Heart Failure Flashcards
What are the features of chronic heart failure?
dyspnoea
cough
orthopnoea
paroxysmal nocturnal dyspnoea
wheeze ('cardiac wheeze')
bibasal crackles on examination
signs of right-sided heart failure: raised JVP, ankle oedema and hepatomegalyWhat is specific about chronic heart failure cough?
may be worse at night and associated with pink/frothy sputum
People with heart failure sometimes lose weight
true
weight loss ('cardiac cachexia'): occurs in up to 15% of patients. Remember this may be hidden by weight gained secondary to oedemaWhat is the first line investigation for suspected chronic heart failure?
N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test first-line
If NT‑proBNP results are ‘high’ what should you do?
arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
If NT‑proBNP results are ‘raised’ what should you do?
arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
What is BNP?
B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels are associated with a poor prognosis.
What are high, raised and normal levels of NTproBNP?
> 2000 pg/ml (236 pmol/litre)
400-2000 pg/ml (47-236 pmol/litre)
< 400 pg/ml (47 pmol/litre)
What factors Increase BNP levels?
Left ventricular hypertrophy Ischaemia Tachycardia Right ventricular overload Hypoxaemia (including pulmonary embolism) GFR < 60 ml/min Sepsis COPD Diabetes Age > 70 Liver cirrhosis
What factors decrease BNP levels?
Obesity Diuretics ACE inhibitors Beta-blockers Angiotensin 2 receptor blockers Aldosterone antagonists
What are high, raised and normal levels of BNP?
> 400 pg/ml (116 pmol/litre)
100-400 pg/ml (29-116 pmol/litre)
< 100 pg/ml (29 pmol/litre)
What classification is widely used to classify the severity of heart failure?
New York Heart Association (NYHA)
4 classes
What is NYHA Class I?
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
What is NYHA Class II?
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
What is NYHA Class III?
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
What is NYHA Class IV?
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
first-line treatment for all patients is?
ACE-inhibitor and a beta-blocker
Which beta-blockers licensed to treat heart failure in the UK?
isoprolol, carvedilol, and nebivolol.
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with what?
preserved ejection fraction
Second-line treatment is?
aldosterone antagonist
spironolactone and eplerenone
Which drugs in management of heart failure can cause hyperkalaemia?
both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia
Which electrolyte should be monitored in management of heart failure?
Potassium
Hyperkalaemia
Third line management is?
should be initiated by a specialist. Options include ivabradine sacubitril-valsartan hydralazine in combination with nitrate digoxin cardiac resynchronisation therapy
What is the criteria for prescribing Ivabridine?
sinus rhythm > 75/min and a left ventricular fraction < 35%
What is the criteria for prescribing sacubitril-valsartan?
left ventricular fraction < 35%
is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
should be initiated following ACEi or ARB wash-out period
When is digoxin strongly indicated?
coexistent atrial fibrillation
Which drugs have not been proven to reduce mortality in patients with heart failure but may however improve symptoms?
Digoxin - inotropic properties
loop diuretics such as furosemide, but important role in managing fluid overload
When is hydralazine in combination with nitrate strongly indicated?
Afro-Caribbean patients
When is cardiac resynchronisation therapy strongly indicated?
widened QRS (e.g. left bundle branch block) complex on ECG
What vaccines should be offered to people with heart failure?
offer annual influenza vaccine
offer one-off pneumococcal vaccine
adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years
Acute heart failure (AHF) is life-threatening emergency
true
HF is a term used to describe the sudden onset or worsening of the symptoms of heart failure. Thus it may present with or without a background history of pre-existing heart failure.
Decompensated acute HF is more common and presents with a background history of HF
true
66-75%
At what age does acute heart failure usually present
after the age of 65-years
AHF is usually caused by what?
reduced cardiac output that results from a functional or structural abnormality.
What is De novo heart failure?
AHF without a past history of heart failure
increased cardiac filling pressures and myocardial dysfunction usually as a result of ischaemia. This causes reduced cardiac output and therefore hypoperfusion. This, in turn can cause pulmonary oedema.
What are the common and uncommon causes of de novo heart failure?
Common: ischaemia less common causes of de-novo AHF are: Viral myopathy Toxins Valve dysfunction
What are the most common precipitating causes of acute AHF are?
Acute coronary syndrome Hypertensive crisis Acute arrhythmia Valvular disease There is generally a history of pre-existing cardiomyopathy
What are the symptoms of AHFt?
Breathlessness Cyanosis
Reduced exercise tolerance Tachycardia
Oedema
What are the signs of AHFt?
Elevated jugular venous pressure Faitgue Displaced apex beat Chest signs: classically bibasal crackles but may also cause a wheeze S3-heart sound
Over 90% of patients with AHF have a normal or increased blood pressure
true
Why do blood tests for AHF?
to look for any underlying abnormality such as anaemia, abnormal electrolytes or infection.
What does CXR show in AHF?
pulmonary venous congestion, interstitial oedema and cardiomegaly
Why do blood echo for AHF?
this will identify pericardial effusion and cardiac tamponade
B-type natriuretic peptide is diagnostic of AHF
false raised levels (>100mg/litre) indicate myocardial damage and are supportive of the diagnosis.
How do you manage acute heart failure?
oxygen IV loop diuretics opiates vasodilators inotropic agents CPAP ultrafiltration mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices
Consideration should be given to discontinuing beta-blockers in the short-term.
