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CR3 > Heart failure > Flashcards

Heart failure Flashcards

1
Q

What is heart failure?

A

An inability of the heart…
to generate a sufficient cardiac output to meet the
demands of the body…
without an increased filling pressure

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2
Q

What is acute heart failure? Include causes.

A
  • Rapid onset of worsening symptoms and/or signs of heart failure e.g pulmonary oedema
  • Life-threatening condition that requires urgent evaluation and treatment
  • May occur acutely (e.g. cardiogenic shock) or as a consequence of acute decompensation of chronic heart failure
  • Most common causes of acute heart failure include acute myocardial dysfunction (ischaemic, inflammatory), acute valvular disease, pericardial tamponade, infection and arrhythmia
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3
Q

What is chronic heart failure? Include causes.

A
  • Progressive cardiac dysfunction due to structural and/or functional cardiac abnormalities
  • Most common feature is breathlessness with
    impaired exercise tolerance. Patient is in a sate of fluid retention and over load, orthopnoea, paroxysmal nocturnal
    dyspnoea
  • Results in reduced cardiac output and/or elevated intracardiac pressures at rest or on stress
  • Precipitated by conditions that affect the muscles (e.g. cardiomyopathy), vessels (e.g. ischaemic heart disease), valves (e.g. aortic stenosis), or conduction (e.g. atrial fibrillation)
  • Patients develop chronic, progressive symptoms but may have periods where they present with acute decompensation.
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4
Q

What are the symptoms of left ventricular heart failure?

A
  • Fluid accumulation
  • Falling exercise tolerance and fatigue
  • Orthopnoea - breathless when lying down
  • paroxysmal nocturnal
    dyspnoea
  • nocturnal cough (± pink
    frothy sputum)
  • Wheeze (cardiac asthma)
  • Nocturia
  • Cold peripheries
  • palpitations
  • depression
  • Gout
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5
Q

What are the symptoms of right ventricular heart failure?

A
  • peripheral oedema (up to thighs, sacrum, abdominal wall)
  • breathlessness
  • ascites
  • nausea
  • facial engorgement
  • Epistaxis- acute bleeding (hemorrhage) from the nostril, nasal cavity, or nasopharynx.
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6
Q

What is systolic heart failure?

A

Heart Failure with reduced Ejection Fraction (HFrEF)
and Heart Failure with mildly reduced Ejection Fraction
(HFmrEF)

The ventricles are unable to contract properly. So the heart is pumping out a reduced proportion of the blood that fills its ventricles during diastole.
ventricular dilatation and characteristic eccentric remodelling

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7
Q

What is diastolic heart failure?

A

Heart Failure with preserved Ejection Fraction (HFpEF)

Impaired ventricular relaxation or filling due to stiffness of the ventricular wall with impaired
filling and reduced cardiac output

Ventricular hypertrophy tends to develop and characteristic concentric remodelling may occur.

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8
Q

On an echo, what would you see in someone with diastolic heart failure?

A

left ventricular hypertrophy

left atrial dilatation

abnormal relaxation

Ejection fracture >50%

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9
Q

What are the causes of right sided heart failure?

A
  • Secondary to advanced left sided heart failure due to increased pressure in the right side of the heart
  • Pulmonary hypertension
  • pulmonary/tricuspid valve pathology e.g. pulmonary stenosis
  • Pericardial disease e.g pericardial effusion or pericardial tamponade
  • Congenital heart disease (Atrial septal defect and ventricular septal defect- cause pulmonary hypertension and then right sided heart failure)
  • Cardiomyopathy
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10
Q

What is congestive heart failure?

A

Biventricular heart failure- both right and left sided heart failure

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11
Q

What are the causes of pulmonary hypertension?

A 
Emphysema
COPD
Pulmonary embolism 
cor pulmonale
Congenital heart defects
Pulmonary valve stenosis
Mitral valve stenosis/ regurgitation
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12
Q

What is the difference between a low output and a high output state? State causes of a high output state

A

Low output-
Low cardiac output which fails to increase normally with exertion
It is further divided into systolic and diastolic heart failure

High output state
Rare 
Heart is overworked 
Cardiac output is normal and able to be increase when need increases
However, cardiac output is still not enough to meet the bodies demands
Causes include:
- Anaemia
-Atrio venous malformations
- Pregnancy
- Thyrotoxicosis 
- Paget's disease 
- Thiamine deficiency (wet beri-beri)
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13
Q

In the pathophysiology of heart failure what are the 3 outcomes caused by activation of the renin-angiotensin, aldosterone system?

A

Vasoconstriction

Salt and water retention

Enhanced sympathetic activation

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14
Q

How is the cardiac output calculated?

A

Heart Rate x Stroke Volume

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15
Q

What are the 3 main causes of left sided heart failure?

A

Ischaemic heart disease (35-40%)
• Dilated cardiomyopathy (30-35%)
• Hypertensive heart disease (15-20%)

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16
Q

What are the causes of left sided heart failure?

A 
Ischaemic heart disease (35-40%)
• Dilated cardiomyopathy (30-35%)
• Hypertensive heart disease (15-20%)
- Arrhythmia: AF and bradycardia
- valvular disease 
- pericardial disease 
- viral myocarditis's
- Rheumatic fever
17
Q

Which metabolic/endocrine conditions can cause heart failure?

A

anaemia, thyrotoxicosis,

haemochromatosis

18
Q

Which drugs can cause heart failure?

A

EtOH (alcohol) and chemotherapy

19
Q

Which system is used to classify the symptoms of heart failure?

A

The New York Heart Association

Class I: no symptoms
• Class II: symptoms
on exertion
• Class III: symptoms
on minimal exertion
• Class IV: symptoms
at rest

Symptoms include: fatigue /
palpitations / dyspnoea /
angina

20
Q

What are the clinical signs of heart failure?

A 
Raised JVP
Displaced apex beat
Pulmonary crepitations
Peripheral or sacral oedema
Ascites 
Hepatomegaly
Cachexia- body wasting
Heart sounds S3/S4
21
Q

Which investigations would your order for someone you suspect has heart failure?

A

FBC and iron studies- Anaemia

U&E- low K+ and low Mg2+ can cause atrial fibrillation which can lead to heart failure

Glucose- Diabetes

Cholesterol- Risk factor

LFTs - congestive hepatopathy (CH) - caused by right sided heart failure and acute cardiogenic liver injury (ACLI)

TFTs (thyroid function test)
BNP ( >100ng/L, this ‘diagnoses’ heart failure, <50ng/L rule out heart failure
Uric acid (gout)
Troponin- I

Ferritin, creatine kinase MB
(raised in heart failure), immunoglobulins, Autoimmune profile, viral titres, genetics

22
Q

Which imaging techniques would you use for someone with suspected heart failure?

A 
Chest X ray
Transthoracic
Echo
ECG/ holter monitoring 
Lung function test
Cardiopulmonary exercise testing
Cardiac Catheterisation
Perfusion Imaging (patient exercises or is given adenosine to make the heart work harder- radioactive tracer helps to show how well blood is flowing through the heart and how well the heart is contracting)
Cardiac MRI
23
Q

How is acute pulmonary oedema treated?

A
  • Sit patient up
  • Give high flow oxygen
  • Morphine and anti-emetic
  • IV GTN
  • Furosemide (fluid over load)
  • ECG monitoring
  • May need ventilatory support
  • If systolic BP ≥100mmHg, start a nitrate infusion,
24
Q

How is heart failure with reduced ejection fracture treated?

A

First lines - Ace inhibitors (or ARB if not tolerated) and beta blockers

If LVEF <35

Second lines - Add Mineralocorticoid receptor antagonists: e.g Spironolactone if not tolerated- Eplerenone if not to

If LVEF <35

Third line :
If ACEI and ARB’s is well tolerated replace with Angiontensin Receptor Neprilysin Inhibitor (ARNI)

Sinus rhythm but QRS >130 msec’s - Cardiac resynchronization therapy (CRT)

Ivabradine- used third line if in sinus rhythm and heart rate is >70bpm

fourth line- Digoxin, Hydralazine and Isosorbide Dinitrate (H-ISDN), Left ventricular assist device (LVAD), heart transplant

Use vasodilators such as hydralazine and isosorbide dinitrate if ace inhibitors and ARB’s are not tolerated. Can also be added with ACE inhibitors

25
Q

When will a patient be considered for implanted cardiac defibrillators or cardiac resynchronization therapy pacemaker?

A
  • Left ventricular dysfunction
  • Left ventricular ejection fracture of 35% or less
  • Increase QRS duration
  • LBBB
26
Q

Which surgical treatment options are available for those with heart failure?

A
  • Valve Surgery
  • Revascularisation
  • Stem Cells
  • Heart Transplant
27
Q

Which beta blockers are licensed to be used to treat heart failure? Which type of heart failure should beta-blockers be used in?

A

bisoprolol, atenolol, meoprolol, carvedilol, and nebivolol (cardio selective)
Beta blockers should only be used in stable heart failure

  • Stable heart failure is when a patient obtains treatment and shows no signs and symptoms of worsening cardiac function
28
Q

How are beta blockers administered in those with heart failure? Why are they administered like this?

A

They are started at a low does and the up titrated
This is because β-blockers may temporarily worsen symptoms of heart failure due to
their negative inotropic effects

29
Q

If someone is suffering from acute heart failure and they were previously taking beta blockers, under which circumstance should these beta blockers be stopped?

A

HR is <50 beats/min or there is second- or third-degree atrioventricular block
or cardiogenic shock.
Hypotension (systolic <90)

30
Q

Someone can have heart failure but show no symptoms at rest- why?

A

In someone with heart failure, it is possible for the heart to be able to supply the body with enough blood at rest. It may have had limited capacity to increase output to meet the needs of the body during sustained activity and exertion

31
Q

How is the Ejection fracture used to assess the severity if heart failure?

A

<35% sever
36-45% moderate
46-55% Mild

32
Q

Which vessels can be used in cardiac revascularisation surgery?

A

Internal Mammary Artery
Saphenous vein
Radial artery

33
Q

What are the Xray findings for someone with heart failure?

A 
Think ADCDE
Alveolar Oedema (bat wings)
Kerley B lines (interstitial oedema) 
Cardiomegaly 
Dilated prominent upper lobe vessels (pulmonary venous hypertension) 
Effusion (pleural)
34
Q

Which life style modifications are suggested for those with heart failure?

A

Smoking cessation
Salt and fluid restriction
Improve diet

35
Q

What are the Indications for the use of Cardiac resynchronisation therapy in heart failure?

A

QRS interval <120, high risk of sudden cardiac death, NYHA class 1-3

QRS interval 120-149 without LBBB, NYHA class 1-3

QRS interval 120-149 with LBBB, NYHA class 1

36
Q

What are the side effects of Beta blockers?

A

Bradycardia
Hypotension
fatigue
Dizziness

37
Q

What are the side effects for ACE inhibitors?

A 
Hyperkalaemia 
renal impairment 
dry cough
light headedness
Fatigue 
GI disturbances 
Angioedema

CR3 (10 decks)

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