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Y3 Medicine: Cardiovascular > Heart Failure (Acute) > Flashcards

Heart Failure (Acute) Flashcards

1
Q

What is acute heart failure (HF)?

A

Acute heart failure refers to rapid onset or worsening of symptoms and/or signs of heart failure, requiring urgent evaluation and treatment.

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2
Q

What can cause acute HF?

A
  • Acute coronary syndrome (ACS)
  • Hypertensive emergency
  • Rapid arrhythmias or severe bradycardia/conduction disturbance
  • An acute mechanical cause (e.g., myocardial rupture as a complication of ACS, ventricular septal defect or acute mitral regurgitation, chest trauma)
  • Acute pulmonary embolism
  • Valve disease
  • Myocarditis
  • Decompensation of pre-existing chronic heart failure
  • Cardiac tamponade
  • Aortic dissection
  • Renal failure
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3
Q

Briefly differentiate between systolic and diastolic HF

A

Systolic- associated with left ventricular dysfunction and characterised by cardiomegaly, third heart sound, and volume overload with pulmonary congestion. Left ventricular ejection fraction (LVEF) is decreased

Diastolic- typically associated with normal cardiac size, hypertension, pulmonary congestion, and a fourth heart sound. LVEF is preserved.

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4
Q

What is the LVEF measurement of HFrEF and HFpEF?

A

Heart failure with reduced ejection fraction (HFrEF) - symptoms and signs and LVEF <40%

Heart failure with preserved ejection fraction (HFpEF) - symptoms and signs and LVEF >50%.

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5
Q

Briefly describe the various classes of acute HF with regards to congestion and hypoperfusion

A
  • Warm and wet (well-perfused and congested); most common
  • Cold and wet (hypoperfused and congested)
  • Cold and dry (hypoperfused without congestion)
  • Warm and dry (compensated, well-perfused without congestion)
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6
Q

What are the risk factors for acute HF?

A
  • Previous cardiovascular disease; coronary heart disease is the most common cause of HF
  • Older age
  • Diabetes
  • Family history of ischaemic heart disease or cardiomyopathy
  • Excessive alcohol intake or smoking
  • Cardiac arrhythmias including tachyarrhythmia or bradyarrhythmia
  • History of systemic conditions associated with heart failure (e.g. sarcoidosis and haemochromatosis)
  • Previous chemotherapy
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7
Q

Whar are the signs of acute HF?

A
  • Peripheral oedema
  • Cold extremities
  • Elevated JVP
  • Displaced apex beat
  • Gallop rhythm (3rd heart sound)
  • Basilar crackles
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8
Q

What are the symptoms of acute HF?

A
  • Breathlessness
  • Reduced exercise tolerance
  • Fatigue
  • Nocturnal cough
  • Wheezing
  • Dizziness
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9
Q

What investigations should be ordered for acute HF?

A
  • ECG
  • CXR
  • Natriuretic peptides
  • Troponin
  • FBC
  • Urea, electrolytes and creatinine
  • Glucose and HbA1c
  • LFTs
  • Thyroid function tests
  • CRP
  • D-dimer
  • Echocardiography
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10
Q

Why investigate using ECG? And what may this show?

A
  • Record and interpret a 12-lead ECG for any patient with suspected heart failure; monitor this continuously
  • Check heart rhythm, heart rate, QRS morphology, and QRS duration, as well as looking for specific abnormalities such as arrhythmias, atrioventricular block, evidence of a previous myocardial infarction (e.g., Q waves) and evidence of left ventricular hypertrophy
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11
Q

Why investigate using CXR? And what may this show?

A
  • Assess for:
    • Pulmonary congestion
    • Pleural effusion
    • Pulmonary oedema
    • Cardiomegaly
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12
Q

Why inestigate using natriuretic peptides? And what may this show?

A
  • Order N-terminal pro-B-type natriuretic peptide (NT-proBNP) if available
  • Normal levels make the diagnosis of acute heart failure unlikely. However, elevated levels of natriuretic peptides do not automatically confirm the diagnosis of acute heart failure as they may be associated with a wide variety of cardiac and non-cardiac causes.
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13
Q

Why investigate using troponin? And what may this show?

A
  • Measure troponin in all patients with suspected acute heart failure
  • Most patients with acute heart failure have an elevated troponin level
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14
Q

Why investigate using FBC? And what may this show?

A
  • Order a full blood count to identify anaemia, which can worsen heart failure and also suggest an alternative cause of symptoms
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15
Q

Why investigate using urea, electrolytes and creatinine? And what may this show?

A
  • Order as a baseline test to inform decisions on drug treatment that may affect renal function (e.g., diuretics, ACE inhibitors) and to exclude concurrent or causative renal failure
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16
Q

Why investigate using glucose and HbA1c? And what may this show?

A
  • Measure blood glucose in all patients with suspected acute heart failure to screen for diabetes
  • May be elevated
17
Q

Why investigate LFTs? And what may this show?

A
  • Order these for any patient with suspected acute heart failure
  • LFTs are often elevated due to reduced cardiac output and increased venous congestion
18
Q

Why investigate using thyroid function tests? And what may this show?

A
  • Order thyroid-stimulating hormone in any patient with newly diagnosed acute heart failure
  • Both hypothyroidism and hyperthyroidism can cause acute heart failure
19
Q

Why investigate using CRP? And what may this show?

A
  • Inflammation is associated with progression of chronic heart failure
  • Raised in acute HF
20
Q

Why investigate using D-dimer? And what may this show?

A
  • Indicated in patients with suspicion of acute pulmonary embolism
  • Raised in acute pulmonary embolism
21
Q

Why investigate using echocardiography? And what may this show?

A
  • Arrange immediate bedside echocardiography for any patient who is haemodynamically unstable or in respiratory failure. Echocardiography is used to assess myocardial systolic and diastolic function of both left and right ventricles and valvular function and measure left ventricular ejection fraction (LVEF).
  • Left ventricular systolic dysfunction, left ventricular diastolic dysfunction, constriction, left ventricular hypertrophy, valve disease, restrictive heart disease, right ventricular dysfunction, pulmonary hypertension, may detect the underlying cause
22
Q

Briefly describe the treatment for acute HF

A
  • Loop diuretic
  • Consider: vasodilator, aldosterone-antagonist, thiazide-type diuretic, beta blocker and respiratory support
  • Plus: treatment of underlying cause and referral
23
Q

What can be used to treat acute HF if the loop diuretic is not effective?

A

Consider adding a thiazide-type diuretic or an aldosterone antagonist if the patient has resistant oedema or symptoms or signs of congestion despite treatment with a loop diuretic.

24
Q

When should vasodilator therapy be considered in acute HF?

A

Do not give intravenous vasodilators routinely in patients with normal blood pressure. Consider them in specific circumstances: for example, for concomitant myocardial ischaemia or aortic/mitral regurgitation.

25
Q

When should beta-blocker be used in acute HF?

A

Continue a beta-blocker if the patient is already taking this, unless they have:

  • Heart rate <50 bpm
  • Second- or third-degree atrioventricular block
  • Shock
26
Q

When should oxygen therapy be considered in acute HF?

A

Give oxygen if the patient has oxygen saturations <90% or PaO2 <8 kPa (<60 mmHg):

  • Aim for a target oxygen saturation of 94% to 96% in acutely ill patients who are not at risk of hypercapnia
  • A lower target SpO2 of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure
27
Q

Why is oxygen therapy not routinely given in acute HF?

A

Do not use oxygen routinely in non-hypoxaemic patients with acute heart failure because it causes vasoconstriction and a reduction in cardiac output.

28
Q

What are the complications of acute HF?

A
  • Arrthymias
  • Complications of glyceryl trinitrate
  • Complications of diuretics
29
Q

What differentials should be considered for acute HF?

A
  1. Pneumonia
  2. Pulmonary embolism
  3. Asthma
30
Q

How does acute HF and pneumonia differ?

A
  • Differentiating signs and symptoms:
    • Fever, cough and productive sputum
    • Focal signs of consolidation- increased vocal fremitus and bronchial breathing
  • Differentiating investigations:
    • WBC: elevated
    • Blood cultures: positive for organism
    • Chest x-ray: consolidation
31
Q

How does acute HF and pulmonary embolism differ?

A
  • Differentiating signs and symptoms:
    • Haemoptysis and sharp, pleuritic chest pain
    • Risk factors of thromboembolism (TE) include personal history of TE, family history, recent trauma, prolonged immobilisation, smoker or combined hormonal contraception use
  • Differentiating investigations:
    • CT pulmonary angiography: clot in pulmonary artery
32
Q

How does acute HF and asthma differ?

A
  • Differentiating signs and symptoms:
    • Wheezing on physical examination
  • Differentiating investigations:
    • Reduced peak flow
    • Spirometry: obstructive pattern, reversibility with beta-agonist inhalers

Y3 Medicine: Cardiovascular (31 decks)

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