Heart Failure Flashcards
What is heart failure?
A complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation
What are some of the causes of heart failure?
Ischaemic (coronary artery disease, AMI - acute MI)
Hypertension
Diabetes (diabetic cardiomyopathy or via CAD)
Valvular (AS, MR common in UK)
Tachycardia induced (uncontrolled AF)
Toxins/ drugs (alcohol, doxorubicin)
Infective (viral myocarditis)
Endocrine (thyrotoxicosis, phaeochormocytoma)
Dilated cardiomyopathy (idiopathic, peripartum)
Pulmonary causes
- COPD, pulmonary fibrosis, recurrent pulmonary emboli, and primary pulmonary hypertension cause right sided heart failure which in turn can cause congestive cardiac failure
Genetic (HOCM)
What are the stages of the NYHA?
NYHA 1: No symptoms and no limitation in ordinary physical activity
NYHA 2: Mild symptoms and slight limitation during ordinary activity
NYHA 3: Marked limitation in activity due to symptoms, even during less-than-ordinary activity
NYHA 4: Severe limitations - experiences symptoms even while at rest
What are the signs & symptoms of LV HF?
Dyspnoea - ‘uncomfortably aware of breathing’
Tachypnoea
Paroxysmal nocturnal dyspnea (PND)
Orthopnoea - SOB when lying flat, so person needs to be propped up
- A sign of pulmonary oedema
Nocturnal cough with pink frothy sputum
Bilateral basal crepitations - typical of LV HF
Nocturia
Cold peripheries
Weight loss
What are the signs & symptoms of RV HF?
Peripheral oedema - may involve: ankles, thighs, sacrum and abdomen Ascites Elevated JVP Hepatomegaly Nausea, anorexia Facial engorgement Epistaxis
What are general signs of HF?
Cyanosis Decreased BP Displaced apex beat -> LV dilatation RV heave (from pulmonary hypertension) Irregularly irregular pulse -> AF Tachycardia S3 gallop
How is HF diagnosed?
Need all 3 features
- Symptoms of HF (e.g. breathlessness, fatigue, tiredness)
- Signs typical of HF (e.g. tachycardia, pulmonary congestion, raised JVP, peripheral oedema)
- Objective evidence of structural or functional cardiac abnormality AT REST (cardiomegaly, S3, echocardiographic abnormality)
What bloods tests may be done to investigate HF?
FBC (check for: anaemia, infection)
Haematinics (nutrients needed for erythropoiesis: iron, vit. B12 and folate)
U&Es (any ion imbalances)
Glucose (diabetes)
Troponin (check for MI)
LFTs (pulmonary congestion - associated liver congestion)
BNP (confirms diagnosis of HF)
What is BNP?
Brain natriuretic peptide
- 32 amino acid polypeptide secreted by the ventricles of the heart in response to excessive stretching of heart muscle cells (occurs in HF due to increase in plasma volume)
- Normal levels rule out heart failure
- Provide prognostic information, i.e. high levels predict was outcomes (greater than 100pg/ml is abnormal)
What investigations other than blood tests can be done for HF?
Chest x-ray
Echocardiography
ECG
What does a CXR show in heart failure?
Alveolar oedema: classically as perihilar ‘bat-wing’ shadowing
Kerley B lines (septal lines): leading out towards lung borders, from interstitial oedema and engorged peripheral lymphatics
Cardiomegaly: heart >50% of thorax on film
Dilated upper lobe veins
Pleural effusions (causing blunted costophrenic angles)
Thickened bronchial walls, fluid in fissures
What does an echocardiograph show in HF?
Ultrasound examination of the heart
Provides information relating to ejection fraction of LV (normal approx 60%)
Patients with HF subdivided into:
- HF with PRESERVED LV function: EF >45%
- HF with LV systolic DYSFUNCTION: EF <45%
Helps define aetiology of HF
- Assessment of valves
- ? Previous AMI (akinetic / hypokinetic areas)
- Provides information relating to cardiac chamber size/structure i.e. DCM, HOCM
Why is an ECG done for HF?
Provides diagnostic/therapeutic information
Check for ACS and presence of atrial fibrillation/other arrhythmias
Presence of evidence of old MI - usually pathological Q waves
Presence of LBBB (may guide therapy such as specialist device therapy)
LVH - may indicate hypertension, aortic stenosis, HOCM
Initially what should treatment of HF be focused on?
The actual cause
e.g. rapid atrial fibrillation, uncontrolled hypertension, critical coronary artery disease, significant valvular disease, uncontrolled DM, thyrotoxicosis etc…
In HF with an ejection fraction >45% (preserved LV function), what should be given?
Diuretics
Treatment of co-morbidities (HTN, diabetes)
In HF with an ejection fraction <45% (LV systolic dysfunction) what should be given?
Diuretics ACE inhibitors ß-blockers Aldosterone receptor antagonist Devices CRT/ICD
What is the first line treatment for HF?
Beta-blockers (e.g. bisoprolol, carvedilol, nebivolol, metoprolol) + ACEi (e.g. ramipril - ends ‘pril’)
What further drugs can be given after first-line treatment of HF?
Aldosterone receptor antagonists
- Eplerenone and spironolactone used in treatment of severe LV dysfunction (EF < 35%, NYHA II)
- Anti-fibrotic effects
Diuretics - furosemide
How is acute HF managed?
Nasal oxygen 100%
Investigations while obtaining IV access: CXR, ECG, U&Es, troponin, ABG
Correct any arrhythmias
IV furosemide 40-80mg, isosorbide dinitrate
If relevant, IV opioids, GTN, inotropes e.g. digoxin
When stable, change to oral furosemide/bumentanide, ACE-I if LVEF <40%, consider adding beta-blocker or spironolactone
How is acute HF diagnosed?
Take a history, perform clinical examination, standard investigations (e.g ECG, CXR, bloods etc…)
Use BNP or NT-proBNP to rule OUT HF if:
- BNP LESS than 100ng/litre
- NT-proBNP LESS than 300ng/litre
In those with raised BNP Perform transthoracic Doppler 2D echo - to establish presence of cardiac abnormalities
- Do within 48 hours id acute HF is suspected
What is initial pharmacological treatment of acute HF?
Give IV diuretics in acute HF
- Monitor renal function, weight and urine output whilst on diuretics
Consider inotropes or vasopressors in people with acute HF with potentially cariogenic shock
What is initial non-pharmacological treatment of acute HF?
If person has cardiogenic pulmonary oedema with severe dyspnoea and academia consider starting NIV WITHOUT delay:
- At acute presentation or…
- As an adjunct to medical therapy if the person’s condition has failed to respond
Consider invasive ventilation in people with acute HF failure that, despite treatment, is leading to or is complicated by:
- Respiratory failure or
- Reduced consciousness or physical exhaustion
In whom are beta-blockers contraindicated?
Heart rate is less than 50 BPM, 2nd or 3rd degree atrioventricular block or shock
(and asthmatics)
For whom should valvular surgery be offered?
Offer surgical aortic valve replacement to patients with HF due to SEVERE aortic stenosis
Those who are unstable for surgical aortic valve replacement consider TAVI (transcatheter aortic valve implantation)
Consider surgical mitral valve repair or replacement for people with heart failure due to severe mitral regurgitation assessed as suitable for surgery
What causes murmurs?
Occur due to turbulent blood flow and are produced by:
- Low viscosity of blood - due to anaemia
- Decreased radius of vessel or valve (due to valvular stenosis, coarctation of aorta and ventricular septal defect)
- Increased velocity of blood through normal structures (due to sepsis and hyperthyroidism)
- Regurgitation across incompetent valve - valvular regurgitation
What should be used to describe the characteristics of a murmurs?
Timing - is it during systole or diastole, systolic murmurs are most common
Location and radiation
Shape (e.g crescendo-decrescendo, decrescendo, uniform)
Intensity (how loud is it?)
Pitch
Quality
Response to manoeuvres
What are the 4 grades of intensity in a murmur?
Grade 1: The murmur is heard only on listening intently for some time
Grade 2: A faint murmur that is heard immediately on auscultation
Grade 3: A loud murmur with no palpable thrill
Grade 4: A loud murmur with a palpable thrill
What do S1 and S2 correspond with?
S1: closure of the mitral and tricuspid valves
S2: closure of the aortic and pulmonary valves
S3 is an extra heart sound, what causes it?
Early diastole, associated with volume overload – large volume of blood rushing into ventricles and tensing cordae tendinae (ventricular gallop)
- NB: Normal in young children
- Associated with ventricular dilation e.g. ventricular systolic failure
What are the types of systolic murmurs?
Aortic/pulmonary stenosis
Mitral/tricuspid regurgitation
Mitral valve prolapse
What does aortic stenosis sound like and where does it radiate?
Ejection click right after S1
Crescendo-decrescendo murmur, as ventricles increase and decrease force of contraction - whooshing noise
Radiation to neck and carotids (for aortic only)
What does mitral/tricuspid regurgitation sound like and where does it radiate?
Pansystolic murmur
Flat murmur, intensity does not change
Radiates to L axilla (for mitral only)
Causes: Rheumatic fever, papillary muscle rupture secondary to ischaemic heart disease, endocarditis, physiological mitral valve regurgitation secondary to dilated LA
What are examples of diastolic murmurs?
Aortic/pulmonary regurgitation (listen along L sternal edge)
Mitral/tricuspid stenosis
What does aortic regurgitation sound like and what may cause it?
Early diastolic murmur
Decrescendo
Causes: Congenital bicuspid aortic valve, rheumatic fever, infective endocarditis, syphilitic aortitis, Marfan’s syndrome, ankylosing spondylitis, hypertension, dissecting aneurysms of the aorta, VSD
What is the Frank-Starling Curve?
Describes the relationship between the volume of blood in the heart at the end of diastole (known as the pre-load or end-diastolic volume) and the force of contraction of the ventricle
