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Cardiology - Renee > Heart failure and cardiomyopathy > Flashcards

Heart failure and cardiomyopathy Flashcards

1
Q

Risk factor for HF

A 
AGE
HTN +++ = 39% of HF in men and 59% in women
MI
Valvular lesions
thyrotoxicosis
Arrhythmias
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2
Q

Pathophysiology of heart failure

A

Index event - MI, HTN, Valvular disease –> myocyte injury

Myocyte injury:

  • > Neurohormonal activation
  • > Peripheral vasoconstriction
  • > Fluid retention
  • > Decreased contractility

–> progressive heart failure

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3
Q

NYHA Criteria

A

Class 1 = asymptomatic
Class 2 = Symptoms with exercise
Class 3 = Symptoms during everyday activities
Class 4 = Symptoms at rest

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4
Q

Signs of chronic heart failure

A

Orthopnoea = most reliable

90% of patients with PCWP >22

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5
Q

What is diastolic heart failure

A

Disordered filling of the ventricle
Stiffening ventricle –> need for increased pressures to fill
Can be isolated but most commonly with systolic HF
Caused by HTN and HOCM most commonly

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6
Q

Treatment for Diastolic heart failure

A

NIL RCTs
Avoid fluid depletion and inotropes
Improve relaxation - beta blockers and calcium channel blockers
Rate control AF

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7
Q

Use of BNP for heart failure diagnosis

A 
>400pg/mL = CHF likely
<100 = unlikely
100-400 = patients history - LV dysfunction, cor pulmonale or PE = CHF
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8
Q

Reducing heart failure in high risk patients

A

Risk factor reduction = Treat HTN, Diabetes, hyperlipidaemia
Education
ACE-Is in high risk groups and IHD

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9
Q

Treatment of structural heart disease without symptoms

A

ACE-Is in all

Beta blockers in IHD cardiomyopathy

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10
Q

Treatment of structural heart disease with symptoms for heart failure

A 
Education
Heart failure MDT
ACE-Is and beta blockers for all
Aldosterone blockers
Diuretics = nil survival benefit 
Digoxin = nil survival benefit but decreases hospitalisations
Ivabradine if SR and HR >77
AICD if EF >35%
CRT if LBBB
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11
Q

HF with refractory symptoms

A

Inotropes
LVAD
Transplant
Palliation

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12
Q

Diuretic Resistance

A

Oral = gut oedema –> reduced uptake

IV resistance = an extension of cardiorenal syndrome –> frusemide infusion or dobutamine/levosemendan

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13
Q

Which is the most potent B blocker?

A

Carvedilol

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14
Q

Which is the most cardioselective B blocker?

A

Nebivolol

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15
Q

Side effects of beta blockers?

A

Dizziness and dyspnoea

Worse in the short term 3 months prior to the onset of improved symptoms

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16
Q

Benefits of beta blockers

A 
Improved morbidity and mortality class 2-3 HF - heart failure and SCDs reduced
Class 4 requires stabilization and euvolaemia prior to commencement

Dose related benefits

17
Q

Which betablockers have evidence

A

Carvedilol, bisoprolol and nebivolol

18
Q

Spironolactone and epleronone side effects

A

Hyperkalaemia

  • -> temporary pacing
  • -> renal insufficiency
  • -> Discontinuation

Must monitor EUCs weekly for the first 4 weeks
Higher doses do not increase benefit

19
Q

What is the mechanism of action for Spironolactone and epleronone?

A

Aldosterone antagonist –> inhibits ENaC –> reduced reabsorption of sodium and water in the collecting duct

20
Q

What is the mechanism of action of ivabradine?

A

A sinus node funny/sodium channel inhibitor which slows the upstroke of depolarisation –> slower heart rate

Does not have neurohormonal effects

21
Q

What is the benefit of ivabradine?

A 
Reduces hospitalisations for heart failure in class 2-4 heart failure
Reduces mortality for patients with HR <77bpm

NO SUBSTITUTE FOR BETA BLOCKERS
SHIFT trial

22
Q

What is LCZ696/Entresto

A

Valsartan + sacubitril

23
Q

What is sacubitril

A

A neprolysin inhibitor

Sacubitril is a prodrug that is activated to sacubitrilat by de-ethylation via esterases –> inhibits the enzyme neprilysin, a neutral endopeptidase that degrades vasoactive peptides, including natriuretic peptides, bradykinin, and adrenomedullin –> increases these peptides –> blood vessel dilation and reduction of ECF volume via sodium excretion

24
Q

Which treatments decrease symptoms but don’t improve mortality?

A

Digoxin and diuretics

25
Q

What is the mortality rate for advanced heart failure?

A

Advanced HF = symptoms despite max therapy
10% of CCF patients/yr

25% mortality at 1yr

26
Q

Lifestyle measures to reduce HF symptoms?

A 
Education
Lifestyle changes:
  - Salt restriction
  - Water restriction
  - Weight reduction
  - Cease smoking
  - Cease alcohol
Rehab programs
Manage co-morbidities
27
Q

Causes of death by NYHA class

A

Class 2 = Sudden death +++
Class 3 = Sudden death ++ Heart failure +
Class 4 = Heart failure

28
Q

When is AICD indicated?

A

Class 2-3 with LVEF <35% with maximal medical therapy

If IHD = must wait at least 40 days

29
Q

When is CRT indicated?

A

Class 3-4 with LVEF <35% and QRS > 120ms
Class 2 with LVEF <35% with LBBB + QRS >150
MUST be in SR and have ongoing symtpoms despite optimal medical therapy

Aims to pace the ventricles constantly to prevent MR

30
Q

What about Bi-Ventricular pacing?

A

For patient with class1-3 and LVEF<50% Bi-V reduces death and HF hospitalizations

31
Q

Indications for Cardiac transplant?

A

Refractory class 3-4 HF
VO2 max <14 mL/kg/min + anaerobic metabolism
Severe ischaemia not amenable to treatment
Recurrent refractory ventricular arrhythmias

32
Q

Disadvantages of Transplantation?

A

Donor shortage
Long waiting times
10-20% wait list mortality

Risks of immunosuppression
Risk of rejection

33
Q

Mortality of transplant patients?

A

4%/yr

34
Q

Pathophysiology of HOCM?

A

Abnormal hypertrophy any any part of the ventricle
+/- LV outflow obstruction
+ Diastolic dysfunction +++

Diastolic dysfunction –> LA dilation –> AF

35
Q

Presentation of HOCM?

A 
Asymptomatic
Palpitations and syncope
SCD
Endocarditis
Angina
36
Q

Signs of HOCM?

A

Ejection systolic murmur which varies with contractility, preload and afterload
Mitral regurgitation

ECG = T wave inversion of Lateral leads

37
Q

Principles of management of HOCM

A

Treat heart failure

  • Beta blockers
  • ACEI-s
  • DO NOT use digoxin and diuretics

Alcohol septal ablation
Myomectomy

Prevent SCD

  • Beta blockers
  • AICD

Screen relatives

38
Q

Risk factors for SCD in HOCM

A 
Family history
Recurrent syncope
NSVT
Severe LVH
Severe obstruction
Abnormal BP response with exercise
Specific genotype - ARG719TRP
39
Q

Restrictive Cardiomyopathy

A

Predominant right heart failure
Preserved LVEF with diastolic dysfunction
Atria dilated
AV regurg

TREATMENT = transplant and fluid balance
Response usually poor

Cardiology - Renee (6 decks)

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