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Cardiovascular > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

What are the key manifestations of heart failure?

A
  • Dyspnoea
  • Fatigue
  • Fluid retention
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2
Q

What is cardiac failure?

How common is it?

A

Occurs when cardiac output is inadequate for the body’s requirements
Prevalence: 1-3% general population, 10% among elderly patients.

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3
Q

What is the most useful diagnostic test for diagnosing HF?

A

Single most useful diagnostic test is 2D echocardiogram coupled with Doppler flow studies & measurement of B-type natriuretic peptide

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4
Q

What is the most common cause of HF?

What are the other common causes and less common causes of HF?

A

Myocardial infarction which usually results from IHD from coronary heart disease.

Other causes:

  • Hypertension
  • Alcohol excess
  • Cardiomyopathy
    • Congenital heart diseases (septal or atrial defect)
  • Valvular disease
  • Endocardial disease
  • Pericardial causes

Less common causes

  • Toxin induced (heroin, cocaine)
  • Endocrine disorders (DM, thyroid disease, acromegaly, GH deficiency, hypoparathyroidism with hypocalcaemia)
  • Infection (bacterial, fungi, viral -HIV)
  • Medications (calcium antagonists, anti-arrhythmics, cytotoxic medication, beta-blockers)
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5
Q

What are the risk factors for HF?

A
  • MI
  • DM
  • Dyslipidaemia
  • Old age
  • Male
  • HTN
  • LV dysfunction
  • Cocaine abuse
  • LV hypertrophy
  • Renal insuffiency
  • Valvular HD
  • Sleep apnoea
  • Elevate C-protein
  • Elevated TNF-alpha and IL6
  • Decreased IGF-1
  • Elevated natriuretic peptides
  • Family hx of HF
  • AF
  • Thyroid disorders
  • Anaemia
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6
Q

Pathophysiology of HF

A
  • Heart failure is a complex syndrome in which an initial myocardial insult results in the over expression of multiple peptides
  • In the acute phase, neurohormonal activation is beneficial in maintaining cardiac output and peripheral perfusion
  • Overtime, sustained neurohormonal activation → increased wall stress, dilation and ventricular remodelling → contributes to failing myocardium and further neurohormones being produced
  • Left ventricular remodelling occurs due to a variety of causes:
  • HTN
  • MI
  • Valvular disease
  • Hall marks of LV remodelling are: hypertrophy, loss of myocytes and increased interstitial fibrosis
  • A potential danger is as the LV remodels and the heart takes a globular shape → mitral regurgitation can occur → increase volume overload on failing LV and progression of disease and symptoms.
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7
Q

Symptoms of heart failure

A
  • Dyspnoea
  • Fatigue
  • Orthopnoea
  • Cold peripheries
  • Increased weight
  • Leg swelling
  • paroxysmal nocturnal dyspnoea (PND) - very specific symptom of HF
  • nocturnal cough with or without ‘pink frothy sputum’
  • pre-syncope or syncope
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8
Q

Signs of HF

  • Cardiovascular
  • Respiratory
  • Abdominal
A

Cardiovascular findings:

  • Tachycardia
  • Displaced apex beat (esp if large LV)
  • Raised JVP
  • Added heart sounds and murmurs (pathological after age of 25)
  • Ankle oedema
  • Hypotension
  • Gallop rhythm on auscultation

Abdominal findings:

  • Hepatomegaly (especially if pulsatile and tender)
  • Peripheral and sacral oedema
  • Ascites

Respiratory findings:

  • Tachypnoea
  • Bibasal end-inspiratory crackles and wheeze
  • Reduced air entry on auscultation with stony dullness on percussion (pleural effusion)
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9
Q

What PMH information would be useful to know for someone with HF?

A
  • HTN, CAD, valvular HD - all common causes of HF
  • Medication hx
  • Family hx - close relatives with cardiomyopathy or CAD
  • Social hx - smoking, excess alcohol, recreational drug use.
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10
Q

How do we assess and classify HF?

A

New York Classification of Heart Failure
I - heart disease present but no undue dyspnoea from ordinary activity
II - Comfortable at rest; dyspnoea during ordinary. activities
III - Less than ordinary activity causes dyspnoea, which is limiting
IV - Dyspnoea present at rest; all activity causes discomfort

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11
Q

What is systolic HF?
What would you expect the EF to be?
What are the causes of systolic HF?

A

Inability of the ventricle to contract normally, resulting in reduced cardiac output
EF = <40%
Causes: IHD, cardiomyopathy, MI.

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12
Q

What is diastolic HF?
What would you expect the EF to be?
What are the causes of diastolic HF?

A

Inability for the ventricles to relax and fill normally, causing increase in filling pressures.
Typically EF >50% (HFpEF)
Causes: ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity.

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13
Q

Causes of RVF?

A

LVF, pulmonary stenosis and lung disease (cor pulmonale)

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14
Q

Symptoms of RVF?

A 
Peripheral oedema
Ascites
Nausea
Anorexia
Facial engorgement
Epistaxis
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15
Q

Symptoms of LVF?

A
  • Dyspnoea
  • Poor exercise tolerance
  • Fatigue
  • Orthopnoea
  • PND
  • Nocturnal cough with or without pink frothy sputum
  • Wheeze
  • Nocturia
  • Cold peripheries
  • Weight loss
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16
Q

Investigations for heart failure?

What do the results from the investigations mean?

A

ECG and B-type natriuretic peptide need to be done for everyone with suspected HF.
If both of these are normal = HF unlikely.
If either is abnormal = echocardiography is required.

ECG

  • Tachycardia
  • AF (enlarged atria)
  • Left axis deviation (LVH)
  • P wave abnormalities (p.mitrale or p.pulmonale due to atrial hypertrophy)
  • Prolonged PR interval (due to AV block)
  • Wide QRS complex (due to ventricular dyssyncrony)
  • Normal ECG means HF very unlikely*

B-type natriuretic peptide
<100 BNP = pulmonary cause
>400 BNP = strongly supports diagnosis of abnormal ventricular function and heart failure
>100 but <400 = grey zone and should search for non-cardiac cause of dyspnoea such as COPD
>2000 NT-pro BNP = 98% have heart failure

Transthoracic echocardiography

  • First line imaging modality & should be performed. on everyone with HF symptoms
  • Size and thickness of chambers
  • How the valves of the heart are functioning
  • Direction of blood flow through the heart
  • Blood clots in the heart
  • Areas of damaged or weak cardiac muscle
  • Problems affecting the pericardium
17
Q

What is B-type natriuretic peptide, why is it measured in suspected HF & how does it help with our differentials?

A

Cardiac hormone produced by the ventricles and released into the blood in response to volume expansion and increased wall stress of cardiac myocytes.
It promotes natriuresis/diuresis, peripheral vasodilation and inhibition of the RAAS and SNS.
In HF, there is increased preload & more myocardial stress so we would expect higher BNP levels in those with HF
It can be used to quickly rule out HF in those with low BNP (<100) and point towards a pulmonary cause

18
Q

What are other causes for elevated BNP other than HF or pulmonary causes?

A
  • Left ventricular hypertrophy
  • Tachycardia
  • Liver cirrhosis
  • Diabetes
  • Acute or chronic renal disease
19
Q

Lifestyle changes for those with HF

A
  1. Smoking cessation
  2. Limit alcohol consumption
  3. Regular low-intensity exercise if appropriate
  4. Weight loss or maintaining a healthy weight
  5. Eating a healthy diet - increased fruit, veg, red salt and fluid if high, red saturated fats.
  6. Monitoring weight at home - can help detect worsening quickly by fluid retention (can increase diuretics or restrict fluid then)
  7. Annual flu and one-off pneumococcal vaccination
20
Q

How do we manage chronic heart failure? (Initially & Treatments)

A
  1. Lifestyle changes
  2. Medication reviews
  3. Manage co-morbidities (dysrhymias; valve disease)
  4. Avoid exacerbating factors (NSAIDs, Verapamil)
  5. Drugs

Drugs used

  1. Loop diuretics for fluid overload (furosemide)
  2. ACEi - for those with LV systolic dysfunction - EF <40%
  3. B-blockers - in small doses over several days used to decrease mortality in those with EF <40%
  4. Mineralocorticoid receptor antagonist (MRAs) - use in those still symptomatic despite previous therapy - Spironolactone decreases mortality
  5. Digoxin - helps symptoms of those in sinus rhythm. Used in those already on other therapy with ACEi, BBlockers, or in those with AF.
  6. Vasodilators
    - Hydralazine and isosorbide dinitrate should be used. if intolerant of ACEi and ARBs as it reduces mortality (also reduces mortality in black patients with HF)

Newer drugs - Dapagliflozin

  • New treatment in 2019 which is a SGLT inhibitor which was initially created to reduce BG in T2DM by causing glucosurea
  • 27% further reduction in morbidity and mortality in adding this drug in patients - patients are living a LOT longer now than 15 years ago with HF with these drugs added
21
Q

How do we manage acute heart failure?

A
  1. Sit pt upright
  2. High flow O2 if hypoxic <95%
  3. IV access and monitor ECG, treat arrhytmias (AF)
  4. Investigations while treating
  5. Diamorphine 1.25-5mg IV slowly
  6. Furosemide 40-80mg IV slowly
  7. GTN spray (not if systolic <90mmHg)
    - Nitrate infusion. if systolic >100mmHg
  8. If pt worsens = furosemide, CPAP, increase nitrate infusion, consider alternative diagonsis.
22
Q

Non-pharmacological interventions (surgery) for HF

A
  • Revasculation (e.g. coronary artery bypass grafting or PCI for those with artherosclerosis)
  • Valve surgery (e.g. aortic valve replacement in aortic stenosis or valve repair for mitral valve regurgitation)
  • Implantable cardiac defibrillator (ICD): inserted if EF <30% for prevention of fatal arrhythmias.
    • Can be primary (recommended in patient with symptomatic HF and LVEF <35%, who is expected to survive >1 year with good functional status to reduce risk of sudden death)
    • Can be secondary prevention (patients with ventricular arrhythmia causing haemodynamic instability whi is expected to survive >1 year with good functional status to reduce risk of sudden death)
  • Cardiac resynchronisation therapy + defibrillator (CRT-D): a biventricular pacemaker for EF <30% + QRS >130 m/sec to re-synchronise left and right ventricular contraction to improve EF.
  • Cardiac transplantation is rare and strict criteria must be met for consideration.
    • <300 per year in the UK with downward trend
23
Q

Prognosis of patients with HF?

Poor prognostic factors?

A
  • Prognosis is poor on a whole with approximately 50% of people with heart failure dying within 5 years of diagnosis
  • Prognosis for HFpEF is slightly better than HFrEF
  • Hard to tell the prognosis at times as some deteriorate rapidly and others stay stable for months or years.

Poor prognostic factors

  • Increasing age
  • Smoking
  • DM
  • Other co-morbid conditions (AF, COPD, CKD, obesity or low BMI)
24
Q

Difficulties associated with HF for the patient?

A

Physical difficulties
- Living with the symptoms eg fatigue, dyspnoea can be quite debilitating and depressing for patients

Emotional difficulties

  • Initial diagnosis can be a shock to a lot of patients.
  • People can feel scared and anxious of being active or doing anything in case it worsens their symptoms, which in turn can cause feelings of isolation, stress or depression.

Symptoms

  • SOB is frightening
  • Loss of independence for pt
  • QOL and mental health is negatively affected
  • Depression present in 20% of those with HF
25
Q

How can heart failure cause pleural effusions?

A

Heart failure is the most common cause of transudative pleural effusions where there is fluid build up between the pleural space (between parietal and visceral pleura)

  • Heart ineffectively pumps blood to body
  • Blood backs up into pulmonary veins and capillaries
  • Causes increase in hydrostatic pressure in vessels
  • Forces fluid out of the pulmonary capillaries & into pulmonary interstitial space initially
  • Fluid then shifts into pleural cavity
  • Also reduced lymphatic drainage due to too much fluid being produced
26
Q

What are the signs, symptoms & treatment of pleural effusions in HF?

A
  • *Symptoms**
  • Often asymptomatic if small but can have chest pain
  • *Signs**
  • Reduced chest wall movement
  • Dull ‘stony’ percussion
  • Absent breath sounds
  • Reduced vocal resonance
  • *Treatment**
  • Loop diuretics
  • Drainage if large - pleural aspiration or chest drain insertion
27
Q

What is the most common arrhythmia in those with HF?

What risks are associated with this arrhythmia when someone has HF?

A

AF is the most common arrhythmia in people with HF and its prevalence increases with the severity of heart failure, increasing from about 10% in people with mild to moderate heart failure to 50% in people with severe heart failure.

Patients with heart failure and AF are at particularly high risk of stroke and other thromboembolic complications as blood can pool in chambers of the heart and form clots, which if these get dislodged can travel to the brain & cause a stroke

28
Q

What arrhythmia accounts for 50% of sudden deaths in patients with HF?

A

Ventricular tachycardia and ventricular fibrillation.

Seen more commonly in those with dilated left ventricle and reduced EF.

29
Q

What is the viscous cyclic relationship between CKD and HF?

A
  • HF is a significant risk factor for kidney disease, and vice versa – strong link between the 2
  • Kidneys filter waste and extra fluid out of the blood, and need a steady blood supply to work efficiently
  • When the heart isn’t pumping efficiently, there is reduced cardiac output so blood supply to body and organs is reduced so renal perfusion is reduced.
  • This causes activation of hormone system RAS pathway and nervous system to increase blood supply to body by increasing BP, holding on to salt (sodium) and water in the body, and increasing heart rate and stroke volume.
  • However, this will increase strain on an already failing heart and eventually will cause further decrease in heart function and reduction in cardiac output.
  • If the cardiac output is very low, this can cause damage to organs, particularly the kidneys through lack of perfusion – get kidney impairment
  • Also with HF blood can back up - this causes increased renal venous pressure leading to renal congestion which can also cause renal damage and impair function
  • Impaired kidneys are less able to help regulateblood pressure (remove excess fluid etc). As a result,blood pressure increases which will cause more heart problems – viscous circle and can result in CKD

Cardiovascular (16 decks)

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