Heart Failure Flashcards
What is the definition of heart failure
An inability of the heart to generate a sufficient cardiac output to meet the demands of the body without an increased filling pressure
- this inability is secondary to an underlying cause
heart failure is a
syndrome
syndrome means that in
- it is caused by something else - secondary to an underlying cause
How does the european society of cardiology define heart failure as
- symptoms consistent with heart failure
- objective evidence of cardiac dysfunction - systolic or diastolic
- if in doubt there is an improvement in symptoms with treatment
How many people have heart failure
- 900,000 heart failure suffers
- 65% caused by coronary artery disease and hypertension
- 1-2% of those under 70 and 10-20% of those over 70
why are women protected from heart failure
- female sex hormones
- other physiolgoical aspect
When do men and women tend to experience heart failure
= Women later than men as they are protected by sex hormones in comparison to men who experience its earlier
Describe what happens in acute heart failure
- Can be dramatic with flash pulmonary oedema - presents in extremis this requires a precipitant
- ischaemia
- arrhythmia
- intercurrent infection
Describe the gradual deterioration of acute heart failure
- Fluid accumulation
- falling exercise tolerance and fatigue
- orthopnoea and paroxysmal nocturnal dyspnoea
Name the other names for systolic heart failure
- Heart Failure with reduced Ejection Fraction (HFrEF) (usually less than 40%)
- Heart Failure with mildly reduced Ejection Fraction (HFmrEF)
Name the different levels of ejection fraction by echos
Severity
- mild = 46-55%
- moderate = 36-45%
- severe = less than 35%
if your ejection fraction is below 35% then your
risk of death month on month climbs more than if you have a higher ejection fraction
Name another name for diastolic heart failure
Heart Failure with preserved Ejection Fraction (HFpEF)
What happens in diastolic heart failure (Heart failure with preserved Ejection Fraction (HFpEF)
- increased stiffness in the ventricular wall and decreased left ventricular compliance leading to impairment of diastolic ventricular filling and decreased cardiac output
What does an echo look like in diastolic heart failure
- Left ventricular hypertrophy
- left atrial dilatation
- abnormal relaxation
what is maintained in diastolic heart failure
- Ejection fraction is maintained above 55%
What happens in left heart failure
- common clinical syndrome of Heart Failure with preserved Ejection Fraction (HFpEF) (diastolic heart failure)
What causes right heart failure
• left heart disease
• pulmonary hypertension (cor pulmonale)
• congenital heart disease and cardiomyopathy
- pulmonary stenos
What are the symptoms of right heart failure
- Peripheral oedema,
- nausea
- anorexia
- ascites
- facial engorgement
- epistaxis
what can the right heart not cope with
The right heart is a conduit to supply blood to the lungs and cannot cope with elevated pressures
What does a low output state mean
- patient has lots of fluid on board, peripherally shut down and capillary refill time is slow
What does a high output state mean
Heart is overworked
- physiological - pregnancy or athlete
- Pathophysiological - metabolic derangement - in those with thyrotoxosis or sickle cell disease
- failure occurs when the cardiac output fails to meet its needs
- there is initially features of RVF and later LVF
How does heart failure keep getting worse
Heart failure
- this causes decreased stroke volume and cardiac output
- this causes a neurohormonal response
- this leads activation of sympathetic system and renin angiotensin aldosterone system is activated
- this causes vasoconstriction, increased sympathetic tone, angiotensin II, endothelins, impaired nitric oxide release, sodium and fluid retention, increased vasopressin and aldosterone
- this causes further stress on the ventricular wall and dilatation leading to worsening of ventricular function
- this leads to further heart failure
Describe how the RAAS system works
- angiontensinogen is produced by the liver
- renin from the kidney acts on it and converts it to angiotensin I
- ACE in the lung then converts angiotensin I to angiotensin II
- angiotensin II causes vasoconstriction and enhanced sympathetic activity
- angiotensin II causes aldosterone release which causes sodium and water retention
describe the pathological process which happens when MI damage occurs
Myocardial damage
- causes activation of the sympathetic nervous system
- this can cause activation of the RAAS system leading to fluid retention and increased wall stress - this causes myocardial hypertrophy
- activation of the sympathetic system leads to vasoconstriction which causes increased wall stress which leads to increased myocardial oxygen demand and decreased contractility
- it also causes increased heart rate and contractility which leads to increased myocardial oxygen demand which leads to decreased contractility
- can cause direct cardiotoxicity which leads to myocyte damage
How do you would out cardiac output
cardiac output = heart rate x stroke volume
How is heart rate increased
via autonomic nervous system
describe how starlings law works
- as the preload increases this causes the heart to stretch
- this causes an increase in contractility
- at one point the heart has stretched too much and can no longer contract effectively
what does contractile function of the heart depend on
- velocity of muscle contraction
- amount of load being moved
- amount of stretch
What is the main cause of heart failure
- Ischaemic heart disease (35-40%)
- Dilated cardiomyopathy (30-35%)
- Hypetension (15-20%)
Heart failure is a state of
chronic system inflammation
what is cardiac cachexia
patients become thin and unwell
what are the other important causes of heart failure
- drugs - EtOH and chemotherpay
- valvular heart disease
- primary heart disease
- AF and bradycardai
- anaemia, thyrotoxicosis, haemochromatosis
- viral mycocarditis
- COPD - for right heart failure
What causes gout in heart failure
climbing ureic acid levels and inflammation
What classification is used for heart failure
New York Heart association classification
Name the classes for the New York Heart association classification (NYHA)
Class One
- no symptoms
Class II
- symptoms on exertion e.g. cant walk very far
Class III
- symptoms of minimal exertion e.g. cant walk around the house without getting breathless
Class IV
- symptoms at rest
What are the signs of heart failure
- Tachycardia
- Raised JVP - how much pressure there is on the right side of the heart
- Third heart sound and fourth heart sound
- cardiomegaly
- Bi-basal crackles
- pleural effusion
- peripheral ankle oedema
- ascites
- Pulmonary crepitations
- Hepatomegaly
- Cachexia
Describe what causes a 3rd heart sound
- immediately after the second heart sound
- so as the aortic valve closes the pressure in LV is low and exceed by LA the blood pours into the LV in heart failure from LA and this is the third heart sound
- pathological in heart failure but normal in children, pregnant women and athletes as there ventricles are enlarged and compliant
Describe what causes a 4th heart sound
- pre systolic
- blood is squeezed into a non compliant stiff ventricle that is failing
What investigations are used in heart failure
- 1st line – ECG and BNP
- FBC, U+E, CXR,
- ECG – may indicate the cause or show evidence of ischemia
- Echo – may indicate the cause MI or valvular heart disease
What other investigations should you use in heart failure
- Holter monitoring • Lung function tests • Cardiopulmonary exercise testing • Cardiac Catheterisation • Perfusion Imaging • Cardiac MRI
What cardiac MRI contrast can be used
Galmodium
- this is used in cardiac MRI to see the scar tissue caused by the MI and see how much it can be improved
in patient that present with acute pulmonary oedema it is a
Medical emergency
How do you manage acute heart failure (acute pulmonary oedema)
Management of acute heart failure
- Sit patient upright
- High flow oxygen is low SpO2
- IV access and monitor ECG – treat any arrhythmias e.g. AF
- Investigations whilst continuing treatment
- Diamorphine 1.25-5mg IV slowly
- Furosemide 40-80mg slowly
- GTN spray 2 puffs
- If systolic BP is less than 100mmHg start a nitrate infusion e.g. isosorbide dinitrate
If patient is worsening
- Further dose of furosemide 40-80mg
- Consider CPAP
- Increase nitrate infusion
- Consider alternative diagnosis
What is the aim of chronic heart failure management
- Prevent decompensation
- Maintain or improve symptoms
- Increase longevity
How do you manage chronic heart failure
• Remove exacerbating factors
• Drug therapy = start with low doses and gradually
uptitrate
• Device therapy
• Surgical therapy
• Exercise training through cardiac rehabilitation
• Palliation
where do beta blockers act
- decrease the activation of the sympathetic nervous system
Where do ACEi and ARB inhibitors act
- Renin-angiotensin system
Where do mineralcortoicd receptor antagonists act
Aldosterone decrease
where do ARNi - angiotensin receptor neprilysin inhibitor
= valsartan inhibitor of the RAAS
= neprilysin inhibitor
- Neprilysin breaks down nautrietic peptides and inhibiting it can increase the dampening of sodium rentention, vascualr tone, fibrosis, and neurochemical actviation
Name examples of angiotensin receptor neprilysin inhibitor
Sacubitril
Valsartan
What does Neprilysin enzyme do
breaks down nautrietic peptides
describe by how much mortality each drug effects heart failure
- ACEi = 15%
- ARB = 10%
- beta blocker - 35%
- MRA = 27%
- ARNi - 20%
Describe the treatment guidelines
Patient with symptoms
- Treat with an ACE inhibitor and change to an ARB if causes cough,
- combine with a beta blocker
If still symptomatic and LVEF is less than or equal to 35%
- add MR antagonists
if still symptomatic and LEVF is less than 35%
- ARNI to replace ACE
if sinus rhythm and QRS duration greater than 130msec evaluate need for CRT
If sinus rhtyhm and heart rate greater than 70 bpm
- ivabradine
if still resistance symtpoms
- consider digoxin or H-ISDN or LVAD or heart transplantation
What does it depend on that determines if you have a cardiac resynchronisation or ICD
- depending on how broad the cardiac complex is
- Depends on the NYHA class
How does cardiac resynchronisation therapy work
takes advantage of the LBBB and uses the third lead to resynchronise the heart and restore pump function
what is the difference between Cardiac resynchronisation and ICD
Cardiac resynchronisation
- Makes you live longer
- makes you feel better
ICD
- makes you liver longer
- doesnt make you feel better
What is the surgical management for heart failure
- Valve surgery
- revascularisation
- stem cells
- Heart transplant
describe the pathophysiology of heart failure
- the heart undergoes sympathetic and RAAS change when the heart starts to fail as a compensatory method to maintain cardiac output
- as heart failure progresses these mechanisms are overwhelmed and become pathophysiological
- cardiac decompensation takes place
what happens to venous return in myocardial failure
- myocardial failure leads to a reduction of the volume of blood ejected with each heart beat and an increase in the volume of blood remaining after systole
- in the failing heart the heart can no longer stretch any further to accommodate the increase in venous return as starling law is overcome and has failed
when there is severe myocardial dysfunction how is the cardiac output maintained
- increase in venous pressure
- sinus tachycardia
What is after load characterised by
- pulmonary and systemic resistance
- physical characteristics of the vessel wall
- the volume of blood that is ejected
What is after load
- this is the load of resistance against which the ventricle contracts
an increase in afterload…
decreases the cardiac output
- this results in more end-diastolic volume and dilation of the ventricle itself and further exacerbates the problem of after load
what affect does chronic sympathetic activation have on the heart
- chronic sympathetic activation has deleterious effects by further increasing neurohormonal activation and myocyte apoptosis
List the pathophysiological changes in heart failure
- ventricular dilation
- mycocyte hypertrophy
- increased collagen synthesis
- altered myosin gene expression
- increased ANP secretion
- salt and water retention
- sympathetic stimulation
- peripheral vasoconstriction
describe the effect heart failure has on the RAAS system
increase in venous pressure that occurs when the ventricles fail leads to retention of salt and water and their accumulation in the interstitum this produces many of the physical signs of heart failure
- reduced cardiac output leads to diminished renal perfusion activating the renin-angiotensin system and enhancing salt and water retention which further increases venous pressure
What are the common causes of peripheral oedema
- injury
- heart failure
- pregnancy
- allergic reaction
- drug reaction
- blood clot
what three conditions does diagnosis of heart failure with reduced ejection fractions require to be diagnosed
- symptoms typical of heart failure
- signs typical of heart failure
- reduced LV ejection fraction
What 4 cognitions does heart failure with preserved ejection fraction enquire to be diagnosed
- symptoms of typical heart failure
- signs of typical heart failure
- normal or only mildly reduced LV ejection fraction and LV not dilated
- relevant structural heart disease and diastolic dysfunction
What are the symptoms of left ventricular failure
Symptoms
- dyspnoea
- poor exercise tolerance
- fatigue
- orthopnoea
- paroxysmal nocturnal dyspnoea
- wheeze
- nocturne
- weight loss
What are the symptoms of right ventricular failure
- peripheral oedema (up to thighs, sacrum, abdominal wall)
- ascites
- nausea
- anorexia
- facial engorgement
- epistaxis.
What is acute heart failure
Often used exclusively to mean new-onset acute or decompensation of chronic heart failure characterized by pulmonary and/or peripheral oedema with or without signs of peripheral hypoperfusion.
What are the causes of low output heart failure
- excessive preload - e.g. mitral regurgitation or fluid overload = causes ventricular dilation
- pump failure - systolic and diastolic - decreases heart rate, negatively inotropic drugs
- chronic excessive after load - e.g. aortic stenosis and hypertension = causes ventricular hypertrophy resulting in stiff walls and diastolic dysfunction
if ECG and BNP are normal then …
heart failure is unlikely and an alternative diagnosis should be considered, if either is abnormal then echocardiography is required
What are the causes of right ventricular failure
- pulmonary stenos
- cor pulmonale
- lung disease
What are the causes of high output heart failure
- anaemia
- pregnancy
- hyperthyroidism
- pagers disease
- beriberi
what are the differential diagnosis for breathlessness
Cardiac
- cardiomyopathy
- cardiac failure
- valve disease
Respiratory
- Asthma attack
- COPD
- Pneumothorax
- pneumonia
Haematological
- PE
- anaemia
Define congestive heart failure/biventricular failure
Heart failure where both the ventricles are affected
What is the defintion of cariogenic shock
Cardiogenic shock (CS) is a medical emergency resulting from inadequate blood flow due to the dysfunction of the ventricles of the heart
What non-pharmacological therapies of a patient with cardiac failure
- diet modification - salt restriction and fat reduction
- stop smoking
- increase physical activity, exercise training and rehabilitation
- annual fluid vaccine
- revascularization
- heart transplant
What is revascularisation
- patients with angina and left ventricular dysfunction have ah higher mortality from surgery (10-20%) but have the most to gain in terms of improved symptoms and prognosis
what are the contraindications to heart transplant
- age over 60
- alcohol/drug misuse
- uncontrolled psychiatric illness
- uncontrolled infection
- severe renal/liver failure
- high pulmonary vascular resistance
- multi organ failure
- treated cancer in remission
- recent thromboembolism
what is the emergency drugs that are used in management of a patient with cardiac failure
MONA
- Morphine
- oxygen
- nitrates
- aspirin
what is the role of the primary care team in the management of chronic cardiac failure
- ensure effective communication links between different care settings and clinical services involved in the person’s care
- lead a full review of the person’s heart failure care, which may form part of a long-term conditions review
- recall the person at least every 6 months and update the clinical record
- ensure that changes to the clinical record are understood and agreed by the person with heart failure and shared with the specialist heart failure MDT
- arrange access to specialist heart failure services if needed.
What does a CXR show when the patient has pulmonary oedema
- A – alveolar oedema
- B – Kerley B lines
- C – cardiomegaly
- D – dilated prominent upper lobe veins (upper lobe division)
- E – pleural Effusions
What is the management of chronic heart failure
Management Chronic heart failure Lifestyle - Stop smoking - Stop drinking alcohol - Eat less salt - Lose weight - Annual flu vaccine - Treat underlying cause such as anaemia, thyroid disease and infection
Medication
- 1st line - Beta blocker (carvediol) and ACE inhibitor
- 2nd line - Spironolactone/furosemide ( to relieve symptoms
- 3rd line – ivabradine, sacubitril-valsartan (don’t use with ACE/ARB), digoxin, hydralazine, cardiac resynchronisation therapy
