HF Flashcards
What is HF
What does the syndrome consist of
Inability of heart to increase CO to meet demand
Clinical syndrome of Dyspnoea Fatique Fluid retention Neurohormonal disturbance Progressive cardiac dysfunction
What are the two types of HF
Acute
Chronic
Acute on Chronic
L most common cause of R (congestive)
Can have high or low output
Low = common
High = rare e.g. due to decreased resistance, severe anaemia and thyrotoxicosis storm
Systolic - reduced EF <40%
- Decreased pumping / CO and fluid back up
- Heart will work with larger EDV and HR to meet demand if CO not increased even if this reduces EF
Diastolic - preserved EF
- Hypertrophy so doesn’t fill or relax
- Fluid back up
- Require other diagnostic evidence as preserved EF e.g. raised BNP or structural HD
What are main causes HF
CAD MI HTN DM FH cardiomyopathy
What causes LVSD
Cardiac vs non-cardiac causes
Cardiac MI IHD Chronic pressure overload - Hypertension - Obstructing valve causing chronic Chronic volume - Valvular regurgitation e.g. after IE can cause acute - Shunt Arrhythmia - tachy or Brady - Common precipitate acute through decompensation HCM or dilated Myocarditis Pericardial effusion / disease
Non-cardiac Pulmonary vascular / Cor-pulmonale = RHF Muscular dystrophy Haemochrmotosis Alcohol HIV Lyme's Sarcoidosis Phaeochromocytoma High output state - anaemia / thiamine Thyroid Drugs -ve inotrope
What causes diastolic dysfunction
Ventricular hypertrophy
Constrictive pericarditis
Cardiac tamponade
Restrictive cardiomyopathy
What are the symptoms of HF
SOB Orthopnoea - pillows PND - attack of cough / SOB waking up Cough - frothy, worse at night Wheeze Fatigue Peripheral oedema Reduced exercise activity Fluid overload - JVP / oedema Cyanosis Weight loss - may not notice due to oedema as overall catatonic state Sarcopenia Nocturia Cold periphery
What are signs of HF
Tachycardia Tachypnoea Bilateral crackles (pulmonary oedema) 3rd HS Displaced apex Hypotension - suggest shock Narrow pulse pressure Pulse aternans - strong and weak beats RV heave Cardiomegaly
What is ejection fraction
Continuous variable measured with ECHO
The amount of blood ejected with each contraction
What is normal, mild, severe
Normal = 50-80% Mild = 40-50% Severe = <30%
Can get HFrEF if <40%
HF mr EF (mildly reduced) if 40-49% + other criteria
HRpEF = normal so >50%
How do you screen for HF
Hx and exam
12 lead ECG
BNP - N type
ECHO if either abnormal within 2-6 weeks for definite Dx
- In clinical practice just get ECHO
Urgent ECHO + specialist review if BNP >2000 within 2 weeks
Previous MI doesn’t require screen- ECHO
HF unlikely if BNP low and ECG normal
What does ECG show
Previous MI or current MI causing acute
Hypertrophy
What are other tests in HF to help confirm
Urine dip Bloods - FBC, U+E, LFT - Renal / cirrhosis can cause overload HbA1c, Lipids, TFT CXR - Look for oedema or other cause for SOB Coronary angiography Stress testing Cardiac MRI - Determine ischaemia vs non-ischaemic cause
What do you need to Dx HF
S+S
Evidence of cardiac dysfunction
Response to therapy
Increased BNP (released to counteract RAAS in response to stretch)
Age LVH Ischaemia Valve Tachycardia Overload Hyperaemia inc PE Low GFR CKD Sepsis DM Liver cirrhosis
What causes decreased BNP
Obesity
ACEI
BB
Diuretic / aldosterone antagonist
What are the CXR findings in HF
Alveolar oedema
B-lines as fluid in interlope fissures
Cardiomegaly >0.5 of largest heart border
Dilated upper lobe veins (increased prominence and diameter)
Effusion - pleural
How do you treat HF
Treat cause - arrythmia/ valve disease Treat exacerbating factors - anaemia. /thyroid / BP / infection Lifestyle Heart failure specialist nurse Rx for reducing mortality Pulmonary oedema Rx Refractory RX
What lifestyle
Stop smoking Reduce alcohol Eat less salt Optimise weight + nutrition Exercise Annual flu vaccine One of pneumococcal vaccine Statin Aspirin 75mg Offer cardiac rehab
What Rx reduces mortality / increases prognosis
ACEI + BB = 1st line
- Don’t give BB in acute
- Bisoprolol or carvediol only one
Hydralazine and nitrate = 2nd line if don’t tolerate or still Sx
Aldosterone antagonist (spironolactone) + nitrate if reduced EF and still symptoms
Can add ANRI to replace ACEI if still symptomatic
How do you treat pulmonary oedema / symptoms
Furosemide oral or IV if acute
GTN (nitrate)
Morphine (vasodilator)
Hydralazine + nitrate = vasodilator + diuretic
Add thiazide if refractory
K sparing if low or concurrent digoxin use
What do you do if refractory / specialist care
When do you consider pacemaker / cardiac resynchronisation
Reasses cause and compliance Digoxin - small inotrope Ivabradine Dobutamine Consider transplant Consider pacemaker / cardiac resynchronisation / PCI
Pacemaker if
- LVEF <35% and >40 days post MI
- Despite OMT still symptoms
- Hx of VT / VF
Cardiac resynchronisation
- If ECHO shows ventricle not contracting properly
- e.g. want bottom part of ventricle to contract to squeeze blood up rather than top
- Consider if EF <35% and prolonged QRS
- if LBBB different parts will contract
When is digoxin used
AF
When would you start on Ivabradine
Max therapy
HR >75
Sinus rhythm
EF <35%
What should you avoid in angina and HF
Rate limiting CCB
What is the New York classification of HF
Class 1 = no symptoms or limitation
Class 2 = mild limitation to exercise - SOB / angina, none at rest
Class 3 = moderate limitation in activity, not at rest
Class 4 = severe limitation at rest, often bed bound
What is BNP
Hormone produced by left myocardium in response to strain to counteract RAAS
What does BNP do
Increase GFR Reduce Na reabsorption and Vasodilator Diuretic Suppress sympathetic and RAAS
What do you want to monitor in HF
Monitor U+E as renal function can be affected
Drugs e.g. diuretic can be nephrotoxic
Get baseline
Re-check within week if change dose
What do you do if K low
If no retention reduce diuretic dose or add in spironolactone
What is also useful in HF
Monitor weight
If increasing increase diuretic
What is your dry weight
No pulmonary oedema
Normal JVP
How do you follow up HF
Every 6-12 months BP HR Symptom - Oedema U+E, FBC, glucose Flu immunisation
What is acute HF and what happens
Sudden onset or worsening of chronic HF that is life threatening
Left ventricle unable to pump blood so backs up in atrium and then lungs
Leak fluid = pulmonary oedema
Interfres with gas exchange causing SOB / desaturations
What causes acute HF without previous Hx
Increased filling pressure or myocardial dysfunction MI / ACS Fluid overload Sepsis Arrhythmia Valve dysfunction Myocarditis Toxins Cardioversion / surgery can cause
What leads to decompensate (worsening of chronic HF)
ACS - look for this Hypertensive crisis Arrhythmia - AF Valve disease Mechanical cause PE
Worsening
- Age
- Stroke / SAH
- Renal or liver dysfunction
- Cirrhosis with ascites
- COPD
- Severe infection or burns
- Anaemia
- Metabolic
What are the symptoms of acute HF
Often present syncope /SOB
Underlying cause - chest pain / viral infection
SOB
- Worse lying flat and better sitting up
Syncope
Sudden onset desaturation
Reduced exercise
Fatigue
Cough + frothy
Cyanosis
Tachycardia
Tachypnoea
Displaced apex
Bibasal crackles due to pulmonary oedema
Wheeze
S3
If severe can get hypotension due to cariogenic shock
R failure can develop - increased JVP + peripheral oedema
