Heart Failure Flashcards
Main causes of heart failure.
Ischaemic heart disease (most common)
Valvular heart disease (Aortic stenosis most commonly)
Arrhythmias (AF most commonly)
Cardiomyopathy (dilated)
Hypertension
Other causes of heart failure.
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
Pathophysiological changes in heart failure.
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
What is ANP?
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.
What is BNP?
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.
What is CNP?
C-type natriuretic peptide limited to vascular endothelium and CNS.
Explain ADH levels in severe chronic heart failure.
Raised. Particularly in patients on diuretic treatment.
A high ADH conc precipitates hyponatraemia, which is a poor prognostic factor.
Give examples of types of heart failure.
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
Most common type of heart failure.
HFREF
about 50%
In which people is HFPEF more common?
Elderly, overweight, hypertension and atrial fibrillation
Explain HFREF.
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.
Explain HFPEF.
Ejection fraction >50% but decreased left ventricular compliance.
This leads to impairment of diastolic ventricular filling and hence decreased cardiac output.
What might an echocardiography show on HFPEF?
Increased left ventricular thickness
Increased left atrial size
Abnormal left ventricular relaxation
When is diastolic heart failure more common?
Elderly hypertensive patients, can also occur with primary cardiomyopathies like hypertrophic, restrictive and infiltrative disease.
What is an ejection fraction of 40-50% called?
Heart failure with mid-range ejection fraction.
Explain right ventricular systolic dysfunction.
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.
Clinical features of heart faillure.
Extertional dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Cough (pink/white frothy sputum)
Ankle oedema
Fatigue
Signs of heart failure
Tachycardia
Raised JVP
Cardiomegaly
Third and fourth heart sounds
Bi-basal crackles
Pleural effusion
Peripheral ankle oedema
Ascites
Tender hepatomegaly
Classification of heart failure
NYHA I-IV
Explain the NYHA classification of heart failure.
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.
Diagnosis of heart failure.
Detailed history
Clinical findings
Natriuretic peptide levels
Objective evidence of cardiac dysfunction using measures of left ventricular structure and function usually by echocardiography.
Diagnosis of HFREF.
Symptoms of typical heart failure
Signs typical of heart failure
Reduced LV ejection fraction
Diagnosis of HFPEF.
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.
Investigations done in heart failure.
- *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.
What blood tests are done in heart failure?
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)
What are you looking for on a CXR?
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
Explain levels of NT-proBNP in patients with heart failure.
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.
When else might NT-proBNP be elevated?
Atrial fibrillation
RV strain etc….
Findings on ECG.
Can identify ischaemia, ventricular hypertrophy or arrhythmia.
What does an echocardiography assess?
Cardiac chambers dimensions
Systolic and diastolic function
Regional wall motion abnormalities
Valvular disease
Cardiomyopathies
Explain stress echocardiography.
Assess viability in dysfunctional myocardium.
Dobutamine identifies contractile reserve in stunned or hibernating myocardium.
Explain nuclear cardiology.
Radionucletoide angiography (RNA) can quantify ventricular ejection fraction.
SPECT or PET can demostrate myocardial ischaemia and viability in dysfuncitonal myocardium.
Explain cardiac MRI.
Assess cardiac structure, function and viability in dysfunctional myocardium.
This is done by dobutamine (mimics exercise) for contractile reserve or gadolinium for delayed enhancement.
Explain cardiac catheterisation.
For diagnosis of ischaemic heart failure and for measurement of pulmonary artery pressure, left atrial pressure and left ventricular end-diastolic pressure.
Assessment of LV function.
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.
Why might you do a cardiac MRI?
It may elaborate the cause of heart failure as an echo may miss right ventricle.
Explain the diagnosis algorithm of chronic heart failure.
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.
When is cardiac biopsy used?
For diagnosis of cardiomyopathies such as amyloid and for follow-up of transplanted patients to assess rejection.
When is abmulatory 24 hour ECG monitoring (Holter) done?
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.
Management aims of heart failure.
Relief of symptoms
Prevention
Control of disease
Slowing down disease progression
Improvement of quality of life and length of life.
Life style modification for management of heart failure.
Smoking cessation
Restriction of alcohol consumption
Salt restriction
Fluid restriction
Effective control of hypertension, diabetes and hyperlipidaemia.
General life style advice for heart failure.
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.
What is the essential monitoring of heart failure?
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.
Give examples of drugs used in management of heart failure.
Diuretics
ACEi/ARBs
Betablockers
Aldosterone antagonists
Angiotensin receptor neprilysin inhibitors
Cardiac glycosides
Vasodilators and nitrates
Inotropic and vasopressor agents
Anticoagulants
Ivabradine
Symtoms of LVF.
Dyspnoea
Poor exercise tolerance
Fatigue
Orthopnoea
PND
Nocturnal cough (+/- pink frothy sputum)
Wheeze
Nocturia
Cold peripheries
Weight loss
Symptoms of RVF.
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
What is acute heart failure?
New-onset acute or decompensation of chronic herat failure characterised by pulmonary and/or peripheral oedema with or without signs of peripheral hypoperfusion.
What is chornic heart failure?
A slowly insidious disease progressing slowly.
Venous congestion is common but arterial pressure is well maintained until very late.
Causes of low-output heart failure.
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.
Diagnosis of heart failure.
Requires symptoms of failure and objective evidence of cardiac dysfunction at rest.
For CCF use Framingham criteria.
Explain Framingham criteria.
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)
Signs of heart failure.
Investigations to be done in heart failure.
FBC, U&Es, BNP, CXR, ECG
Echocardiography (key investigation)
Stress ECHO
Cardiac MRI
Biopsy
CXR findings in left ventricular failure.
Dilated prominent upper lobe vessels
Alveolar oedema (Bat’s wings)
Kerley B lines (interstitial oedema)
Cardiomegaly
Pleural effusion
Diagnosis of acute heart failure.
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.
Management of acute heart failure (easy way)
Pour SOD
Pour away (stop) their IV fluids
Sit up
Oxygen
Diuretics
Management algorithm of acute heart failure.
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
Management of acute heart failure once stable and improving?
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
Is heart failure likely if EG and BNP are normal?
It is not likely.
Diagnostic algorithm of heart failure.
Lifestyle management of chronic heart failure.
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.
Drugs used in treating chronic heart failure.
Diuretics like furosemide or bumetanide
ACEi (LVEF)
B-blocker like carvedilol titrated up.
Spironolactone
Digoxin
Vasodilators
Management of intractable heart failure.
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
Causes of acute heart failure.
Ischaemic heart dsiease
Valvular heart disease
HTN
Acute and chronic kindey disease
A-fib
Medication used in heart failure according to workbook.
Diuretics first line
ACEi
ARBs
ARNI
Beta-blockers
Vasodilators
Ivabradine
Nitrates
Diuretic therapy in HF.
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.
ACEi therapy in HF.
Useful when the patient is also hypertensive.
Improves symptoms, signs, exercise tolerance, survival and slows disease progression.
It is considered in all with LVEF.
ARBs therapy in HF.
Valsartan and candesartan is used if ACEi is CId or not tolerated.
It’s titrated up.
ARNI therapy in HF.
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.
B-blocker therapy in HF.
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.
Vasodilator therapy in HF.
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.
Ivabradine therapy in HF.
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.
Nitrate therapy in HF.
Reduces preload
Reduces pulm oedema and reduce ventricular size.
Can be used in chronic especially for relief of orthopnoea and exertional dyspnoea.
What can be tried when medication fails?
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.
Other pacemakers that can be useful in heart failure.
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.
Chronic heart failure algorithm
