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Week 5 - Cardiology > Heart Failure and therapeutics > Flashcards

Heart Failure and therapeutics Flashcards

1
Q

What is the definition of heart failure?

A
  • Failure of the heart to pump blood at a rate sufficient to meet the metabolic requirements of the tissues
  • Caused by an abnormality of any aspect of cardiac function and with adequate filling pressure
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2
Q

What is heart failure characterised by?

A

Typical haemodynamic changes (e.g. systemic vasoconstriction) and neurohumoral activation

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3
Q

What are the common causes of heart failure in the UK?

A
  • Corornary artery disease
  • Hypertension
  • Idiopathic as in unknown
  • Toxins (alcohol, chemotherapy)
  • Genetic
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4
Q

What are the causes of heart failure which are less common in the UK

A
  • Valve disease
  • Infections (virus, Chaga’s)
  • Congenital heart disease
  • Metabolic (haemochromatosis, amyloid, thyroid disease)
  • Pericardial disease (e.g. TB)
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5
Q

What are the 4 types of heart failure?

A
  • HF-REF (systolic HF)
  • HF-PEF (diastolic HF)
  • Chronic (congestive)
  • Acute (decompensated)
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6
Q

Describe the typical presentation of HF-REF

A
  • Younger
  • Male
  • Coronary aetiology
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7
Q

Describe the typical presentation of HF-PEF

A
  • Older
  • More often female
  • Hypertensive aetiology
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8
Q

What is the breif overall pathology-physiology of heart failure?

A
  • Myocardial injury results in left ventricular systolic dysfunction
  • This results in perceived reduction in circulating volume and pressure
  • Resulting in neurohumoral activation (SNS, RAAS, ET and AVP, Natriuretic peptides etc. )
  • This leads to systemic vasoconstriction and the renal retention of sodium and water which then leads to further left ventricular systolic dysfunction and the cycle continues
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9
Q

What are the symptoms of heart failure?

A
  • Dyspnoea and cough
  • Ankle swelling (also legs and abdomen)
  • Fatigue/tiredness
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10
Q

What are the signs of heart failure?

A
  • Peripheral oedema (ankles, legs, sacrum and abdomen)
  • Elevated JVP
  • Third heart sound
  • Displaced apex beat
  • Pulmonary oedema (lung crackles)
  • Pleural effusion
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11
Q

What are the symptoms in NYHA class I

A

No symptoms and no limitation in ordinary physical activity i.e. they don’t get short of breath from walking

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12
Q

What are the symptoms in NYHA class II?

A

Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity

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13
Q

What are the symptoms in class III NYHA?

A

Marked limitation in activity due to symptoms, even during less than ordinary activity e.g. walking short distances
Comfortable only at rest

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14
Q

What are the symptoms in class IV heart failure?

A

Severe limitations. Experience symptoms even while at rest. Mostly bed bound patients

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15
Q

What investigations should be carried out in all heart failure patients?

A
  • ECG
  • Chest X ray
  • Echocardiogram (chamber size, systolic and diastolic function, valves)
  • Blood chemistry (U+Es, Creatinine, urea, LFTs, urate)
  • Haematology (Hb, RDW)
  • Natriuretic peptides (BNP, NT-proBNP)
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16
Q

What is the diagnostic algorithm for heart failure?

A
  • Suspected heart failure: risk factors/ symptoms and signs/ abnormal ECG
  • Carry out NT-proBNP or BNP. If NT-proBNP is equal to or higher than 125 pg/mL or BNP is equal to or greater than 35pg/mL then carry out echocardiography
  • If abnormal findings then heart failure is confirmed, carry on to find the HF phenotype
17
Q

How can you define the heart failure phenotype?

A
  • LVEF measurement
  • If =/<40% it is HFREF (reduced ejection fraction)
  • If 41-49% then HFMREF (mildly reduced)
  • If =/>50% then HFPEF (preserved)
18
Q

What is the treatment of HFrEF?

A
  • ACEi or ARNI
  • Beta blocker
  • MRA
  • Dapagliflozin or empagliflozin
  • Loop diuretic for fluid retention
19
Q

What medications should be given to all HF patients as stated in the ESC HFA guidelines?

A
  • ACEi or APRN
  • Beta blocker
  • MRA (aldosterone receptor antagonist)
  • SGLT2i
20
Q

What is the effect of angiotensin II on the blood vessels?

A
  • Vasoconstriction
  • smooth muscle cell hypertrophy
  • Superoxide generation
  • endothelial secretion
  • Monocyte activation
  • inflammatory cytokines
  • Reduced fibrinolysis
21
Q

What is the effect of angiotensin II in the kidney?

A
  • Sodium and water retention
  • Efferent arteriolar vasoconstriction
  • Glomerular and interstitial fibrosis
22
Q

What is the effect of angiotensin II on the heart?

A
  • cellular hypertrophy
  • myocyte apoptosis
  • Myocardial fibrosis
  • Inflammatory cytokines
  • Coronary vasoconstriction
  • Positive inotropy (strengthened heart contractions)
  • Proarrhythmia
23
Q

What is the effect of angiotensin II on the adrenal gland?

A

Aldosterone secretion

24
Q

What is the effect of angiotensin II on the brain?

A
  • Vasopressin secretion

* Sympathetic activation

25
Q

Describe the action of the ARNI LCZ696

A

ARNI= Angiotensin receptor Neprilysin Inhibition
•It combines valsartan and sacubitril
•Valsartan is a AT1 antagonist, Redding vasoconstriction, sodium/water retention and fibrosis/hypertrophy
•Sacubitril is a neprilysin antagonist. Neprilysin degrades natriuretic peptides. Sacubitril results in increased NTPs resulting in vasodilation, natriuresis, diuresis and inhibition of pathologic growth/fibrosis

26
Q

Give two examples of SGLT2is

A
  • Dapagliflozin

* Empagliflozin

26
Q

Give two examples of SGLT2is

A
  • Dapagliflozin

* Empagliflozin

27
Q

What are the devices that can be used in heart failure?

A

•ICD- implantable cardioverted defibrillator

28
Q

What are the devices that can be used in heart failure?

A

•ICD- implantable cardioverted defibrillator

29
Q

Describe biventricular/multi site pacing (or cardiac resynchronization therapy)

A
  • 3 leads
  • One in the right atrium
  • One in the right ventricle
  • Lead through the coronary sinus to the left ventricle (this makes it different to a normal pace maker)
30
Q

Who qualifies for CRT-D and CRT-P?

A
  • Anyone with a QRS over 150ms, CRT-P for class IV, option of either for class III
  • QRS 120-149 and LBBB NYHA class II-IV, CRT-p if class IV, option of either in class III
  • QRS 120-149 no LBBB, NYHA class IV CRT-P
31
Q

What can be used to inhibit the sinus node?

A

Ivabradine (slows the rate)

32
Q

What can Ivabradine be used to treat?

A

Systolic heart failure

33
Q

What drugs can be used in African Americans with heart failure?

A

Hydralazine and isosorbide dinitrate

34
Q

What drugs have the best evidence base for the treatment of heart failure with a midly reduced ejection fraction?

A

Diuretics

35
Q

Describe the management of acute heart failure

A
  • Aqua Natriuresis: Ultrafiltration
  • Arterial vasodilation: nitrates/dobutamine/nitroprusside
  • Venodilation: nitrates/morphine
  • Natriuresis: Furosemide
  • Increased inotropy: Dobutamine, dopamine, milrinone
  • Preload reduction: bilevel or continuous positive airway pressure

Week 5 - Cardiology (8 decks)

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