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
What investigations do you do if suspect acute HF (treat first even before Dx confirmed)
ECG - look for arrhythmia / MI
Blood - FBC (anaemia), U+E, CRP, troponin?, glucose, D-dimer
CXR - fluid / cardiomegaly
ABG - type 1 resp failure
Treat before these tests
ECHO - effusion / tamponade
Do immediate if unstable or within 48 hours
BNP
Look for cause
How do you treat acute HF
How do you treat if severe / cardiogneic shock
What is important to do
IV access
Stop fluids
Sit patient up
Oxygen if sats <96 but careful in COPD
Loop diuretic - Often IV
Vasodilator e.g. nitrate only if BP >90
IV opiates - act as vasodilator and reduce anxiety
Monitor fluid balance - UO / intake, U+E
Put catheter in
DVT propphylaxis - TED + LMWH
Do daily weight + Na and fluid restrict when stable
If resp failure but no shock
- Oxygen
- NIV - CPAP or BiPAP
- Intubation
If cardiogenic shock / not-responding Transfer ICU Inotropes - NA / dobutamine (often need CCU / ITU) Vasopressors NIV - CPAP Ultra filtration if resistant Mechanical circulatory assistance
Treat and look for underlying cause
- AF = digoxin not BB
- ACS = revascularise
- Arrhythmia = cardiovert
- HTN crisis = aggressive BP reudction
- PE = anti-coag
If patient dry and perfusing
- Oral therapy adequate
if patient dry but not perfusing
- Try fluid challenge
- Consider inotrope if hypo-perfused
What should you think of discontinuing short tern
BB as -ve inotropic
Sometimes used in chronic setting
What causes peripheral oedema
Heart failure = most common Cellulitis DVT Lack of mobility Chronic venous insuffinecy Lymphoedema
What investigations do you do for oedema
FBC, U+E, LFT, albumin
CXR - look for pulmonary
ECHO
USS if ascites
How do you treat
Elevate leg
Compression
Furosemide if severe or cardiac cause
What causes severe pulmonary oedema
Left ventricular failure LVF post ACS or IHD Acute valve regurgitation - IE/ dissection Arrhythmia Myocarditis HTN crisis PE ARDS any cause Fluid overload High altitude Neurogenic - seizure / stroke / head injury Re-exapnsion Infections
What are the symptoms of pulmonary oedema
What suggests cardiac cause
Dyspnoea Orthopnea Cough Distressed Pale, clammy and sweaty Tachycardia Tachypnoea JVP increased Wheeze Fine crackles - bilateral Type 1 and type 2 failure High cardio-pulmonary wedge pressure suggest cardiac cause
What should you consider
Changes to drugs / fluid
Acute illness
Prior MI
How do you investigate
CXR ECG U+E, troponin, ABG Consider ECHO BNP
What does CXR look like for oedema
Bilateral shadowing Upper lobe venous diversion Small effusion at costophrenic angle Fluid in fissures Fluid in septal lines Same as HF
How do you monitor oedema
ABG ECG BP Pulse Cyanosis RR JVP Urine output
How do you treat pulmonary oedema
Sit patient up High flow O2 if sats low IV access Treat arrythmia Diamorphine 5mg IV Furosemide IV GTN spray - don't give if low systolic IV nitrate - if BP >100 (last resort) - AVOID OPAITE
What do you do if patient worsening
Further furosemide
Consider CPAP
Increase nitrate
Consider Doputamine to increase CO if HF
Intropes
Consider other causes - dissection / PE / pneumonia
What do you do if BP <100
Treat as cariogenic shock
What is DDX
Asthma
COPD
Pneumonia - usually unilateral
What do you do once stable
Daily weight Repeat CXR Oral furosemide / bumetanide Addition of thiaizde ACEI if LVEF <40% BB or spirnolactone Pacing Optimise AF
What are nitrates and when are they CI
Vasodilator + diuretic
If low systolic
What causes congestive HF
Ischaemia Valve LVF PS Lung disease - cor pulmonale
What are symptoms of congestive
SOB PND Orthopnoea Pulmonary oedema Tachycardia Crepitation’s due to fluid Increased JVP Hepatomegaly Peripheral oedema / ascites Nausea Anorexia Epistaxis
What drugs do you stop if pulmonary oedema / acute HF as worsen
ACEI = retention
BB = -ve inotrope
Rate limting CCB
Lithium
What should you give if acute HF due to AF
Digoxin
BB CI in HF as -ve inotropic
What should you monitor with digoxin
K
Renal
When is morphine useful / when do you have caution
If distressed
Vasodilator so reduces preload
Prescribe anti-emetic as well
Caution if liver / COPD
What dose of GTN
2x 500mg one of
Regular 250mg
What anti-emetic
Metaclopramide
What do you want to know when on diuretic
Urine Output
When do you get urgent assessment
if BNP >2000
What do you monitor
U+E as treatment of HF affects
When are ACEI CI
Valvular heart disease
What should everyone with HF get
HF specialist nurse
What do you think if patient suddenly desaturations
Have they had fluid and can they process it - CKD / AS
If heart failure is severe what can occur
Cardiogenic shock - hypotension
What type of resp failure in HF
Type 1
do ABG
What is most important thing to look at on ECHO
EF - % of blood pumped out with each contraction
Should be >50%
What do you look at for future CVS risk
Cholesterol BP Weight SMoknig DM
What are RF of chronic heart failure
Hypertension CAD Previous MI Valve issues DM Age Alcohol Smoking Obesity Infection High or low haematocrit
What is pathophysiological behind HF
CO decreased so compensatory mechanism kick in Systolic dysfunction Neurohormonal Sympathetic RAAS / BNP
What is neurohormonal changes
Vasoconstriction
Renal sodium retention by RAAS to increase preload
Activation of sympathetic system
What does sympathetic system do
Peripheral vasconstriction to increase resistance and after load
Renin stimulation
Myocyte hypertension
All increases after load and worsens HF
What does RAAS do
Activate by increased sympathetic
Peripheral vasoconstriction - ANG II
Aldosterone = increased Na and H20 retention
Leads to more overload and CO drops further
What is systolic dysfunction
If heart healthy if stretched it will contract harder
In HF the heart dilates and contraction weakens
Overincrease in preload and increase in after load leads to cardiac strain
CO drops further
Reduces GFR
Activation of sympa and RAAS = further damage
Role of BNP
Vasodilator + diuretic but much weaker than RAAS
What is Cor Pulmonale
R sided heart failure
What causes
COPD = most common Interstitial lung disease PE CF Pulmonary hypertension
What are symptoms
Asymptomatic SOB - also caused by disease Peripheral oedema Cyanosis Syncope Chest pain
What are signs
Hypoxia Cyanosis Raised JVP 3rd HS RV heave Tricuspid regurgitation = pan systolic Pulsatile hepatomegaly
How do you Rx
Treat cause
Long term O2
Poor prognosis
What do you think if young patient present with Sx of HF
Have they had flu like Sx/ myocarditis in the past
What is DDX of breathlessness / HF SX
Heart failure Pulmonary HTN COPD Asthma Pulmonary fibrosis
All cause SOB
Don’t all cause peripheral oedema
What does ECHO look at - trans thoracic
Ejection fraction
Contraction and pumping function of ventricle
What should you do before management of HF
Work out haemo-dynamic profile
Are they congested
Are they perfusing
How do you treat HFpEF
Diuretics and manage co-morbid
No benefit with other drugs
What are risks of HF
Arrythmia Sudden cardiac death CKD and liver Depression Cachexia
