Heart Failure Flashcards
What is heart failure?
The inability of the heart to pump enough blood to the rest of the body, due to a structural or mechanical problem to do with ventricular filling or ejection
What are the risk factors for heart failure?
Male sex
Increased age
Diabetes
Smoking
50% of people diagnosed with heart failure die within 5 years, true or false?
True
What is the average age of diagnosis for heart failure?
76 years
What are the causes of heart failure?
Coronary artery disease Hypertension Cardiomyopathies Valvular heart disease Arrhythmias Chronic kidney disease
What are complications of heart failure?
Cardiac arrhythmias (usually AF and ventricular arrhythmias) Depression Cachexia Chronic kidney disease Sudden cardiac disease
What is the most common cause of heart failure?
Coronary artery disease
What is the definition of ejection fraction, and how is it calculated?
The fraction of blood volume ejected from the ventricles per beat
SV/EDV x100
What is systolic heart failure?
The heart can’t pump forcefully enough
What is ejection fraction in systolic heart failure, and why?
Reduced
The heart can’t pump enough blood out of the ventricles so SV is reduced, which reduces ejection fraction
What is systolic heart failure defined as, in terms of ejection fraction?
Ejection fraction of 35-40%
What is diastolic heart failure?
Heart is pumping forcefully enough but there isn’t enough preload (blood volume in ventricles before ejection)
What is ejection fraction in diastolic heart failure, and why?
Normal (about 70%) because SV and EDV are both reduced
What is left-sided heart failure usually caused by?
Systolic dysfunction
Why does atherosclerosis cause left-sided heart failure?
Less oxygenated blood gets through coronary arteries to the myocardium, so the heart does not have enough energy to contract forcefully enough
Why does a previous MI cause left-sided heart failure?
Scar tissue prevents myocardium from stretching so the heart can’t contract forcefully enough
Why does hypertension cause left-sided heart failure?
As aortic pressure increases it gets harder for ventricles to eject against the pressure
LV hypertrophies to compensate but eventually the muscle weakens leading to weaker contractions
Also the hypertrophy reduces the amount of space in the ventricle, decreasing preload and leading to diastolic heart failure
What is dilated cardiomyopathy and how does it cause left-sided heart failure?
Ventricular wall stretches and thins out to accommodate increased preload but contraction strength weakens
What is restrictive cardiomyopathy and how does it cause left-sided heart failure?
The ventricle becomes too stiff to contract properly, and also can’t stretch so preload is decreased
How does the body try to compensate for systolic dysfunction?
Activating the RAAS to increase blood flow
Causing fluid retention in the lungs
What is the main sign of left-sided heart failure?
Pulmonary oedema
How is pulmonary oedema caused?
Blood gets backed up into the lungs as not enough can be pumped into systemic circulation
Fluid eventually moves from blood vessels to interstitial space and alveoli
What are the symptoms of pulmonary oedema?
Dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Basal crepitations
Why does pulmonary oedema cause dyspnoea?
Increased fluid in the lungs makes oxygen exchange difficult
What is orthopnoea?
Difficulty breathing when lying flat
What is paroxysmal nocturnal dyspnoea?
Shortness of breath and night coughing which wakes patient up
What are the signs of pulmonary oedema on CXR?
Alveolar bat wings Kerley B lines Cardiomegaly Dilated prominent upper lobe vessels Pleural effusion
What are alveolar beat wings a sign of?
Alveolar oedema
What are Kerley B lines a sign of?
Interstitial oedema
What is right-sided heart failure usually caused by, and how?
Left-sided heart failure
Blood backs up from pulmonary circulation to right side of the heart
Which congenital heart defects can cause right sided heart failure?
Left to right shunts, e.g. atrial septal defects, ventricular septal defect
Heart failure called if the primary cause is a lung problem?
Cor pulmonale
What is the pathology in right-sided heart failure?
Right ventricle hypertrophies to cope with increased pressure in arteries
Once this fails fluid retention occurs in systemic veins
What are the signs and symptoms of right-sided heart failure?
Raised JVP Hepatosplenomegaly Ascites Pitting oedema Light-headedness/syncope Tachycardia Laterally displaced apex beat Heart murmurs and added heart sounds
What investigations are done for heart failure?
Measure BNP Echocardiography 12 lead ECG CXR Lung function tests Blood tests Urine dipstick
What is the classification system for heart failure?
New York Heart Association classification
What are the 4 classes in the NYHA classification of heart failure?
1 - no limitation of physical activity, activity doesn’t cause SOB
2 - slight limitation of physical activity, comfortable at rest but normal activity causes SOB
3 - marked limitation of physical activity, comfortable at rest but less than normal activity causes SOB
4 - unable to carry out any activity without symptoms, can be symptomatic at rest
What is the medical management for heart failure if there is reduced ejection fraction?
Loop diuretic ACE inhibitor Beta blocker Aldosterone antagonist (spironolactone) Anti-platelet Statin
What is the purpose of loop diuretics in heart failure management?
To relieve symptoms
What is the purpose of ACE inhibitors and beta blockers in heart failure management?
To reduce mortality
When is spironolactone used in heart failure management?
2nd line as an add-on if symptoms persist
When are anti-platelets used in heart failure management?
If patient has atherosclerotic disease
What further medications should be considered as part of heart failure management?
Digoxin Amiodarone Ivabradine Sacubitril and valsartan Hydralazine and nitrates
When is digoxin used as part of heart failure management?
Add on if patient suffering from persistent symptoms, good for acute exacerbations
When are ivabradine, sacubitril and valsartan used as part of heart failure management?
Symptomatic relief for patients with stable NYHA class 2-4, HR >75, LVEF <35%, already on beta blockers
When are hydralazine and nitrates used as part of heart failure management?
Especially in Afro-Caribbean patients
What is the medical management for heart failure with preserved ejection fraction?
Loop diuretic
Anti-platelet
Statin
What general measures are done for patients with heart failure?
Monitor weight regularly to spot fluid retention
Reduce salt consumption
Fluid restriction in severe disease
Lifestyle - smoking, alcohol
Exercise - low intensity for stable HF
Notify DVLA for symptomatic lorry/busdrivers
Flu and pneumococcal vaccines
What are the surgical options for patients with heart failure?
Implantable Cardioverter Defibrillator (ICD)
Cardiac resyncronisation therapy
Heart transplant
What is an ICD?
Used for patients at risk sudden death, detects abnormal rhythms and delivers anti-tachycardia pacing/shocks
What is cardiac resynchronisation therapy?
Coordinates right and left ventricles via a pacemaker for patients with long QR intervals
