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Y3M - Cardiology > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q
A
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2
Q

Main causes of heart failure.

A

Ischaemic heart disease (most common)

Valvular heart disease (Aortic stenosis most commonly)

Arrhythmias (AF most commonly)

Cardiomyopathy (dilated)

Hypertension

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3
Q

Other causes of heart failure.

A

Cardiomyopathy undilated (hypertrophic, restrictive (amyloidosis, sarcoidosis))

Valvular heart disease

Congenital heart disease

Alcohol and drugs

Haeodynamic circulation issues like anaemia, thyrotoxicosis, haemochromatosis and Paget’s disease.

Arrhythmias

Pericardial disease

Infections like myocarditis and Chagas’ disease.

Previous cancer chemo drugs

HIV

Chronic lung disease

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4
Q

Pathophysiological changes in heart failure.

A

Ventricular dilation

Myocyte hypertrophy

Increased collagen synthesis

Altered myosin gene expression

Altered sarcoplasmic Ca2+

Increased atrial natriuretic peptide (ANP) secretion

Salt and water retention

Sympathetic stimulation

Peripheral vasoconstriction

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5
Q

What is ANP?

A

Released from atrial myocytes in response to stretch.

It induces diuresis, natriuresis, vasodilation and suppression of the RAAS.

Levels of ANP increases in congestive cardiac failure and correlate with functional class, prognosis and haemodynamic state.

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6
Q

What is BNP?

A

B-type natriuretic peptide.

Predominantly secreted by the ventricles in response to increased myocardial wall stress.

N-terminal (NT)-proBNP is an inactive protein that is cleaved to form proBNP and then BNP.

Both BNP and NT-proBNP are increased in patients with heart failure and levels correlate with ventricular wall stress and severity of heart failure.

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7
Q

What is CNP?

A

C-type natriuretic peptide limited to vascular endothelium and CNS.

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8
Q

Explain ADH levels in severe chronic heart failure.

A

Raised. Particularly in patients on diuretic treatment.

A high ADH conc precipitates hyponatraemia, which is a poor prognostic factor.

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9
Q

Give examples of types of heart failure.

A

Acute Heart Failure

Chronic Heart Failure

Heart failure with reduced ejection fraction HFREF

Heart failure with preserved left ventricular ejection fraction HFPEF

Diastolic heart failure

Heart failure with mid-range ejection fraction HFmrEF

Right ventricular systolic dysfunction

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10
Q

Most common type of heart failure.

A

HFREF

about 50%

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11
Q

In which people is HFPEF more common?

A

Elderly, overweight, hypertension and atrial fibrillation

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12
Q

Explain HFREF.

A

When the ejection fraction is < 40%

Commonly caused by ischaemic heart disease, valvular heart disease and hypertension.

It means that the heart fills properly but doesn’t eject properly.

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13
Q

Explain HFPEF.

A

Ejection fraction >50% but decreased left ventricular compliance.

This leads to impairment of diastolic ventricular filling and hence decreased cardiac output.

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14
Q

What might an echocardiography show on HFPEF?

A

Increased left ventricular thickness

Increased left atrial size

Abnormal left ventricular relaxation

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15
Q

When is diastolic heart failure more common?

A

Elderly hypertensive patients, can also occur with primary cardiomyopathies like hypertrophic, restrictive and infiltrative disease.

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16
Q

What is an ejection fraction of 40-50% called?

A

Heart failure with mid-range ejection fraction.

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17
Q

Explain right ventricular systolic dysfunction.

A

May be secondary to chronic left-sided heart disease.

Can occur with primary and secondary pulmonary hypertension, right ventricular infarction, arrhythmogenic right ventricular cardiomyopathy and adult congenital heart disease.

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18
Q

Clinical features of heart faillure.

A

Extertional dyspnoea

Orthopnoea

Paroxysmal nocturnal dyspnoea

Cough (pink/white frothy sputum)

Ankle oedema

Fatigue

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19
Q

Signs of heart failure

A

Tachycardia

Raised JVP

Cardiomegaly

Third and fourth heart sounds

Bi-basal crackles

Pleural effusion

Peripheral ankle oedema

Ascites

Tender hepatomegaly

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20
Q

Classification of heart failure

A

NYHA I-IV

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21
Q

Explain the NYHA classification of heart failure.

A

I - No limitation. Normal exercise gives no symptoms.

II - Mild limitation. Comfortable at rest but normal physical activity produces fatigue, dyspnoea or palpitations.

III - Marked limitation. Comfortable at rest but gentle physical actiity produces marked symptoms.

IV - Symptoms of heart failure occur at rest and are exacerbated by any physical activity.

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22
Q

Diagnosis of heart failure.

A

Detailed history

Clinical findings

Natriuretic peptide levels

Objective evidence of cardiac dysfunction using measures of left ventricular structure and function usually by echocardiography.

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23
Q

Diagnosis of HFREF.

A

Symptoms of typical heart failure

Signs typical of heart failure

Reduced LV ejection fraction

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24
Q

Diagnosis of HFPEF.

A

Symptoms of typical heart failure

Signs typical of heart failure

Normal or only mildly reduced LV ejection fraction and LV not dilated.

Relevant structural heart disease.

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25
Q

Investigations done in heart failure.

A
  • *Renal** function (baseline and for diuretic effect),
    2. FBC (anaemia should be treated as consequence of bone marrow issue)
    3. LFT’s hepatic congestion
    4. TFT’s Thyroid disease
    5. Ferritin and transferrin (Younger patients with possible haemochromatosis)
    6. Brain natriuretic peptide (NT-proBNP)

Furthermore you should do a CXR an ECHO and possibly a cardiac MRI if ECHO is inconclusive.

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26
Q

What blood tests are done in heart failure?

A

FBC

Serum crea (to find eGFR for baseline and diuretic effect)

Electrolytes

LFTs

Cardiac enzymes

BNP

NT-proBNP

Thyroid function

Ferritin and transferrin (rule out haemochromatosis)

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27
Q

What are you looking for on a CXR?

A

Cardiomegaly

Pulmonary congestion with upper lobe diversion

Fluid in fissures

Kerley B lines (shown in picture)

Pulmonary oedema

Perihilar shadowing/consolidations

Alveolar oedea

Air bronchograms

Increased width of vascular pedicle

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28
Q

Explain levels of NT-proBNP in patients with heart failure.

A

Levels less than 100 ng/L essential rule out acute heart failure.

NT-proBNP should be measured only where there is doubt about the diagnosis.

A level above the normal range does not equate to a diagnosis of heart failure as any stimulus which causes cardiac chamber stress elevate these peptides.

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29
Q

When else might NT-proBNP be elevated?

A

Atrial fibrillation

RV strain etc….

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30
Q

Findings on ECG.

A

Can identify ischaemia, ventricular hypertrophy or arrhythmia.

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31
Q

What does an echocardiography assess?

A

Cardiac chambers dimensions

Systolic and diastolic function

Regional wall motion abnormalities

Valvular disease

Cardiomyopathies

32
Q

Explain stress echocardiography.

A

Assess viability in dysfunctional myocardium.

Dobutamine identifies contractile reserve in stunned or hibernating myocardium.

33
Q

Explain nuclear cardiology.

A

Radionucletoide angiography (RNA) can quantify ventricular ejection fraction.

SPECT or PET can demostrate myocardial ischaemia and viability in dysfuncitonal myocardium.

34
Q

Explain cardiac MRI.

A

Assess cardiac structure, function and viability in dysfunctional myocardium.

This is done by dobutamine (mimics exercise) for contractile reserve or gadolinium for delayed enhancement.

35
Q

Explain cardiac catheterisation.

A

For diagnosis of ischaemic heart failure and for measurement of pulmonary artery pressure, left atrial pressure and left ventricular end-diastolic pressure.

36
Q

Assessment of LV function.

A

Echocardiography is the key investigation. It will confirm whether the diagnosis is correct.

Possible findings inclue dilated poorly contracting left ventricle i.e. systolic function. Stiff, poorly relaxing, often small diameter left ventricle i.e. diastolic dysfunction.

Valvular disease

Atrial myxoma

Pericardial disease.

37
Q

Why might you do a cardiac MRI?

A

It may elaborate the cause of heart failure as an echo may miss right ventricle.

38
Q

Explain the diagnosis algorithm of chronic heart failure.

A

Heart failure suspected because of symptoms and signs…

Assess presence of cardiac disease by ECG, CXR, natriuretic peptides.

If these are normal heart failure is unlikely.

If abnormal do imaging by echocardiography.

If this is normal heart failure is unlikely.

If abnormal assess the aetiology, degree, precipitating factors and type of cardiac dysfunction. Do additional diagnostic tests where appropriate.

Choose treatment.

39
Q

When is cardiac biopsy used?

A

For diagnosis of cardiomyopathies such as amyloid and for follow-up of transplanted patients to assess rejection.

40
Q

When is abmulatory 24 hour ECG monitoring (Holter) done?

A

Used in patients with suspected arrhythmia and may be employed in those with severe heart failure or inherited cardiomyopathy to determine whether a defibrillator is appropriate.

41
Q

Management aims of heart failure.

A

Relief of symptoms

Prevention

Control of disease

Slowing down disease progression

Improvement of quality of life and length of life.

42
Q

Life style modification for management of heart failure.

A

Smoking cessation

Restriction of alcohol consumption

Salt restriction

Fluid restriction

Effective control of hypertension, diabetes and hyperlipidaemia.

43
Q

General life style advice for heart failure.

A

Education

Salt restriction and important for patients to weigh themselves to see if they collect fluids.

Stop smoking

Low-level endurance physical activity. Strenuous should be avoided.

Vaccination against pneumococcal and influenza.

Patients on nitrate should not also take sildenafil for sex.

Driving is okay unless you want to drive large lorries or buses and have HFREF.

44
Q

What is the essential monitoring of heart failure?

A

Funcitonal capacity by NYHA class, exercise tolerance test and echocardiography.

Fluid status (body weight, clinical assessment and serum crea + electrolytes)

Cardiac rhythm with ECG and Holter.

45
Q

Give examples of drugs used in management of heart failure.

A

Diuretics

ACEi/ARBs

Betablockers

Aldosterone antagonists

Angiotensin receptor neprilysin inhibitors

Cardiac glycosides

Vasodilators and nitrates

Inotropic and vasopressor agents

Anticoagulants

Ivabradine

46
Q

Symtoms of LVF.

A

Dyspnoea

Poor exercise tolerance

Fatigue

Orthopnoea

PND

Nocturnal cough (+/- pink frothy sputum)

Wheeze

Nocturia

Cold peripheries

Weight loss

47
Q

Symptoms of RVF.

A

Causes usch as LVF, pulmonary stenosis, lung disease.

Symptoms:

Peripheral odeema up to thighs, sacrum and abdominal wall.

Ascites

Nausea

Anorexia

Facial engorgement

Epistaxis

Raised JVP

48
Q

What is acute heart failure?

A

New-onset acute or decompensation of chronic herat failure characterised by pulmonary and/or peripheral oedema with or without signs of peripheral hypoperfusion.

49
Q

What is chornic heart failure?

A

A slowly insidious disease progressing slowly.

Venous congestion is common but arterial pressure is well maintained until very late.

50
Q

Causes of low-output heart failure.

A

Excessive preload like mitral regurg or fluid overload.

Pump failure such as systolic or diastolic HF, bradycardia

Chronic excessive afterload like aortic stenosis or hypertension.

51
Q

Diagnosis of heart failure.

A

Requires symptoms of failure and objective evidence of cardiac dysfunction at rest.

For CCF use Framingham criteria.

52
Q

Explain Framingham criteria.

A

Major Criteria

2+ required for positive diagnosis (or 1, plus 2 minor)

Acute pulmonary edema

Cardiomegaly

Hepatojugular reflux

Neck vein distention

Paroxysmal nocturnal dyspnea or orthopnea

Pulmonary rales

Third heart sound (S3 gallop rhythm)

Weight loss >4.5 kg in 5 days in response to treatment

Minor Criteria

2+ required for positive diagnosis (or 2 major)

Ankle edema

Dyspnea on exertion

Hepatomegaly

Nocturnal cough

Pleural effusion

Tachycardia (HR >120)

53
Q

Signs of heart failure.

A
54
Q

Investigations to be done in heart failure.

A

FBC, U&Es, BNP, CXR, ECG

Echocardiography (key investigation)

Stress ECHO

Cardiac MRI

Biopsy

55
Q

CXR findings in left ventricular failure.

A

Dilated prominent upper lobe vessels

Alveolar oedema (Bat’s wings)

Kerley B lines (interstitial oedema)

Cardiomegaly

Pleural effusion

56
Q

Diagnosis of acute heart failure.

A

Clinically

Do a NT-ProBNP as well but do not wait for results because of the risk of deterioration in the time between.

Do ECHO as well once treated.

57
Q

Management of acute heart failure (easy way)

A

Pour SOD

Pour away (stop) their IV fluids

Sit up

Oxygen

Diuretics

58
Q

Management algorithm of acute heart failure.

A

1 - Sit patient upright

2 - High-flow oxygen if SpO2

3 - IV access and monitor ECG, treat any arrhythmias like AF

4 - Investigations whilst continuing treatment

5 - Diamorphine 1.25-5mg IV slowly (not routinely used according to NICE)

6 - Furosemide 40-80 mg IV slowly (more might be needed in renal failure)

7 - GTN spray 2 puffs SL or 2 x 0.3 mg tablets SL (do not give if SBP < 90 mmHg) (Not routinely used according to NICE)

8 - Necessary investigations, examinations and history

9 - If SBP > 100 mmHg start nitrate infusion like isosorbide dinitrate 2-10 mg/h IVI. Keep the SBP > 90 mmHg. (Not routinely used according to NICE)

If still worsening;

Further dose of furosemide
Considered CPAP
Increase nitrate infusion
Consider differentials

If SBP < 100 mHg treat as cardiogenic shock

59
Q

Management of acute heart failure once stable and improving?

A

Daily weights and aim to reduce weight 0.5kg/day

Check obs

Repeat CXR

Change to oral furosemide or bumetanide

If on large doses of loop diuretic considered the addition of a thiazide like bendroflumathiazide or metolazone.

ACEi if LVEF <40%, if ACEis is CI consider hydralazine and nitrate

Considered b-blockers and spironlactone if LVEF <35%

Consider biventricular pacing or cardiac transplant

60
Q

Is heart failure likely if EG and BNP are normal?

A

It is not likely.

61
Q

Diagnostic algorithm of heart failure.

A
62
Q

Lifestyle management of chronic heart failure.

A

Stop smoking

Stop drinking alcohol

Less salt

Optimise weight and nutrition

Treat underlying cause such as arrhythmias and valve disease

Treat exacerbating factors like anaemia, thyroid disease, infection and HTN

Avoid exacerbating factors like NSAIDs, and verapamil

Annual flu and one-off pneumococcal vaccine.

63
Q

Drugs used in treating chronic heart failure.

A

Diuretics like furosemide or bumetanide

ACEi (LVEF)

B-blocker like carvedilol titrated up.

Spironolactone

Digoxin

Vasodilators

64
Q

Management of intractable heart failure.

A

Consider differentials

Assess adherence

Switch furosemide to bumetanide

Minimal extertion and fluid/salt restriction

Metolazone and IV furosemide

Opiates and IV nitrates for symptom control

Weight daily

Frequent U&Es

DVT prophylaxis

65
Q

Causes of acute heart failure.

A

Ischaemic heart dsiease

Valvular heart disease

HTN

Acute and chronic kindey disease

A-fib

66
Q

Medication used in heart failure according to workbook.

A

Diuretics first line

ACEi

ARBs

ARNI

Beta-blockers

Vasodilators

Ivabradine

Nitrates

67
Q

Diuretic therapy in HF.

A

Furosemide 40-500 mg daily in divided doses - titrate up if renally impaired.

IV only when very fluid overloaded.

Bumetanide (2.5 mg OD) better oral bioavailability - can be better when very oedematous.

Metolazone can be used for dramatic diuresis.

Bendroflumethiazide is sometimes used in adjunct to a loop.

If there is hypokaelamia (usually countered by ACEi but…) consider spironolactone.

Spironlactone is also used when there is liver failure as well.

68
Q

ACEi therapy in HF.

A

Useful when the patient is also hypertensive.

Improves symptoms, signs, exercise tolerance, survival and slows disease progression.

It is considered in all with LVEF.

69
Q

ARBs therapy in HF.

A

Valsartan and candesartan is used if ACEi is CId or not tolerated.

It’s titrated up.

70
Q

ARNI therapy in HF.

A

Angiotensin Receptor Neprilysin inhibitor.

Sacubitril/valsartan.

It’s an option for treating symptomatic chronic heart failure with reduced ejection fraction.

Only in NYHA II-IV with a left ventricular ejection fraction of 35% or less and who are already taking a stable dose of ACEi or ARBs.

71
Q

B-blocker therapy in HF.

A

START LOW AND GO SLOW.

Start B-blocker if patient’s systolic > 100 mmHg with a resting heart rate > 60 bpm.

CIs such as AV block and postural hypotension or bronchospasms/asthma.

Carvedilol is titrated up from 3.125 mg BD orally with food for 2 weeks and then increase to 25 mg BD there after.

If using bisoprolol start with 1.25 mg OD orally for 1 week and increase to 2.5 mg OD for 1 week. Incrase to 3.75 mg OD for 1 week, then 5 mg OD for 4 weeks. 7.5 OD for 4 weeks and then finally to 10 mg OD.

72
Q

Vasodilator therapy in HF.

A

Hydralazine and isosorbide mononitrate in combination have a beneficial effect on survival.

Especially in african or carribean origin.

ACEi or ARBs should not be used as well.

73
Q

Ivabradine therapy in HF.

A

If cannot tolerate B-blockers.

Or if resting heart rate is higher than 75 bpm despite b-blockers.

Patient must be sinus rhythm to benefit.

Avoid with diltiazem or verapamil.

Useful when BP is low and has now impact on BP.

74
Q

Nitrate therapy in HF.

A

Reduces preload

Reduces pulm oedema and reduce ventricular size.

Can be used in chronic especially for relief of orthopnoea and exertional dyspnoea.

75
Q

What can be tried when medication fails?

A

Special pacemaker devices if there is evidence of LBBB.

This means QRS complex is broad and there is early depolarisation.

Pacemaker can help the QRS complex to narrow again and heart can pump normally.

It is called CRT or cardiac resynchronisation pacemaker.

76
Q

Other pacemakers that can be useful in heart failure.

A

ICDs (implantable cardiac defibrillators)

They do not improve symptoms but prevent sudden cardiac death by cardioverting VT/VF by detection.

Are used as secondary prevention in survivers of sudden cardiac arrest or for primary prevention.

77
Q

Chronic heart failure algorithm

A

Y3M - Cardiology (34 decks)

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