HF part 1 Flashcards

1
Q

Definition of HF / CF

A

An inability of the heart to deliver blood (and O2) at a rate proportionate with the requirements of the metabolising tissues, despite normal or increased cardiac filling pressures

Congestive cardiac failure describes a combination of left and right-sided ventricular failure.

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2
Q

Epidemiology of CF

A
  • M>F
  • More prevalent with increasing age
    Common: 2-10 (20) %
    Costly: 2% of the NHS expenditure in the UK
    Disabling: The worst quality of life.
    Treatable - not really curable
    25-50% of patients die within 5 years of diagnosis
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3
Q

RFs

A
  • Prev MI - greatest RF
  • Male, age
  • IHD
  • HT
  • DIabetes
  • Renal failure
  • AF
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4
Q

Causes of HF

A
  • Myocardial dysfunction - greatest cause
  • HT
  • Alcohol
  • Cardiomyopathy
  • valvular
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5
Q

What is HFrEF?

A

HF with reduced ejection fraction

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6
Q

What is HFpEF?

A

HF with preserved ejection fraction

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7
Q

Phenotypes of HF

A

HF due to severe valvular heart disease (HF-VHD)
HF with pulmonary hypertension (HF-PH)
HF due to right ventricular systolic dysfunction (HF- RVSD)

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8
Q

Classes of HF (NYHA)?
Used for assessment of severity of symptoms

A

Class I: No limitation (Asymptomatic)
Class II: Slight limitation (mild HF)
Class III: Marked limitation (Symptomatically moderate HF)
Class IV: Inability to carry out any physical activity without discomfort (symptomatically severe HF)

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9
Q

What is systolic HF

A

Inability of the ventricle to contract normally resulting in a
decrease in cardiac output

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10
Q

Systolic HF

A
  • Cardiac output = stroke volume x heart rate
  • The ejection fraction is not preserved: an ejection fraction of 40% or less would indicate systolic heart failure.
  • The low stroke volume is due to the ventricles not pumping enough blood out.
  • HFrEF
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11
Q

Diastolic HF

A
  • Cardiac output = stroke volume x heart rate
  • In this case, the stroke volume is low but the ejection fraction is preserved. The reason for the low stroke volume is due to reduced filling of the ventricle (reduced preload)
  • HFpEF
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12
Q

Why does right sided HF occur?

A
  • usually occurs as a result of left-sided heart failure.
  • Blood starts backing up into the lungs causing pulmonary oedema and congestion
  • pulmonary hypertension puts pressure on the right ventricle (cor pulmonale) and causes right-sided heart failure
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13
Q

Causes of systolic failure 1

A
  • Ischaemic heart disease: as less blood and oxygen get to the myocardium, the myocytes start to die
  • Hypertension: as arterial pressure increases in the systemic circulation, it gets harder for the left ventricle to pump blood out into that hypertensive systemic circulation.
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14
Q

Causes of Systolic failure 2

A
  • Left ventricular hypertrophy: increased muscle mass requires increased oxygen supply - making it more likely for that the muscle will die
  • Dilated cardiomyopathy: heart chambers dilate and thin out, leading to weaker contractions.
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15
Q

Causes of diastolic failure

A
  • Left ventricular hypertrophy: causes the ventricular chamber to decrease in size which means less blood can enter.
  • Restrictive cardiomyopathy: ventricle can’t stretch enough to accommodate the blood
  • Valvular disease: e.g. aortic stenosis causes LVH or mitral regurgitation means blood doesn’t enter the ventricles in the right amount as it leaks back into atria
  • Arrhythmias e.g. atrial fibrillation
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16
Q

Normal heart mechanism

A

Increased ventricular filling results in increased contraction via the Frank-Starling law→ increased cardiac output

In HF mechanism fails

17
Q

Pathophysiology of Congestive HF

A
  • As the heart continues to fail →compensatory mechanismsare activated, including anincrease in heart rate,catecholamine releaseandRAAS activation (due to decreased blood flow to kidneys)
  • These mechanisms are useful in theinitialperiod but are usuallyoverexpressed, thus instigating avicious cycle.
  • Compensatory mechanisms are usually responsible for the fluid retention and fluid overload symptoms experienced by the patient
18
Q

Signs of Left sided Heart failure

A
  • Tachypnoea and tachycardia
  • Cool peripheries
  • Peripheral or central cyanosis
  • Displaced apex beat
  • Stony dull percussion
  • Third heart sound (S3)
19
Q

Symptoms of Left sided HF

A
  • Dyspnoea: particularly exertional
  • Orthopnoea (SOB when lying flat) and paroxysmal nocturnal dyspnoea (SOB at night)
  • Fatigue and weakness
  • Cough with pink, frothy sputum
  • Cardiogenic wheeze
20
Q

Right sided HF signs

A
  • Due to backing up of fluid:
    • Raised JVP
    • Peripheral pitting oedema
    • Hepatosplenomegaly
    • Ascites
21
Q

Symptoms of Right sided HF

A
  • Fatigue and weakness
  • Due to backing up of fluid
    • Swelling in the legs
    • Distended abdomen
22
Q

Investigations

A
  • NT-proBNP: increased in chronic heart failure
  • ECG:broad QRS complexes; evidence of left ventricular hypertrophy
  • CXR
  • Transthoracic echocardiogram
23
Q

What is shown on an Chest X ray?

A
  • A-Alveolar oedema (batwing opacities)
  • B- KerleyBlines
  • C-Cardiomegaly
  • D-Dilated upper lobe vessels
  • E- Pleural effusion
24
Q

1st line management

A

BB (Bisoprolol) + ACEi (Ramipril)
If ACEi intolerant - ARB (Losartan) or hyrdalazine with nitrate

25
Q

2nd line management

A

Aldosterone antagonist (e.g. spironolactone) if symptoms not controlled with 1st line management

26
Q

3rd line management

A
  • Digoxin: an alternative option, particularly for patients with AFand heart failure due to its inotropic effects.
  • Ivabradine: an alternative option ifHR >75 bpmandLVEF <35%; slows the heart rate so the heart can pump more blood through the body each time it beats.
  • Cardiac resynchronisation therapy(CRT): involves biventricular pacing and forces both ventricles to contract in synchrony, thereby improving cardiac output
27
Q

Complications of HF

A
  • Pleural effusion:heart failure causes an elevated pulmonary capillary pressure, usually resulting in bilateral transudative pleural effusions
  • Acute decompensation of chronic heart failure:patients usually present with acute respiratory distress due to significant pulmonary oedema
  • Arrhythmias
  • Acute renal failure:reduced cardiac output and drug overuse (ACE inhibitors, aldosterone antagonists, diuretics) results in poor renal perfusion