activity
Describe stage 3 HF
Marked limitation in ordinary activity, comfortable only at rest
Describe stage 4 HF
Dyspnoea at rest, severe limitations on activity
