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Cardiovascular Year 1 > Heart failure - acute and chronic > Flashcards

Heart failure - acute and chronic Flashcards

1
Q

What is heart failure?

A

Clinical syndrome that results from an inability of the heart to maintain adequate cardiac output. It is commonly secondary to ischaemic heart disease or hypertensive heart disease.

Characterised by progressive shortness of breath, fatigue and fluid overload. Unfortunately, HF is a progressive disorder associated with high morbidity and mortality.

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2
Q

What are the 4 ways to classify heart failure?

A
  1. Acute versus chronic
  2. Right-sided versus left-sided
  3. Systolic (HFrEF) versus diastolic (HFpEF)
  4. High output versus low output
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3
Q

Acute heart failure (AHF)

A

Is a life-threatening emergency. AHF 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.

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4
Q

What are the most common causes of acute heart failure?

A

Include acute myocardial dysfunction, acute valvular, pericardial tamponade.

Acute heart failure may present suddenly with cardiogenic shock or sub acutely with decompensation of chronic heart failure.

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5
Q

What is chronic heart failure?

A

Due to progressive cardiac dysfunction from structural and/or functional cardiac abnormalities. There is a reduction in cardiac output and/or elevated intracardiac pressure at rest or on stress.

Chronic heart failure is characterised by progressive symptoms with episodes of acute deterioration.

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6
Q

Systolic heart failure

A

Refers to a reduction in the left ventricular ejection fraction (LVEF). In other words, the heart is pumping out a reduced proportion of the blood that fills its ventricles during diastole.

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7
Q

Diastolic heart failure

A

Refers to impaired ventricular relaxation or filling. The contraction during systole is unaffected, which means the LVEF is preserved. This leads to the term heart failure with preserved ejection fraction or HFpEF.

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8
Q

What complications arise from diastolic heart faiure?

A

Ventricular hypertrophy tends to develop, and diastolic heart failure is characterised by concentric remodelling.

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9
Q

What complications arise from systolic heart faiure?

A

The increase in blood at the end of systole leads to ventricular stretch, dilatation, and eccentric remodelling.

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10
Q

Cardiac remodelling

A

Refers to changes in cardiac size, shape and function in response to cardiac injury or increased load (e.g. exercise).

Pathological remodelling may occur after conditions such as myocardial infarction or cardiomyopathy. The type of remodelling may predispose to systolic or diastolic heart failure.

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11
Q

What is congestive heart failure?

A

The combination of left and right failure is known as congestive cardiac failure.

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12
Q

Left-sided heart failure

A

Most common form of heart failure that is associated with a reduced or preserved pumping function of the left ventricle. Advanced left-sided heart failure commonly causes right-sided failure due to increased intrathoracic pressure and pulmonary hypertension

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13
Q

Right-sided heart failure

A

Commonly occurs as a result of advanced left-sided failure.

Primary right-sided heart failure is uncommon and broadly related to three categories:

  1. Pulmonary hypertension
  2. Pulmonary/Tricuspid valve disease
  3. Pericardial disease
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14
Q

Stroke volume

A

the amount of blood pumped out of the heart from each contraction.

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15
Q

Cardiac output

A

the amount of blood pumped out of the heart in one minute, equivalent to HR x SV.

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16
Q

Preload

A

stretching of cardiomyocytes at the end of diastole.

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17
Q

Afterload

A

pressure or load against which the ventricles must contract.

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18
Q

Ionotropy

A

refers to myocardial contractility (i.e. the force of muscular contractions).

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19
Q

Frank starling Law

A

The relationship between ventricular stretching and contractility. Essentially stretching of cardiac muscle (within physiological limits) will increase the force of contraction.

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20
Q

MAP equation

A

MAP = diastolic blood pressure + 1/3rd of the pulse pressure

MAP = CO x SVR 
MAP = SV x HR x SVR

Pulse pressure is the difference between systolic and diastolic blood pressure.

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21
Q

Pulse pressure

A

Pulse pressure is the difference between systolic and diastolic blood pressure.

22
Q

Systemic vascular resistance

A

Resistance to blood flow offered by all of the systemic vasculatures, excluding the pulmonary vasculature.

23
Q

What factors affect strove volume and thus cardiac output?

A
  1. Preload: stretching of cardiomyocytes at the end of diastole.
  2. Afterload: pressure or load against which the ventricles must contract.
  3. Contractility (Inotropy): refers to myocardial contractility (i.e. the force of muscular contractions)
24
Q

What factors affect preload?

A
  1. Venous return: increased venous return increases the preload and thus stretch on the cardiomyocytes
  2. Filling time: a longer filling time in diastole increases the blood within the ventricle
25
Q

What factors affect afterload?

A
  1. Vascular resistance: vasoconstriction increases the pressure the heart has the pump against decreasing SV.
  2. Valvular disease: stenotic valves increases the pressure the heart has to pump against decreasing SV
26
Q

What factors affect contractility?

A
  1. Muscular function: increased muscular bulk (e.g. hypertrophy) is a physiological and pathological response to increase SV
  2. Autonomic nervous system: innervation from the parasympathetic and sympathetic nervous systems alter the strength of contraction
27
Q

The failing heart

A

As a heart fails the amount of blood left after each contraction increases i.e. the ejection fraction decreases. This increased end-systolic volume (ESV) means the myocardium experiences greater stretch. In a normal heart, this would lead to an increase in myocardial contractility by the Frank-Starling principle.

However, in a failing heart, this causes a reduction in stroke volume (and thus cardiac output). This is because the relationship between cardiomyocyte stretch, and contractility cannot continue unfettered. There is a physiological limit.

28
Q

Compensatory mechanisms in heart failure

A
  1. Increasing preload (increasing venous pressures):
  2. Increasing heart rate (a sinus tachycardia):
  3. Activation of the (RAAS)
  4. Sympathetic nervous system activation
29
Q

Symptoms of heart failure

A
  1. Shortness of breath (SOB), Wheeze
  2. Fatigue. Weight loss
  3. Paroxysmal nocturnal dyspnoea
  4. Orthopnoea, Ankle swelling
30
Q

Signs of heart failure

A
  1. Raised JVP, Displaced apex, Crackles
  2. Ankle swelling
  3. Heart sounds S3/S4
  4. Pulsus alternans, Hepatomegaly, Ascites
31
Q

Diagnosis of heart failure

A
  1. First step is clinical history and examination along with ECG
  2. Step 2 is measure BNP
    > Increased BNP needs review and echocardiography.
    > Normal BNP levels – consider another diagnosis
  3. A transthoracic echocardiography (TTE) may still be warranted, regardless of BNP, if clinical examination reveals a murmur or the ECG is abnormal.
32
Q

Why is a transthoracic echocardiography (TTE) used in heart failure?

A

To look at the ejection fraction of the heart. This helps to differentiate suspected heart failure into three groups:

  1. Heart failure with reduced ejection fraction (HFrEF): LVEF <40%
  2. Heart failure with minimally reduced ejection fraction (HFmrEF): LVEF 40-49%
  3. Heart failure with preserved ejection fraction (HFpEF): LVEF ≥50%
33
Q

What drug is recommended for all patients with heart failure?

A

IV loop diuretics e.g. furosemide or bumetanide

34
Q

What management is offered to HF patients with respiratory failure?

A

CPAP

35
Q

Apart from loop diuretics. what other possible management is available for HF?

A

> 

oxygen - aim for 94-98%

> vasodilators

36
Q

Management of HF patients with hypotension/cardiogenic shock

A
  1. inotropic agents e.g. dobutamine
  2. vasopressor agents e.g. norepinephrine
  3. mechanical circulatory assistance: e.g. intra-aortic balloon counter pulsation or ventricular assist devices
37
Q

What is a contraindication for beta blocker use in HF?

A

Asthma, COPD, pulmonary oedema, or bradycardia

38
Q

What is the 1st line treatment for all HF patients?

A

Both an ACE-inhibitor and a beta-blocker

39
Q

What is the 2nd line treatment for all HF patients?

A

Second-line treatment is an aldosterone antagonist - these are sometimes referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and eplerenone

40
Q

When are aldosterone antagonists contraindicated in HF?

A

Hyperkalaemia, hyponatraemia, acute kidney injury

41
Q

Third line treatment for HF (after ACE, Beta blocker and aldosterone antagonists)

A

Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

42
Q

Criteria for using Ivabradine as a third line treatment in HF

A

criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%

43
Q

Criteria for using sacubitril-valsartan as a third line treatment in HF

A

o criteria: left ventricular fraction < 35%
o is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
o should be initiated following ACEi or ARB wash-out period

44
Q

Criteria for using digoxin as a third line treatment in HF

A

it is strongly indicated if there is coexistent atrial fibrillation

45
Q

Criteria for using hydralazine in combination with nitrate as a third line treatment in HF

A

This may be particularly indicated in Afro-Caribbean patients

46
Q

Criteria for using cardiac resynchronisation therapy as a third line treatment in HF

A

indications include a widened QRS (e.g. left bundle branch block) complex on ECG

47
Q

Vaccines offered in HF

A
  1. offer annual influenza vaccine

2. offer one-off pneumococcal vaccine

48
Q

Cor pulmonale

A

Is right sided heart failure caused by respiratory disease. The increased pressure and resistance in the pulmonary arteries (pulmonary hypertension) results in the right ventricle being unable to effectively pump blood out of the ventricle and into the pulmonary arteries. This leads to back pressure of blood in the right atrium, the vena cava and the systemic venous system.

49
Q

Respiratory causes of Cor pulmonale

A 
>	COPD is the most common cause
>	Pulmonary Embolism
>	Interstitial Lung Disease
>	Cystic Fibrosis
>	Primary Pulmonary Hypertension
50
Q

Signs and symptoms of cor pulmonale

A
  1. Hypoxia
  2. Cyanosis
  3. Raised JVP ( back-log of blood in the jugular veins)
  4. Peripheral oedema
  5. Third heart sound
  6. Murmurs (e.g. tricuspid regurgitation)
  7. Hepatomegaly - back pressure in the hepatic vein
51
Q

Management of Cor pulmonale

A

Management involves treating the symptoms and the underlying cause. Long term oxygen therapy is often used. The prognosis is poor unless there is a reversible underlying cause

Cardiovascular Year 1 (19 decks)

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