Heart Failure and Acute Coronary Syndromes (ACS) Flashcards
What is the definition of heart failure?
‘a complex syndrome that can occur from any structural or functional cardiac disorder that impairs the ability of the heart to fill with and eject blood and therefore to function efficiently as a pump to support a physiological circulation’
What are the main types of heart failure?
Heart failure due to reduced ejection fraction
- often called Left Ventricular Systolic Dysfunction or Systolic Heart Failure.
- Heart failure with preserved ejection fraction
- often called Diastolic heart failure.
What are the main signs and symptoms of Heart Failure?
SYMPTOMS
- Fatigue
- Breathlessness
- Decreased exercise tolerance
- Paroxysmal Nocturnal Dyspnoea
CLINICAL SIGNS
- Fluid retention (oedema)
- Raised venous pressure (elevated JVP) – usually raised by about 3cm
- Abnormal heart sounds (S3 gallop rhythm)
NYHA Classification of Heart Failure
Class 1 - no limitations on physical activity
Class 2 - slight limitation, comfort at rest but ordinary physical activity causes symptoms
Class 3 - marked limitation of activity, comfort at rest but less than ordinary activity causes symptoms
Class 4 - unable to carry out any physical activity without discomfort, symptoms at rest
Aetiology of Heart Failure
Is not a disease by itself but a consequence of some other disease process
Inability of myocytes to contract normally causes reduced cardiac output
Neuro-hormonal feedback further stresses already struggling cardiovascular system
In the developed world the most common cause is CORONARY ARTERY DISEASE
How is Heart Failure diagnosed?
- History, Clinical signs
- ECG
- Chest X-ray
- Lab tests – troponin, U&E
- Natriuretic peptides
- Echocardiography
- Cardiac angiography
- Cardiac MRI
ECHO diagnosis of heart failure
- Reduced ejection fraction
What are the treatment aims in Heart Failure?
- Reduce symptoms
- Improve quality of life
- Improve life expectancy
- Reduce hospital admissions
What are the main non-pharmacological treatments for heart failure?
- Exercise
- Diet
- Weight reduction
- Reduce alcohol consumption
- Stop smoking
What are the main pharmacological treatments for heart failure to improve mortality/morbidity?
First-line
- ACEi / ARBs
- Beta blockers
- Aldosterone antagonists
Additional therapy
- Hydralazine and Nitrate combination
- Ivabradine
What are the main pharmacological treatments for heart failure to improve symptoms?
- Diuretics
- ACEi / ARBs
- Beta blockers
- Aldosterone antagonists
- Hydralazine and Nitrate combination
- Digoxin
- Ivabradine (slows the heart rate down and is useful for when you can’t increase other meds due to risk of low BP)
What monitoring is normally necessary in patients with heart failure?
Patient education
Carer support
Monitor fluid balance and U&Es
- Recommend that paitnets weigh themselves often to monitor fluid gain. ‘dry weight’ = weight on discharge. If increased fluids -> increase diuretic
End of life discussion
Role of Heart Failure Nurse
What are the initial symptoms of acute coronary syndrome?
- Chest pain
- Raised cardiac markers (e.g. troponin)
- ECG changes
What are the cardiac markers that will be raised in acute coronary syndrome?
Cardiac troponins (Tnt and TnI)
- Sensitive and specific for myocardial damage
- Levels taken on arrival, at 6 hours and at 12 hours.
- Levels peak within 12 hours and fall slowly for up to 2 weeks
- Damage to cardiac muscle of any kind will cause increased markers
Creatinine Kinase (CK, CK-MB)
- Rises 6 hours post infarction and falls after around 36 hours
- Not selective for myocardial damage as also found in skeletal muscle
What are the comparisons between unstable angina (UA), NSTEMI and STEMI?
Unstable Angina (UA)
- Chest pain
- Troponin negative
- Normal/unchanged ECG
NSTEMI
- Chest pain
- Troponin positive
- ST segment depression and/or T wave inversion
STEMI
- Chest pain
- Troponin positive
- ST segment elevation greater than 1mm
What treatment is normally used for STEMI?
Thrombolytics and PCI (Percutaneous Coronary Intervention)
Ideally within 1 hour of the onset of symptoms
+ Drugs for secondary prevention of CHD
What treatment is normally used for NSTEMI?
Glycoprotein 2B/3A inhibitors
+ Drugs for secondary prevention of CHD
What drugs are normally used for the secondary prevention of CHD?
Antiplatelet therapy (typically low dose aspirin)
Statin
ACEi
B-blocker
In addition the following may also be indicated
- Clopidogrel/Ticagrelor/Prasugrel for up to 12 months (depending on diagnosis)
- Aldosterone antagonist (Eplerenone or Spironolactone)
Oral anti-platelet drugs for secondary prevention of CHD
Aspirin 75mg, usually lifelong.
Second antiplatelet drug in combination with aspirin for 12 months following NSTEMI and after PCI.
- Options are Clopidogrel, Ticagrelor or Prasugrel (STEMI only)
- Ticagrelor and Prasugrel have more predictable effect. Greater risk reduction but greater bleed risk
Statins for secondary prevention of CHD
Aggressive high dose treatment should be offered to patients presenting with ACS
- Atorvastatin 80mg daily
- Simvastatin 80mg nocte (risk of rhabdomyolysis)
- Rosuvastatin 20mg daily (not licensed for this indication)
B-blockers for secondary prevention of CHD
Beta-blockers confer prognostic benefit acutely and medium term following myocardial infarction. Also give symptomatic benefit from angina.
Stay on for at least 12 months
- may then be stopped if necessary as the evidence for effectiveness is not as good after this point. No real harm in carrying on.
ACEi for secondary prevention of CHD
Clinically ACEi reduce arterial pressure and cardiac load
- however as they do not effect cardiac contractility, unlike other vasodilators, cardiac output is increased.
Particularly important in the presence of any left ventricular impairment whether symptomatic or not.
Monitor for cough
- switch to ARB if necessary
Aldosterone antagonists for secondary prevention of CHD
Recommended by NICE for patient with evidence of heart failure post MI (ejection fraction
