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Cardiovascular Medicine > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

Define heart failure

A

A clinical syndrome comprising of dyspnoea, fatigue or fluid retention due to cardiac dysfunction, either at rest or on exertion, with accompanying neurohormonal activation

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2
Q

What demographic is most affected by heart failure?

A

Elderly

F>M

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3
Q

What are the 4 most common symptoms of heart failure?

A
  • breathlessness
  • Fatigue
  • Odema
  • Reduced exercise capacity
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4
Q

What are the 6 clinical signs of heart failure?

A
  • Odema
  • Tachycardia
  • raised JVP
  • chest crepitations or effusions
  • 3rd heart sound
  • Displaced or abnormal apex beat
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5
Q

Why is objective evidence of heart failure required to make the diagnosis?

A

Because it is misdiagnosed in 40-50% of cases due to sharing similar features with other conditions

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6
Q

Name the three things that are required in order to make a diagnosis of heart failure

A
  1. Symptoms of heart failure at rest
  2. Objective evidence of heart failure
  3. Response to diuretics
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7
Q

List the 4 techniques that can be used to obtain evidence of cardiac dysfunction

A
  • Echocardiography (most commonly used)
  • Radionuclide ventriculography (RNVG/MUGA)
  • MRI
  • Contrast left ventriculography
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8
Q

Name the serum biomarker elevated in heart failure patients

A

Brain naturitic peptide (BNP)

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9
Q

What is the first test that should be conducted if a patient has suspected heart failure?

A

BNP blood test

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10
Q

What causes heart failure?

A

If sufficiently severe, almost any structural cardiac abnormality will cause heart failure

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11
Q

List the three main causes of left ventricular systolic dysfunction

A
  • Ischaemic heart disease (usually MI)
  • Severe aortic valve disease or mitral regurgitation
  • Dilated cardiomyopathy (this means that the left ventricular systolic dysfunction is not due to ischaemic heart disease or secondary to another lesion i.e. valves or a ventricular septal defect)
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12
Q

How should left ventricular systolic dysfunction be invesigated?

A
  • N-type pro-B-naturitic peptide
  • ECG, echo and chest X-Ray
  • Consider coronary angiography (this is essential if the patient is suffering from chest pain or if the patient is <70)
  • CT coronary angiogram should be used instead of instead of cor angio
  • Consider evaluating for ischaemia/hibernation (is revascularisation appropriate in the absence of angina)
  • Use a cardiac MRI to look for infarction/inflammation/fibrosis
  • Most patients should be assessed by a cardiologist
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13
Q

Which 2 pathologies are not easily picked up by an echocardiogram?

A

Shunt & constriction

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14
Q 
What is the % associated with a 
A) Normal
B) Mildly impaired 
C) Moderately impaired 
D) Severely impaired

Left ventricular ejection fraction?

A

A) Normal = 55-70%
B) Mildly impaired = 40-55%
C) Moderately impaired = 30-40%
D) Severely impaired = <30%

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15
Q

How can the volume of the left ventricle be calculated?

A

Biplane modified Simpson’s Rule or the endocardial border can traced

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16
Q

How is the left ventricular ejection fraction determined?

A

Using a multigated acquisition scan (MUGA) scan

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17
Q

Why is a MUGA scan not repeated even though it is easily reproducable?

A

It exposes the patient to ionising radiation

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18
Q

Is a cardiac MRI more or less accurate than an echo?

A

More accurate

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19
Q

What are the disadvantages of MRI?

A

is Expensive, time-consuming, cannot be done at bedside, requires breath holding and can be claustrophobic.

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20
Q

Name the classification system used to classify the varying severities of heart failure

A

New york association classification for heart failure

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21
Q

Describe the exercise tolerance and the symptoms associated with class I-IV on the New York Association Classification for heart failure

A

I- No limitations, no symptoms during usual activity

II- mild limitation, comfortable with rest or mild exertion

III- Moderate limitation- comfortable only at rest

IV- Severe limitation, any physical activity brings discomfort and symptoms occur at rest

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22
Q

Name the three prognostic indicators used in heart failure

A
  1. Degree of LV impairment or valvular dysfunction
  2. New york association classification
  3. Degree of BNP elevation
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23
Q

Is cardiac output the only aspect of cardiac function important in heart failure?

A

No

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24
Q

Is heart failure a multi-system disorder?

A

Yes

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25
Q

What pathological impacts does the renin-angiotensin system have during heart failure?

A

In heart failure, the renin-angiotensin-aldosterone system causes;
• Salt and water retention
• Adverse haemodynamics
• Left ventricular hypertrophy, remodelling and fibrosis
• Hypokalaemia and hypomagnesaemia

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26
Q

What happens to the sympathetic nervous system in heart failure and what pathological effect does this have?

A

The sympathetic nervous system is overactivated in heart failure. This causes the following effects;

  • Arrhythmias
  • Adverse haemodynamics
  • increased renin
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27
Q

Briefly explain the pathophysiology of heart failure

A

Initial cardiac injury/disease/event

  1. Left ventricular injury
  2. Pathological remodelling
  3. Left ventricular dysfunction
  4. Vasoconstriction, endothelial dysfunction, renal sodium retention
  5. Dyspnoea, fatigue & oedema
  6. Heart failure!
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28
Q

What causes the vasoconstriction, endothelial dysfunction & renal sodium retention that occurs during the heart failure disease process?

A

Neurohormonal activation caused by left ventricular injury and left ventricular dysfunction

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29
Q

What is the impact of heart failure on the rest of the body?

A

Organs become damaged because the heart is not supplying enough blood to them

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30
Q

What is the frank starling law?

A

If the muscle of a healthy heart is stretched it will contract with greater force and pump out more blood.

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31
Q

What happens to cardiac output as the circulating volume increases and why? What is the significance of this in regards to the progression of heart failure?

A

As circulatory volume increases the heart dilates, the force of contraction weakens and cardiac output drops further . Low- cardiac output then activates the sympathetic and RAAS which leads to further salt and water retention.

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32
Q

Explain the difference between heart failure with reduced ejection fraction and heart failure with preserved ejection fraction

A

Heart failure with reduced ejection fraction = Occurs when the ventricles’ contraction is impaired. This causes systolic impairment , which results in fluid back up in the lungs and heart failure

Heart failure with preserved ejection fraction = Involves a thickened and stiff heart muscle; as a result, the ventricles ability to relax is impaired the heart does not fill with blood properly (diastolic impairment), resulting in fluid backup in the lungs and heart failure

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33
Q

What are the two biggest risk factors associated with heart failure?

A

Hypertension and MI

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34
Q

Explain how acute left sided heart failure results in pulmonary oedema

A

If the left heart fails suddenly, there is a rapid increase in left atrial pressure which causes a backup of blood in the lungs resulting in pulmonary oedema

35
Q

Explain how chronic left sided heart failure eventually causes right sided heart failure

A

If the left heart fails gradually (chronic heart failure) pulmonary vasoconstriction occurs in an attempt to compensate, this causes an increase in pulmonary vascular resistance which leads to pulmonary hypertension and eventually causes right ventricular impairment

36
Q

What is right sided heart failure otherwise known as?

A

Cor Pulmonale

37
Q

What is right sided heart failure caused by?

A

Pulmonary disease (e.g. PE and chronic lung disease) and chronic left sided heart failure

38
Q

What are the signs and symptoms associated with left sided heart failure? (9)

A
  1. Paroxysmal nocturnal dyspnea
  2. Elevated pulmonary wedge capillary pressure
  3. Pulmonary congestion (cough, crackles, wheezes, blood tinged sputum, tachypnea)
  4. Restlessness
  5. orthostatic hypotension
  6. tachycardia
  7. Exercise induced dyspnoea
  8. Fatigue
  9. Cyanosis
39
Q

What are the signs and symptoms associated with right sided heart failure? (7)

A
  1. fatigue
  2. Increased peripheral venous pressure
  3. Enlarged liver and spleen
  4. Distended jugular veins
  5. Anorexia and complaints of GI distress
  6. Weight gain
  7. Dependent oedema
40
Q

What are the aims of treatment in heart failure treatment?

A

improve their clinical status, functional capacity and quality of life, prevent hospital admission and reduce mortality.

41
Q

Which blood tests should be run when investigating heart failure?

A 
BNP
FBC (to check for anaemia)
TFT
LFT
U&E
Lipids
Glucose
42
Q

What might you see on the chest x-ray of a patient with heart failure?

A
  • Alveolar oedema (bat’s wings)
  • Kerley B lines- Fluid in the oblique/ horizontal fissures
  • Cardiomegaly- Increased cardiothoracic ratio
  • Dilated prominent upper lobe vessels- Upper lobe venous diversion
  • Effusions
43
Q

What is the next step if the patient has a BNP level of >2000?

A

refer for transthoracic angiogram within 2 weeks

44
Q

What is the next step if the patient has a BNP level of 400-2000?

A

refer for transthoracic angiogram within 6 weeks

45
Q

What might you see on the ECG of a patient with heart failure?

A
  • Left ventricular hypertrophy
  • Evidence of ischaemic heart disease
  • Prolonged QRS duration
  • Rhythm abnormalities (AF, paroxysmal ventricular arrhythmia)
46
Q

Which three things should be assessed when carrying out an electrocardiogram on a patient with heart failure?

A
  1. Ejection fraction
  2. Assess for valve disease
  3. Assess for left ventricular hypertrophy
47
Q

What lifestyle changes should a heart failure patient make?

A
  1. Exercise as tolerated
  2. Decrease alcohol intake
  3. Stop smoking
  4. Restrict salt (<6g/day) and water (<1.5L/day)
  5. Stop driving
  6. Flu jab
48
Q

Which 3 medications can a heart failure patient be offered to manage symptoms?

A
  1. Diuretics- monitor renal function. Good initial treatment whilst waiting for results
  2. Digoxin (If in AF)
  3. Calcium channel blockers to control blood pressure (Avoid verapamil and diltiazem)
49
Q

Which drugs can you offer on top of the symptom control drugs if the patient has heart failure with a preserved ejection fraction

A

There are no drugs which have been proven to improve prognosis

50
Q

Which drugs can you offer on top of the symptom control drugs if the patient has heart failure with a reduced ejection fraction

A

Beta- blockers and ACEi can be used but only once a diagnosis has been made

51
Q

Why are loop diuretics used in chronic heart failure?

A

To reduce fluid overload

52
Q

Name a loop diuretic

A

Furosemide

53
Q

Briefly explain how loop diuretics work

A

Act on the ascending loop of henle where they inhibit the Na+/K+/2Cl- co-transporter Which normally moves Na+ & K+ out of the loop of Henle and back into the epithelial cell (water would follow). By inhibiting this co-transporter, the reabsorption of water is prevented and diuresis can occur, correcting fluid overload.

54
Q

What medication should be added to the loop diuretic if the patient becomes resistant to it?

A

Thiazide like diuretics

55
Q

Lit the 5 adverse reactions associated with loop diuretics

A
  • Dehydration
  • Hypotension
  • Hypokalaemia, Hyponatraemia (due to increased urinary loss of Na+ and K+)
  • Gout
  • Impaired glucose tolerance, diabetes
56
Q

List the 5 furosemide drug interactions and subsequent effects

A

– Aminoglycosides (aural and renal toxicity)
– lithium (renal toxicity)
– NSAIDs (renal toxicity)
– Antihypertensives (profound hypotension)
– Vancomycin (renal toxicity)

57
Q

Name a Mineralocorticoid receptor antagonists

A

Spironolactone

58
Q

Briefly explain how Spironolactone works

A

potassium sparing diuretics which act in the distal tubule. They block receptors that bind aldosterone.

59
Q

What is Spironolactone used to manage in heart failure patients?

A

Oedema

60
Q

Which drug is Spironolactone recommended to be used in conjunction with and why?

A

Spironolactone or eplerenone are recommended in conjunction with ACEi drugs in all symptomatic patients to reduce mortality and HF hospitalization

61
Q

In which kind of heart failure is valsartan-sucubitril used in?

A

Chronic heart failure with a reduced ejection fraction with New York Heart Association (NYHA) class II to IV symptoms or with a left ventricular ejection fraction of 35% or less and

62
Q

How does valsartan-sucubitril work?

A

inhibits the breakdown of natriuretic peptides resulting in varied effects including increased diuresis, natriuresis, and vasodilation

63
Q

Which drugs must the patient already be taking before they can be put onto valsartan-sucubitril?

A

Angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs).

64
Q

Name 3 angiotensin converting enzyme inhibitors

A

Ramapril
Enalapril
Lisinopril

65
Q

Explain how angiotensin converting enzyme inhibitors work

A

competitively block angiotensin converting enzyme which prevents the conversion of angiotensin I to angiotensin II. This reduces the preload and afterload on the heart

66
Q

In which kind of patient do these drugs significantly reduce mortality?

A

Patients with chronic heart failure

67
Q

Name the 5 studies which support the use of ACE inhibitors in chronic heart failure

A

CONCENSUS, SOLVD, SAVE, AIRE, ISSIS-4

68
Q

List 5 adverse drug reactions associated with ACE inhibitors

A
  • Cough
  • Angioedema
  • Renal impairment
  • Renal failure
  • Hyperkalaemia
69
Q

Describe the three main drug reactions associated with ACE inhibitors

A
  • NSAIDs can cause acute renal failure
  • Potassium supplements can cause hyperkalaemia
  • Potassium sparing diuretics can cause hyperkalaemia
70
Q

If the patient is intolerant of ACE inhibitors, what drug can be used instead?

A

Angiotensin receptor blockers

71
Q

Name three angiotensin receptor blocker drugs

A

Losartan, candesartan & Irbesartan

72
Q

How do angiotensin receptor blockers work?

A

selectively block the angiotensin II AT1 receptor

73
Q

Name the 4 major angiotensin receptor blocker outcome studies

A

Elite II, Charm, Val-Heft, Valiant

74
Q

How do beta blockers impact upon the mortality of heart failure patients?

A

reduce morbidity and mortality in mild/moderate and severe heart failure by 30%

75
Q

When is it appropriate to give beta blockers to a patient with heart failure?

A

when a patient has been stabilized and not during an acute presentation as precipitate severe deterioration to Chronic Heart Failure if the patient is fluid overloaded

76
Q

Briefly explain how beta blockers work

A

They block the actions of the sympathetic system

77
Q

Explain how Ivabradine works

A

blocks hyperpolarization-activated cyclic nucleotide-gated (HCN) channels in the SA node

78
Q

Which kind of heart failure patients are able to take Ivabradine?

A

Patients with mild to severe heart failure in sinus rhythm

79
Q

Why would ivabradine be given when it has the same effect as beta blockers (slows down the heart)?

A

Ivabradine can be used instead of beta blockers to slow the heart rate if beta blockers are not tolerated OR used in addition to beta bockers if the beta blockers are not slowing the heart down enough

80
Q

What impact does digoxin have upon the heart?

A

helps an injured or weakened heart pump more efficiently. It strengthens the force of the heart muscle’s contractions, helps restore a normal, steady heart rhythm, and improves blood circulation.

81
Q

When should digoxin be prescribed for a patient with heart failure?

A

Digoxin should be used as a second-line drug after diuretics, angiotensin-converting enzyme inhibitors and beta-blockers in patients with congestive heart failure who are in sinus rhythm. Digoxin should be used as a first-line drug in patients with congestive heart failure who are in atrial fibrillation.

82
Q

What kind of heart rhythm must patients be in to receive digoxin safely?

A

SINUS RHYTHM

83
Q

What is the name of the study that investigated the usefulness of digoxin in heart failure?

A

DIG study

84
Q

What were the 5 main findings of the DIG study?

A

in heart failure, digoxin;

  • Increases availability of calcium in the myocyte
  • Was shown to reduce number of hospitalisations of heart failure patients
  • Had no effect on mortality
  • Has a narrow therapeutic index
  • Can cause Nausea & confusion

Cardiovascular Medicine (24 decks)

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