Heart Failure r: Cameron McCloskey Flashcards
What may cause heart failure?
- Coronary artery disease
- Valvular heart disease
- Arrhythmias
- Cardiomyopathies
Name some causes of cardiac myopathy
- Inherited - dilated cardiomayopathy
- Thyrotoxicosis
- Alcohol
- Drugs - chemo agents
- Pregnancy
- Pericardial effusions
Right heart failue will cause congestion ____________
Systemically
Left heart failure will cause congestion in the ________
Lungs
Pulmonary oedema will lead to what?
Orthopnoea
Paroxysmal dyspnoea
Chronic right heart failure may lead to what?
- Hepatomegaly
- Ascities
- GI distress
What is PND, and what causes it specifically?
Paroxysmal nocturnal dyspnoea
Left heart failure
Pulmonary oedema is associated with which type of sputum?
A cough with frothy sputum
What is orthopnoea and what sided heart failure is associated?
Breathlessness when lying flat
Left sided heart failure
Why does left sided heart failure often present with cyanosis?
Pulmonary oedema is often present which impairs gas exchange meaning oxygen cannot enter as easily into the bloodstream
Whta are signs of right sided heart failure?
- Elevated JVP
- 3rd heart sound - early systole caused by blood flowing quickly into a failing heart
- Murmur
- Peripheral oedema
- Hepatomegaly
- Ascities
- Tachycardia
In relation to the different times during a heart cycle that heart failure can manifest, what are the two heart failure classifications?
Systolic - the heart fails to pump sufficiently
Diatolic - the heart fails to relax sufficiently - often as a result of hypertension
What are the two types of chronic heart failure?
- Compensated - stable - patient appears well and in control
- Decompensated - unstable
Blood pressure is often very ____ in patients with decompensated heart failure
Low
What investigations should be taken for suspected heart failure?
- FBC
- U+Es
- LFTs
- Lipids
- Thyroid function
- BNP - B-natriuretic peptide (not in Tayside)
What causes B-natriuretic peptide to rise?
Can be released due to atrial stretch
It is not specific to heart failure
Yet is is high in heart failure, so a normal result will rule out heart failure
Which tests should be done for suspected heart failure?
- ABGs
- ECG
- CXR
- ECHO
- Troponin I - only when ACS is suspected
What can be seen on a CXR for heart failure?
- Cardiomegaly
- Alveolar oedema
- Prominent upper lobe vessels
- Kerley B lines
What is the gold standard investigation for heart failure?
ECHO
What is the first step in treating heart failure?
Treat cause
- Stop alcohol
- Control AF
- Valve replacement
- Reduce BP
- Revascularisation
How may you treat a patient to make them feel better during heart failure?
- Fluid balance
- Diuretics if overloaded and breathless (furosemide)
How can heart failure be treated pharmacologically to remove symptoms?
- ACEI (or ARB)
- Beta blocker
- Aldosterone antagonist
Which ACEI could be used to treat heart failure?
- Lisinopril
- Enalapril
ACEI have what side effects?
- Angioneurotic oedema (rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues - similar to urticaria (hives))
- Dry cough
- Renal impairment
Why are beta blockers used to treat heart failure?
They are used to “calm” to sympathetic influence on the heart
Why should beta blockers be used only when heart failure has stabilised?
They reduce contractility so can worsen heart failure initially
Which beta blockers may be used to treat heart failure?
- Bisoprolol
- Carvedilol
Which drug class is used in moderate and severe heart failure?
Aldosterone antagonists
Which aldosterone antagonists will be used to treat heart failure?
- Spironolactone
- Eplenerone
What are the side effects of aldosterone antagonists?
- Hyperkalaemia
- Renal dysfunction
- Gynaecomastia
How can the side effect of gynnaecomastia be avoided when using spironolactone?
Switch to eplenerone instead
Which drug is used when the beta blocker dose is at its maximum and the heart rate will still not reduce?
Ivabradine
Which drug is set to replace ACEI in the future?
Sacubitril-valsartan
How does cardiac resynchronisation therapy (CRT) work?
It involves the right atrium, right ventricle and left ventricle being stimulated in order for them to contract
This allows synchronisation between the RV and LV
(used in BBB for example)
In acute heart failure how is treatment approached?
ABCDE
Why are opiates used in acute HF?
- They relax the patient
- They venodilate
Why are ntrates useful in acute HF?
Venodilatation
why acute left-sided heart failure does not directly cause peripheral oedema, but does directly cause pulmonary oedema?
capillary hydrostatic force driving tissue fluid out of capillaries is reduced when aortic pressure decreases. By contrast, the failure of the left heart causes congestion of the lungs and an increased backpressure. Consequently, the pulmonary capillary pressure will increase due to the congestion of the pulmonary circulation.
How would right heart failure can causes left heart failure ?
Sometimes left sided heart failure can lead to pulmonary congestion which in turn also pushes the right ventricle into failure. In these cases signs and symptoms of both left and right sided heart failure may be present.
How would right heart failure can causes left heart failure ?
Sometimes left sided heart failure can lead to pulmonary congestion which in turn also pushes the right ventricle into failure. In these cases signs and symptoms of both left and right sided heart failure may be present.
New York Heart Association Classification of Heart failure
I - no limitation
II- slight limitation Palpitation and or dyspnoea
III- comfort at risk
IV- Orthopnoea
what is BNP
BNP>2000ng/L urgent two weeks referral and ECHO
If BNP 400-2000ng/L 6 week referral and ECHO
type of blood test for CHEF and why we do them ?
- U+Es to assess renal function (for medication) and to look for hyponatraemia
- LFTs for hepatic congestion
- TFTs to check for hyperthyroidism
- Glucose and lipid profile to assess modifiable cardiovascular risk factors
- BNP is significantly associated with a diagnosis of heart failuare
X ray findings ABCDEF
Alveolar
Kerley B line
Cardiomegaly
upper limb diversion
Pleural effusion
Fluid in the horizontal fissure
what are the drugs for CHEF to improve mortality
ACE and Beta
also
spironolactone or eplerenone. can improve mortality
improve symptoms of patients with CHEF
furosemide or bumetanide . (hypocalcaemia )
patient is presented with Class 3 or 4 NYHA consider
spironolactone or eplerenone.
Hydralazine and a nitrate
Ivabradine if in sinus rhythm and impaired ejection fraction
Angiotensin receptor blocker ARB
Digoxin
