Heart Failure Flashcards
What is heart failure?
The inability of the heart to meet the demands of the body.
What is systolic failure?
Name some causes
The inability of the ventricle to contract normally, resulting in reduced cardiac output.
Causes - IHD, MI, cardiomyopathy, arrythmia
What is the ejection fraction in systolic failure?
<40%
What is diastolic failure?
Name some causes
Inability of the ventricle to relax and fill normally, causing reduced EDV
Causes - Ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity
What is the ejection fraction with diastolic failure?
> 50%
Called HF with preserved ejection fraction
Why does cardiac output reduce in heart failure?
- Excessive preload (mitral stenosis, renal failure) - Causes ventricular dilation, which exacerbates pump failure.
- Pump failure
- Chronic excessive afterload (hypertension, aortic stenosis) - More pressure against which the ventricle is contracting. Causes ventricular hypertrophy, stiff walls then diastolic dysfunction.
What are the 4 classifications of heart failure?
Class I - No symptomatic limitation of physical activity
Class II - Slight limitation of activity, ordinary activity causes symptoms, no symptoms at rest.
Class III - Marked limitation of activity, less than ordinary activity causes symptoms, no symptoms are rest.
Class IV - Symptoms at rest, inability to do any physical activity without symptoms.
What are some symptoms of left sided heart failure?
- Dyspnoea
- Poor exercise tolerance
- Fatigue
- Orthopnea
- PND
- Nocturnal cough (with pink frothy sputum)
- Wheeze
- Nocturia
- Cold peripheries
- Weight loss
What are some signs that can occur in heart failure?
- Cardiomegaly - Displaced apex beat
- Pulmonary oedema - Basal pulmonary crackles
- Cyanosis
- Reduced BP
- RV heave (pulmonary hypertension)
- Elevated JVP
What are some causes of right ventricular heart failure?
- LVF
- Pulmonary stenosis
- Lung disease (cor pulmonale)
What are some symptoms of right ventricular heart failure?
- Peripheral oedema (up to thighs, sacrum, abdominal wall)
- Ascites
- Nausea
- Facial engorgement
- Epistaxis
What is high output cardiac failure?
What are some causes?
How does it present?
Cardiac output is normal/increased in the face of increased needs. Failure occurs when cardiac output does not meet the needs.
It can occur with a normal heart.
Causes -
- Anaemia
- Pregnancy
- Paget’s disease
- AV malformation
- Initially features of right sided heart failure, then left
What bloods would you do for a patient with suspected heart failure and why?
- FBC - Anaemia
- U+E - Baseline and diuretic effect
- LFT - Baseline and hepatic congestion
- TFT’s - Thyroid disease
- Ferritin and transferrin if young (hereditary haemachromatosis)
- NT-proBNP (less than 100 can rule out heart failure)
What would a CXR show in heart failure?
A - Alveolar oedema - perihilar bats wing shadowing B - Kerley B lines C - Cardiomegaly (>50% on PA film) D - Dilated prominent upper lobe veins E - Pleural effusion
How would you assess LV function in heart failure patients?
Echocardiogram is the KEY investigation.
- It may indicate the cause of failure eg MI, valvular problem
- Confirms the presence or absence of LV dysfunction
Cardiac MRI can also be used as echo may miss right ventricle. Can assess viability of cardiac muscle.
What is the standard workup for a heart failure patient?
- Bloods - FBC, U+E, BNP
- CXR
- ECG
- ECHO
What lifestyle modifications should a patient with heart failure take?
- Smoking cessation
- Restrict alcohol consumption
- Salt restriction
- Fluid restriction - especially in presence of hyponatraemia
What medications should you start a patient on in heart failure?
- Diuretics and ACE-i’s first line
- add Beta blockers
- add Mineralcorticoid receptor antagonists
What diuretics should you put a patient on and why?
- First line furosemide
- Most effective symptomatic treatment
- Thiazide diuretics can be added on
What do you need to monitor on an inpatient on diuretics?
- Renal function
- Fluid input and output
- Daily weight
Why do you give ACE-i’s in heart failure?
- Useful if the patient is also hypertensive
- Improve signs and symptoms of heart failure
- Improve exercise tolerance, slow disease progression and improve survival
What do you need to monitor with a patient on an ACE-i?
- Renal function (Na+ and K+)
Why do you give beta blockers to a patient with heart failure?
- Improve survival after a MI. Useful in diastolic dysfunction, help with coexisting angina.
- Start low and go slow
Why would you give nitrates in a patient with heart failure?
- Nitrates reduce preload, reduce pulmonary oedema and reduce ventricular size
- Useful in acute heart failure (IV)
- If chronic, relieves orthopnoea and exertional dyspnoea
When do you give ivabradine?
- When patient cannot tolerate beta blockers, it slows the heart rate
- Resting HR is over 75 despite beta blockers
- Patient must be in sinus rhythm
When do you give hydralazine?
- When patients cannot tolerate ACEi/ARBs
What complex device therapy can be offered?
- Pacemakers - if evidence of LBBB (CRT)
- Implantable cardiac defibrillators - Do not improve symptoms, but prevent sudden cardiac death associated with heart failure by cardioverting VT.
