HF (more) Flashcards
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What is systolic HF due to?
reduced ejection fraction > Heart can’t pump hard enough
Ejection fraction - less than 40%
What is diastolic HF due to?
Preserved LV ejection fraction
Heart not filling enough→ Low stroke volume and total volume, so normal ejection fraction
Causes for systolic HF
ischaemic heart disease, valvular heart disease and hypertension
Causes for diastolic HF
increased stiffness of ventricle + impaired relaxation of the venticle
NYHA Classification of heart failure - Class 1
Class I - pain only on extreme exertion
- no limitation of physical activity, activity doesn’t cause shortness of breath
NYHA Classification of heart failure - Class 2
Class II - pain on moderate exertion
- slight limitation of physical activity, comfortable at rest but normal activity causes shortness of breath
NYHA Classification of heart failure - Class 3
Class III - pain on low exertion
- marked limitation of physical activity, comfortable at rest but less than normal activity causes shortness of breath
NYHA Classification of heart failure - Class 4
Class IV - pain at rest
- unable to carry out any activity without symptoms, can be symptomatic at rest
What would an echogram do?
Confirm diagnosis, ejection fraction, valvular defects
What would a CXR do?
Highlight;
- Pulmonary oedema → haziness in perihilar region, Kerley B lines, bat-wing shadowing
- Cardiomegaly
What does a BNP do?
Detects enzymes released due to cardiac distension
What does a cardiac MRI do?
assess if scar tissue is present in myocardium
Medications for acute HF
Loop diuretics (furosemide)
Morphine IV
Nitrates - sublingual or oral
Oxygen
Position - sit patient up
Treat the cause of decompensation (MI, arrhythmia, myocarditis)
β-blockers contraindicated
Medications for preserved ejection fraction
Loop diuretics e.g. furosemide
Manage cause/precipitating factors
Medications for reduced ejection fraction
- ACE inhibitor (e.g.ramipril)
- β blocker (e.g.bisoprolol)
- Aldosterone antagonist when symptoms are not controlled with A and B (spironolactoneoreplerenone)
- Loop diuretics to improvesymptoms(e.g.furosemide)
Other add-ons if symptoms are not controlled with the above measures:
- Sacubitril/valsartan - stop ACEi/ARB, continue β-blocker and spironolactone
- Ivabradine - sinus rhythm ≳75 bmp
- Digoxin
- Hydralazine + nitrates
Complications with surgical interventions such as pacemakers
Arrhythmias - most commonly AF and ventricular arrhythmias
Depression
Cachexia
Chronic kidney disease
Sudden cardiac death
A 65-year-old man presents to the cardiology clinic for a follow-up appointment for his known left ventricular failure. A recent echocardiogram has shown an ejection fraction of 20-30%. On examination, his pulse is regular, at 80 beats per minute, alternating between strong and weak beats.
What is the likely cause of his examination findings? and why
Pulsus alternans
= Pulsus alternans is an arterial pulse which alternates between strong and weak beats due to variations in systolic pressures
A 60-year-old male patient presents to the general practitioner with a 3-month history of shortness of breath, particularly when lying flat. He has a past medical history of type 2 diabetes, hypertension, and hypercholesterolaemia.
On physical examination the jugular venous pressure is elevated 3 cm above normal, there are bibasal fine crackles on auscultation of the chest, and there is bipedal pitting oedema.
Which chest x-ray findings are consistent with the most likely diagnosis?
Bilateral blunting of the costophrenic angles
= Chest x-ray typically reveals the ABCDEF patter: Alveolar oedema, Kerley B lines, Cardiomegaly, upper lobe blood diversion, pleural effusions, and fluid in the horizontal fissure
Is Pulsus Alternans associated with right or left-sided HF?
Left
A 65-year-old male patient presents to the general practitioner with a 2-month history of shortness of breath on exertion. He has also noticed a few episodes of waking up at night gasping for breath. His past medical history is significant for a myocardial infarct 2 years ago.
On physical examination, the jugular venous pressure is elevated 3 cm above normal and there is pitting oedema to the mid-shins.
What is the most appropriate next step in the management?
Measure BNP and refer for trans-thoracic echocardiogram if elevated
BNP is always done before echocardiogram
A 53-year-old female patient visits her GP due to worsening shortness of breath and difficulty laying flat. The GP wonders if the patient may have left-sided heart failure and decides to request a serum brain natriuretic peptide level.
Where is brain natriuretic peptide secreted from?
Cardiac ventricles
What is the criteria for consideration of CRT- cardiac resynchronisation therapy?
LBBB on ECG - Left bundle branch block
LVEF <30%
NYHA Class III
An 84 year old man is seen in a cardiology clinic for annual review. He has been symptomatic for the past two years with breathlessness on mild exertion, inability to lie flat and occasional episodes of palpitations.
These symptoms have worsened slightly.
On examination, he is comfortable at rest with pedal oedema to the mid-shins and sparse bilateral basal crackles. He has a pulse rate of 64bpm (irregularly irregular) and blood pressure of 128/77mmHg.
The echocardiogram demonstrates an ejection fraction of 25%. ECG indicates atrial fibrillation with left bundle branch block (LBBB), QRS duration 160ms. Blood tests are within normal limits.
His current medications include enalapril, bisoprolol, eplerenone, atorvastatin, furosemide, aspirin, and apixaban.
Which treatments should be offered to this patient and why?
Digoxin as a person has AF.
Digoxin co-exists with HF and atrial fibrillation
When would a beta blocker not be used?
when a patient has a HR less than 50BPM
Left ventricular ejection fraction of 45% and normal diastolic filling patterns why is this incorrect?
normal left ventricular ejection fraction is >55%
An 85 year old male presents to the emergency department with shortness of breath. He has a history of heart failure managed medically, but has significantly worsened in the last 48 hours. On examination, his vital signs are: RR 30 breaths per minute, HR 100 bpm, BP 130/95 mmHg, oxygen saturations 93% on air, afebrile. He has a mildly raised jugular venous pressure. Auscultation of his chest demonstrates a fourth heart sound and bibasal respiratory crepitations.
With regard to the 4th heart sound, what does this sound correspond to on ECG?
P wave
Which is the most likely side effect from a high-dose treatment of furosemide?
Tinnitus
NT-pro-BNP results are as follows:
2000ng/L (236pmol/L)
What should you do?
Refer urgently for specialist assessment and Transthoracic Echocardiogram <2 weeks
NT-pro-BNP results are as follows:
400-2000ng/L (47-236pmol/L)
What should you do?
Refer for specialist assessment and TTE <6 weeks
NT-pro-BNP results are as follows:
<400ng/L
What should you do?
Diagnosis of heart failure is less likely
What does the QRS complex respond to? (Heart sounds)
The QRS complex corresponds to ventricular contraction
What does the T wave respond to? (Heart sounds)
The T wave corresponds to repolarization of the ventricles
Symptoms of LHF
(1) Shortness of breath on exertion
(2) Orthopnoea
(3) Paroxysmal nocturnal dyspnoea
(4) Nocturnal cough (± pink frothy sputum)
(5) Fatigue
Symptoms of RHF
(1) Ankle swelling
(2) Weight gain
(3) Abdominal swelling and discomfort
(4) Anorexia and nausea
Signs of LHF
(1) Tachypnoea
(2) Bibasal fine crackles on auscultation of the lungs
(3) Cyanosis
(4) Prolonged capillary refill time
Hypotension
(5) Pulsus alternans (alternating strong and weak pulse)
(6) S3 gallop rhythm (produced by large amounts of blood striking the compliant left ventricle)
(7) Pulmonary odema
Signs of RHF
(1) Raised JVP
(2) Pitting peripheral oedema
(3) Tender smooth hepatomegaly
(4) Ascites
(5) Transudative pleural effusions (typically bilaterally)
When do surgical aortic valve replacements become available to people and used over TAVI?
aged 75 and over
