Heart Failure Flashcards
What is heart failure?
Inability of heart to meet demands of body despite an adequete filling pressure/cardiac output is inadequete for body’s requirements)
What is the name for both left & right sided HF?
What is name for right sided HF?
- Both= congestive
- Right= Cor pulmonale
Heart failure can be low or high output cardiac failure; describe low output HR and state some causes
Low Output
- Cardiac output is low and fails to increase during exertion/when required
- Causes:
- Pump failure: systolic or diastolic HF, decreased HR, negatively inotropic drugs
- Excessive preload
- Chronic excessive afterload e.g. aortic stenosis, hypertension
Heart failure can be low or high output; describe high output cardiac failure and state some causes
- Ouput needs are increased but heart fails to meet those increased needs (even if the cardiac output has increased it hasn’t increased enough to meet the increased needs)
- Causes:
- Anaemia
- Pregnancy
- Hyperthyroidism
- Pagets disease
- Arteriovenous malformation
Explain the difference between systolic and diastolic heart failure, include:
- Where the failure is in each
- Ejection fraction
- Causes
*
Systolic heart failure
- Inability of ventricle to contract properly resulting in reduced cardiac output
- Ejection fraction <35-40%
- Causes:
- IHD
- MI
- Dilated cardiomyopathy
- Myocarditis
Diastolic Heart Failure
- Inability of ventricle to relax and fill normally
- Ejection fraction >50%
- Causes:
- Constrictive pericarditis
- Cardiac tamponade
- Restrictive cardiomyopathy
- Hypertrophic obstructive cardiomyopathy
In reality, patients often have both systolic and diastolic HF; true or false?
True
State some causes of heart failure- highlight which is most common
- Ischaemic heart disease
- Hypertension
- Valvular heart disease (rheumatic fever in elderly)
- AF
- Chronic lung disease
- Cardiomyopathy (this can be hypertrophic heart, dilated heart, post viral infec, post partum)
- Previous cancer or chemo drugs
- HIV
State some risk factors for heart disease
*Similar to causes, but think about thinks that increase risk of IHD
Since ischaemic heart disease is main cause of heart failure, most of risk factors are risk factors associated with IHD such as:
- Diabetes
- Hypertension
- Age
- Male
- Dyslipidaemia
- Family history
Others include:
- Cocaine abuse
- Anaemia
- AF
- Increased CRP
What are the symptoms of heart failure?
*In your answer think about the different syptoms for LV and RV failure
General Symptoms
- Fatigue
- Palpitations
- Exercise intolerance
- Dizziness
LV Failure
- Dyspnoea
- Orthopnoea
- Nocturnal paroxysmal dyspnoea
- Nocturnal cough (+/- pink frothy sputum)
- Asthma
RV Failure
- Peripheral oedema
- Ascites
- Facial engorgement
- Epistaxis
- Nause, vomitting, abdo discomfort (due to hepatic engorgement of blood in liver)
- Nocturia
Explain why a pt with RV heart failure may have nocturia
What would you find on clinical examination of someone with heart failure- in your answer distinguish the signs you would see in LVF and RVF
Both
- Pale peripheries
- Cool peripheries
- Tachycardia
- Low volume pulse
- Additional heart sounds
- Cyanosis
LVF
- Bibasal pulmonary crackles
- Pleural effusion (stony dull to percuss)
- Heart murmur
- Wheeze (cardiac asthma)
- Displaced apex beat
RVF
- Elevated JVP
- Pitting bilateral peripheral oedema
- Hepatic enlargment (may be tender)
- Ascites
- Heart murmur of tricupsid regurg
- Parasternal heave
Give two reasons why you might hear extra heart sounds in someone with heart failure
- Rush of blood hitting non-compliant ventricle
- Loss of coordination in valve closure
What investigations would you order if you suspect someone has heart failure, include:
- Bedside
- Bloods
- Imaging
*Where approrpiate, exp
Bedside
- ECG
- Usual observations
- BM’s (suspect diabetes as risk factor)
- Weight
Bloods
- B-type natriuretic peptide (NT-pro-BNP) (raised in HF) FIRST LINE BLOOD TEST
- FBC (severe anaemia can cause HF. HF can cause mild anaemia)
- U&E
- LFTs (liver func may be impaired due to congestion)
- TFTs (both hypo- and hyperthyroidism can cause HF)
- Ferritin & transferritin (haemochromatosis can cause cardiomyopathy)
- Lipids (dyslipidaemias as risk factor)
Imaging
- CXR (look for cardiomegaly, pulmonary oedeam, pleural effusion)
- Echocardiogram
- Cardiac MRI ***(maybe)
Discuss what you should do, in regards to referral and further investigations if NT-proBNP is:
- Raised
- High
- Raised: specialist assessment including transthoracic echo within 6 weeks
- High: specialist assessment including transthoracic echo within 2 weeks
State what you may find on CXR of a pt with heart failure
*Think ABCDE
*Can be remembered as ABCDE
- Alveolar oedema(bat wing distribution- around Hila)
- Kerley B lines
- Cardiomegaly (cardiothoracic ratio >0.5)
- Dilated prominent upper lobe vessels
- Pleural effusions
May also see…
- Fluid in fissures
- Air bronchograms
- Increase width of vascular pedicle
What is the vascular pedicle on CXR?
Distance between parallel lines drawn from the point at which the superior vena cava intersects the right main bronchus and a line drawn at the takeoff of the left subclavian artery from the aorta
Normal: 38-58mm on PA CXR
What is an air bronchogram on a CXR?
Phenonenom where air filled bronchi are made visible by the opacification of surrouding alveoli; alveoli are opacified as they are filled with something other than air (in case of heart failure filled with fluid)
What are Kerley B lines on CXR?
Thickened, oedematous interlobular septa found at peripheries of lungs usually at bases
Why might you do a cardiac MRI on someone with heart failure?
- ECHO may miss right ventricle
- Can estimate amount of scaring and use this, alongside coronary artery disease assessment, to assess viability of cardiac muscle
Describe the Framingham criteria for congestive heart failure
Describe the New York Classification of Heart Failure
- I: Heart disease present but no limitations; ordinary physical activity doesn’t cause undue fatigue, dyspnoea or palpitations
- II: Comfortable at rest but ordinary activity results in fatigue, dyspnoea or palpitations
- III: Comfortable at rest but less than ordinary activity results in symptoms
- IV: symptoms present at rest and unable to carry out any physical activity without discomfort
State the four main types of treatment for heart failure
- Treat any causes or exacerbating factors (e.g. dysrhythmias, valve disease, anaemia, thyroid disease, infection)
- Lifestyle modification
- Medication/pharmacological
- Complex device therapy
State the lifestyle modifications involved in the management of heart failure
- Smoking cessation
- Restriction of alcohol
- Salt restriction
- Fluid restriction may be indicated- especially if have hyponatraemia
- Weight loss if appropriate
Discuss the treatment of chronic heart failure with preserved ejection fraction
- Manage co-morbidities e.g. hypertension, diabetes, IHD etc..
- Offer cardiac rehabilitation programme
Outline the pharmacological management of chronic heart failure with reduced ejection fraction
Vaccinations
- Annual influenza
- One of pneumococcal vaccine
Treatment of fluid overload:
- diuretics (usually loop)
Treatment of heart failure
- First line: ACE inhibitor and beta blocker (use clinical judgement to decide which to start first)
- Second line: aldosterone antagonist
-
Third line treatment to be initiated by specialist:
- __Consider replacing ACE inhibitor or ARB with angiotensin receptor-Neprilsin inhibitor (ARNI) e.g. sacubitril-valsartan
- Ivabradine
- Hydralazine and isosorbide dinitrate
- Digoxin
Which of the medications used in heart failure has no mortality benefit?
Digoxin
Discuss which diuretics are used in heart failure
-
Loop diuretics e.g. Furosemide or bumetanide are most effective
- Furosemide dose= 40-500mg daily in divided doses
- Can be given IV if pt very overloaded
- Increased doses may be needed in pts with renal impairment
- Prolonged infusions sometiems give better effects
- Bumetanide may be absorbed better orally
-
Thiazide diuretics e.g. bendroflumethiazide or metolazone
- Useful when added to a loop
- Small dose= profound diuresis
- Bendroflumethiazide dose= 2.5mg OD
- Metolazone dose= 2.5-5mg OD
- Metolazone may produce greater diuresis
-
Long term diuretic use can cause hypokalaemia hence:
- Consider ACE inhibitor if pt not already on
- If hypokalaemia persists add spironolactone (25mg OD)
How do we assess a pts response to diuretics in heart failure?
Daily weight to see how much fluid is lost
Dicuss why ACE inhibitors are beneficial in heart failure
- Improve symptoms and signs of all grades of heart failure (even if pt asymptomatic)
- Improve exercise tolerance
- Slow disease progression
- Improve survival
- Particularly useful if pt also hypertensive
Which ARBs have good evidence that supports their use in heart failure?
- Candesartan
- Valsartan
Describe the mechanism of action of angiotensin receptor-neprilysin inhibitors
Dual action:
- Block angiotensin II receptor preventing vasoconstriction, aldosterone release, renin release, ADH release
- Prevent degradation of natriuretic peptides to increase vasodilation and diuresis
ARNIs (angiotensin receptor-Neprilysin inhibitors) should only be used in which people?
Only used in pts with all of the following:
- New York Heart Association (NYHA) class II to IV symptoms
- Left ventricular ejection fraction of <35%
- Already taking stable doses of ACEI or ARBS
Discuss how to assess whether it is safe to start beta blockers in a pt with heart failure
START LOW AND GO SLOW!
Usually safe to initiate if:
- Systolic BP >100mmHG
- Resting HR >60bpm
- No AV block
- No significant postural drop
Usually safe to increase dose subsequently as long as systolic BP stays >90mmHG and resting HR stays above 50bpm with no postural drop.
Which three beta blockers are licensed to treat chronic heart failure
- Carvedilol
- Bisoprolol
- Nebivolol
The general rule with beta blockers is START LOW AND GO SLOW; discuss the dosages of beta blockers carvedilol and bisoprolol in heart failure
Carvedilol
- Start 3.125mg BD for 2 weeks
- 6.25mg BD fro 2 weeks
- 12.5mg BD for 2 weeks
- 25mg BD thereafter
Bisoprolol
- Start 1.25mg OD for 1 week
- 2.5mg OD for 1 week
- 3.75mg OD for 1 week
- 5mg OD for 4 weeks
- 7.5mg OD for 4 weeks
- 10mg OD thereafter
State two vasodilators that are used in the treatment of chronic heart failure
- Hydralazine
- Isosorbide dinitrate
When would you consider using vasodilators for the treatment of chronic heart failure?
- Generally should be used if pt cannot take ACEi or ARB
- Occasionally they may be used as add on therapy (in addition to ACEi/ARB, diuretics, beta blocker) in resistant CCF
If ACEi and beta blocker aren’t enough to treat heart failure you can consider adding ivabradine. For ivabradine state:
- Mechanism of action
- Who it can be used in
- Two drugs it should not be used in combination with
- Impact on blood presure
- Inhibits HCN channels/funny current in SA node to decrease HR
- Used in pts who:
- Sinus rhythm
- HR >75bpm
- LVF <35%
- Avoided with diltiazem or verapamil
- No impact on bp (hence good when bp is low)
For nitrates discuss:
- How they work
- Positive benefits nitrates have in chronic heart failure
- Positive benefits nitrates have in acute heart failure
- Circumstances in which you should use nitrates with caution
- Smooth muscle vasodilation (see image) to reduced preload
- Chronic heart failure: useful in relief of orthopnea & exertional dyspnoea
- Acute heart failure: useful if there is underlying ischaemia, hypertension or aortic/mitral regurg
- Caution used if: aortic/mitral stenosis, pericardial restriction, hypertrophic cardiomyopathy
ACE inhibitors and aldosterone antagonists both increase concentration of what ion?
K+ therefore should monitor
When medical therapy fails to adequetly treat HF, you can opt for complex device therapy. State two complexes devices used in heart failure and state when they are used
- CRT (cardiac resynchronisation pacemaker): used when widened QRS e.g left bundle branch block
- ICD (implantable cardiac device): purpose is to prevent sudden cardiac death by detecting and cardioverting VF/VT. Used in secondary prevention in survivors of sudden cardiac arrest or for primary prevention
Describe when cardiac resynchronisation is indicated and how the device works
It is indicated:
- Symptomatic HF
- LVEF <30% despite optimal therapy
- LBBB with QRS >130ms
- RBBB with QRS >150ms
Depolariation can be delayed between mutliple points in heart; pace at these points to make QRS narrow again so the heart can pump normally.
Describe how ICDs (implantable cardiac defribrillators) work
- Do not improve symptoms
- Purpose is purely to prevent sudden cardiac death by detecting and cardioverting VF/VT by delivering an electric shock
ICDs can co-exist with CRTs; true or false?
True
Discuss the complications of heart failure
- Pleural effusion
- Anaemia
- Acute or chronic renal insufficiency (due to decreased CO and/or drugs used to treat HF reducing renal perfusion)
- Sudden cardiac death
- Decreased quality of life
Discuss the prognosis of heart failure
- High mortality (inpatients 10%, following discharge up to 50% in the following 12 months)
- Pts with any of the following have an even worse prognosis:
- Severe fluid overload
- Very hgih NT-proBNP levels
- Severe renal impairment
- Advanced ag
- Multi-morbidity
- Frequent hosp admissions
Whath is meant by acute heart failure?
Life threatening emergency in which there is sudden onset or worsening of heart failure symptoms (hence can occur in pts with “decompensated heart failure” or without hx of heart failure “de novo heart failure”)
*decompensated heart failure accounts for most cases of AHF
Describe the pathophysiology of AHF
- Left ventricle is unable to adequately move blood through the left side of the heart and out into the body.
- Causes a backlog of blood that increases the amount of blood stuck in the left atrium, pulmonary veins and lungs
- . As the vessels in these areas are engorged with blood due to the increased volume and pressure they leak fluid and are unable to reabsorb fluid from the surrounding tissues.
- Causes pulmonary oedema, which is where the lung tissues and alveoli become full of interstitial fluid.
- This interferes with the normal gas exchange in the lungs, causing shortness of breath, oxygen desaturation and the other signs and symptoms.
State some potential causes of acute heart failure
- ACS
- Hypertensive crisis
- Acute arrhythmia
- Valvular disease
- Sepsis
- Iatrogenic (e.g. too much fluid)
State the symptoms of acute heart failure
Sudden onset:
- Dyspnoea
- Orthopnoea
- Pink frothy sputum
- Reduced exercise tolerance
- Fatigue
- Oedema
- Symptoms eased by sitting and leaning forward
State some signs of acute heart failure that you might find on clinical examination
- Tachycardia
- Tachypnoea
- Raised JVP
- Fine pulmonary crackles
- Wheeze
- Pulsus alterans
- Triple/gallop rhythm
State what investigations you would do for acute heart failure, think about:
- Bedside
- Bloods
- Imaging
Bedside
- ECG
- ABG
Bloods
- U&E’s
- FBC: ?underlying infection, anaemia
- BNP
- Troponin: if thinking ACS
Imaging
- CXR
- Echo
Discuss the management of acute heart failure
- Sit pt up
- Stop IV fluids
- High flow oxygen (15L via non-rebreathe mask)
- Obtain IV access
- IV furosemide
- Treat any arrhythmias
- Consider nitrates (not routinely recommended but can help if there is concomitant ischaemia or htn)
- If have hypotension/cardiogenic shock can consider inotropes (e.g. dobutamine), vasopressors (e.g. noradrenaline)- ICU Care
- Consider opiates to help reduce dyspnoea/distress BUT NOT ROUTINELY RECOMMENDED
- CPAP if respiratory failure
NOTE: don’t routinely offer nitrates, opiates or inotropes to pts with acute heart failure
Following acute management reassess and manage as chronic heart failure if appropriate
Remind yourself why the bodys response to heart failure makes heart failure worse
What is an echocardiogram?
What is recorded throughout the duration of an ECHO?
- Imaging procedure which uses high frequency ultrasound waves to view the heart..
- An ECG is recorded throught the ECHO
Describe the two types of ECHO and explain advantages and disadvantages of each
TOE (transoesphageal echocardiogram):
- ADV: higher sensitivty, better quality images, more effective at visualising the posterior heart
- DIS: more invasive
TTE (transthoracic echocardiogram):
- ADV: less invasive**, often good enough for what is required
- DIS: not as sensitive, some structures better visualised using TOE
Compare what structures can be visualised in a transthoracic ECHO and a transoesophageal ECHO
Structures imaged in transthoracic:
- Atria & ventricles
- Cardiac valves
- Pericardial sac
- Cardiac wall thickness & muscle contractions
- Ascending aorta
- Intracardiac masses (if any)
Structures imaged in TOE:
- Atria & ventricles
- Valves
- Interatrial septum
- Left atrial appendage
- Aorta (up to level of upper abdomen)
Which is considered better, a transthoracic or transoesphageal echo?
TOE produces more detailed images
What type of ECHO would you opt for if you wanted to visualise a prosthetic valve?
TOE
