HF, pericarditis, cardiomyopathy (Cardiac SOB) Flashcards
Cardiac SOB
What is heart failure?
Failure for the heart to maintain the cardiac output required to meet the body’s metabolic demands
How do you calculate cardiac output?
Heart rate x stroke volume
What are the categories of causes for a left-sided heart failure?
Valvular
Muscular
Systemic
What are the risk factors for a right-sided heart failure?
Lungs
Pulmonary hypertension (cor pulmonale)
Pulmonary embolism
Chronic lung disease e.g. interstitial lung disease, cystic fibrosis
Valvular
Tricuspid regurgitation
Pulmonary valve disease
CONGESTIVE: LHF –> CHF
What is cor pulmonale?
Enlargement and failure of RV
Secondary to vascular resistance (pulmonic stenosis)
OR pulmonary HTN
What is a high-output heart failure?
Higher than normal cardiac output due to increased peripheral demand
What are the causes of a high-output heart failure?
NAPMEALS Nutritional (B1- thiamine) Anaemia Pregnancy Malignancy (multiple myeloma) Endocrine (hyperthyroidism) AV malformations Liver cirrhosis Sepsis
What are the risk factors for heart failure?
Older men PMHx/FHx of heart disease Diabetes Dyslipidaemia Drug abuse
What is the epidemiology of heart failure?
10% of >65yrs
1-3% of general population
What are the common symptoms of LHF?
CAUSED BY FLUID ACCUMULATING IN LUNGS: Dyspnoea: Paroxysmal nocturnal dyspnoea (PND) Exertional dyspnoea Orthopnoea
Nocturnal cough (+/- pink frothy sputum) Fatigue
What are the common signs of LHF?
HEART SIGNS- OF CAUSE Raised HR and RR AF Displaced apex beat S3 gallop S4 (severe HF) Murmur (AS, MR, AR)
LUNG SIGNS- OF CONSEQUENCE
Fine, end-expiratory bi-basal crackles (pulmonary oedema)
Wheeze (cardiac asthma)
What are the common symptoms of RHF?
CAUSED BY FLUID ACCUMULATING IN PERIPHERIES: Fatigue Weight gain (due to oedema) Reduced exercise tolerance Anorexia Nausea NOCTURIA- quite specific
These are non-specific so we rely more on signs
What are the common signs of RHF?
Face: face swelling Neck: ↑ JVP Heart/Chest: TR murmur, ↑ HR, ↑ RR, parasternal heave Abdomen: ascites, hepatomegaly Other: ankle and sacral pitting oedema
What investigations would you do for HF?
Bedside:
- ECG
Bloods:
- FBC/U+E/LFT/TFT/glucose
- Brain natriuretic peptide (BNP)- KEY SIGN
Imaging:
- TTE with doppler = DIAGNOSTIC
- CXR- pulmonary oedema (A-E)
Why would you do and FBC for HF?
Anaemia is a cause of HF
Why would you do LFTs for HF?
To rule out other causes of abdominal congestion
Why would you measure glucose for HF?
To assess for diabetes
Why would you do TFTs for HF?
To assess for hypo/hyperthyroidism
Why would you measure the BNP for HF?
If it is not elevated, you can rule out HF
How do you calculate the ejection fraction?
Stroke volume/end diastolic volume
What is a normal ejection fraction?
50-70%
What is the ejection fraction of systolic HF/HF with reduced ejection fraction (HFrEF) and why?
<40%
Indicates inability of the ventricle to contract normally
–> decreased stroke volume
What is the ejection fraction of diastolic HF/ HF with preserved ejection fraction and why?
> 50%
Indicates inability of the ventricle to relax and fill normally
There is also an abnormal diastolic function hence the ratio may appear normal
What are the findings of HF seen on an X-ray?
Hint: ABCDE
Alveolar oedema B-lines (Kerley) Cardiomegaly Dilated upper lobe vessels + Diverted upper lobe Effusion (plural [in late stage])
What is the conservative management for chronic HF?
Smoking cessation Weight loss (exercise) Dietary changes (reduce salt and fat)
What are the main medical management options for chronic HF?
ACE inhibitors (enalapril, ramipril)- treats hypertension + prevents it from worsening
Beta blockers (bisoprolol, carvedilol)- reduce oxygen demand on heart
Diuretics - if evidence of fluid retention (Loop = furosemide, aldosterone antagonists = spironolactone)
What are the alternate medical management options for chronic HF?
Hydralazine and nitrates (for Afro-Caribbeans)
Digoxin (improves inotropy, improve symptoms not survival)
Cardiac resync therapy
Aspirin
What is the management for acute HF? (DMONS)
A-E protocol:
- Sit the Pt up
- O2 sats to 94-98%
- IV diamorphine 2.5-5mg
- GTN infusion/sublingual
- IV furosemide 40-80mg
DMONS
What are the complications for HF?
Respiratory failure- pleural effusion
Renal failure - due to hypoperfusion
Acute exacerbations
Death
What is the prognosis for severe HF?
Very poor, worse than most malignancies
50% mortality within 2 years
Acute HF in-hospital mortality = 2-20%
A 78-year-old woman is admitted with heart failure. The underlying cause is determined to be aortic stenosis. What will you hear in the lungs?
Bi-basal crepitations
A 60-year-old man presents to his GP with gradually increasing fatigue and some exertional dyspnoea. Blood pressure is 118/74mmHg and pulse rate is 81/minute. There are no abnormal physical findings and on echocardiography the ejection fraction is 0.47. However, the clinical impression remains one of early heart failure. Which biomarker would lend support to that conclusion?
Brain natriuretic peptide
A 55-year-old male presents with increasing exertional dyspnoea, fatigue, weight loss and bone pain. Blood results reveal elevated calcium levels and normocytic anaemia. He is treated for heart failure. What is the underlying cause for his heart failure?
Multiple myeloma
What are the signs of a multiple myeloma?
CRAB C- hypercalcaemia R- renal failure A- anaemia B- bony lesions
A 74 year old male with a 30 pack year smoking history is admitted to AMU. He has had 2 myocardial infarctions in the last 5 years. On examination he is producing frothy pink sputum, he has bilateral pitting oedema, bibasal crackles and oxygen saturations of 89%. Which of the following is most likely to be identified by auscultating the chest?
A. Third heart sound
B. Carotid bruit
C. Pericardial rub
D. Fourth heart sound
A. Third heart sound
B. presents in carotid stenosis
C. presents in pericarditis
D. can occur but only after a third HS
A 74 year old man presents to AMU with a history of fatigue and breathlessness. On examination, he has an oedematous ankles, a raised JVP, and finger clubbing. When you ask about work, he says he used to work as a ship builder. He is diagnosed with acute heart failure. What is the most likely cause of his heart failure?
A. Smoking B. Rheumatic heart disease C. Interstitial lung disease D. Aortic stenosis E. Aortic regurgitation
C. Interstitial lung disease
A. never mentioned
B. no other features
D. lack of end-systolic murmur
E. lack of diastolic murmur
A 85 year old woman is seen in heart failure clinic for a review of her long term condition. She is currently taking enalapril and bisoprolol. Which other drug can be added to help control her symptoms?
A. Spironolactone B. Amlodipine C. Salbutamol D. Morphine E. Omeprazole
A. Spironolactone
B. CCB used for HTN
C. B-agonist would worsen symptoms
D. analgesic is used for acute management
E. PPI used for GORD
Regarding the management of acute HF, which statement is not true?
A. The patient should be given a diuretic, such as IV frusemide.
B. High-oxygen is not always recommended
C. Opiate analgesia is always recommended
D. A vasodilator, such as nitrates, can be given
E. An ECG may not show an arrythmia
C. Opiate analgesia is always recommended
A. manages oedema
B. O2 may already be adequate
D. 2 puffs sub-lingual
E. 10% have normal ECGs
Which of these x-ray findings is most likely to be seen on a Chest X-ray of a patient with heart failure?
A. Cardiothoracic ratio <50% B. Blunting of the costophrenic angles C. Air bronchograms D. Dilated lower lobe vessels E. Cannon-ball opacities
B. Blunting of the costophrenic angles
You are at Calais and you see a 10 year old boy who is acutely breathless, fatigued and feels nauseous. His mother tells you he has had several episodes of fevers, elbow pains and difficulty walking for the past 2 years, and has developed a rash. On examination, he has an ejection systolic murmur. He is treated for heart failure. What is the most likely underlying cause of his heart failure?
A. Cor pulmonale B. Cystic fibrosis C. Familial cardiomyopathy D. Rheumatic heart disease E. Congenital heart disease
D. Rheumatic heart disease
A. RHF
B. no other features of CF
C. no mention of FHx
E. no mention of DDx
Causes of SOB
- not enough oxygen in lungs
- not enough oxygen getting into blood (V/Q mismatch- pulmonary)
- not enough oxygen reaching rest of body (cardiac)
Define chronic HF
Long term condition where heart fails to maintain adequate circulation for body’s metabolic requirements
Define acute HF
Rapid onset symptoms of HF, requiring urgent management
caused by ACS or decompensation of CHF
Define congestive cardiac failure
LHF + RHF
will start with LHF, pressure backs into pulmonary circulation + into right heart causing failure.
Classify HF by cardiac output
Low Output State: Heart fails to pump in response to normal exertion -> low CO
High Output State: CO is normal but higher metabolic needs
In general, how do symptoms of LHF and RHF differ in terms of pathogenesis?
Left heart receives blood from pulmonary circulation -> fluid congesting backwards causes pulmonary oedema and SOB
Right heart receives blood from systemic circulation -> fluid congesting backwards causes peripheral swelling and oedema
JB is a 34-year-old male, with a history of infective endocarditis, complaining that he’s tired all the time and struggles to run as far as he used to. He also says that his ankles and face feel more swollen than before.
On examination, he has a raised JVP, breathing rate and heart rate. You also hear a pansystolic murmur on auscultation.
What is the most likely diagnosis?
A. Left heart failure secondary to mitral regurgitation B. Left heart failure secondary to cocaine abuse C. Right heart failure secondary to tricuspid regurgitation D. Myocardial infarction E. High output heart failure
Right heart failure secondary to tricuspid regurgitation
A. Left heart failure secondary to mitral regurgitation
No breathlessness symptoms – LHF unlikely
B. Left heart failure secondary to cocaine abuse No breathlessness symptoms – LHF unlikely C. Right heart failure secondary to tricuspid regurgitation Signs of RHF, pansystolic murmur, infective endocarditis D. Myocardial infarction This would present more acutely with crushing chest pain E. High output heart failure No mentioned condition like anaemia or hyperthyroidism
cover the efficacy of BNP as a diagnostic tool for HF
release when heart muscle stretches
Sensitive but not specific- elevated by other heart conditions
If BNP is low, HF is unlikely but if BNP is high, still need to do a TTE to confirm the heart failure.
Gold standard test for HF?
Transthoracic echocardiogram (TTE) coupled with doppler = DIAGNOSTIC
2 functions of TTE
- Visualise the structure and function of the heart -> may show the cause of HF
- Can calculate ejection fraction (EF): % of the blood present in the LV that gets pumped during systole – normal = 50-70%
Define cardiomyopathy
A group of diseases in which the myocardium becomes structurally and functionally abnormal
In the absence of coronary artery disease, valvular disease and congenital heart disease
It can affect young people
How is cardiomyopathy classified?
Dilated – ventricle dilated, thin walls, reduced ventricular pressure
Hypertrophic – muscle hypertrophies inwards, more rigid, obstruction
Restrictive – same amount of muscle but rigid and doesn’t pump as well as normal
Symptoms/history of cardiomyopathy
Symptoms of HF: SOB on exertion Fainting Fatigue Sudden death often 1st presentation Family history
What are the signs of cardiomyopathy?
Signs of HF:
Respiratory crackles
Murmurs
S3, S4
Investigations for cardiomyopathy
No single diagnostic test for all types
ECHO
Can also do bloods, BNP, CXR, ECG, cardiac catheterisation, stress test
Pathophysiology of dilated cardiomyopathy
Ventricles enlarge and become dilated.
Walls thin and weaken -> can’t contract effectively.
Think of the Law of Laplace: increased radius leads to reduced ventricular pressure
RF for dilated cardiomyopathy
Alcohol, post-viral, haemochromatosis, genetic
Presentation of dilated cardiomyopathy
Signs and symptoms of HF
KEY FEATURE: Displaced apex beat
TR/MR murmur, S3
Ix for dilated cardiomyopathy
Globular heart on CXR, dilated ventricle on Echo
aetiology of hypertrophic cardiomyopathy
50% = familial (autosomal dominant)
3 ways in which hypertrophic cardiomyopathy can cause impaired function
- Increased stiffness of the muscle affects pumping.
- Thickened muscle disrupts electrical conduction and causes arrythmia.
- Hypertrophic Obstructive Cardiomyopathy (HOCM) = thickened ventricle obstructs the outflow of blood
Symptoms of hypertrophic cardiomyopathy
Usually asymptomatic
Sudden cardiac death is often the 1st presentation
Angina, dyspnoea on exertion, palpitations, syncope
Signs of hypertrophic cardiomyopathy
Ejection systolic murmur- obstruction ventricular outflow by muscle
Jerky carotid pulse
Double apex beat but NOT DISPLACED- muscle growing inwards not outwards
S4
What investigations would you do for hypertrophic cardiomyopathy? What would you see
ECG: Q waves, left axis deviation, signs of left ventricular hypertrophy
Echo: ventricular hypertrophy (asymmetrical septal hypertrophy
Explain the pathophysiology/features of restrictive cardiomyopathy
ventricles become abnormally rigid and lose flexibility.
Impaired ventricular filling during diastole.
Reduced preload –> reduced blood flow + backing up of blood.
Causes of restrictive cardiomyopathy
Sarcoidosis, amyloidosis, haemochromatosis (the infiltrative ”osis” diseases)
Familial
Idiopathic
Rarer than dilated or hypertrophic cardiomyopathy
Symptoms of restrictive cardiomyopathy
Asymptomatic or HF symptoms
Signs of restrictive cardiomyopathy
Face: face swelling Neck: ↑ JVP Heart/Chest: TR murmur, ↑ HR, ↑ RR Abdomen: ascites, hepatomegaly Other: ankle and sacral pitting oedema Kussmaul’s sign = paradoxical rise in JVP during inspiration
Define constrictive pericarditis
Chronic inflammation of the pericardium (outer sac) with thickening and scarring
Very similar to restrictive cardiomyopathy- just affects different layers o the heart
causes of constrictive pericarditis
Idiopathic
Infectious (TB, bacterial, viral)
Acute pericarditis
Cardiac surgery and radiation
signs and symptoms of constrictive cardiomyopathy
RHF presentation (raised JVP, oedema) Kussmaul’s sign
What investigations would you do for restrictive pericarditis and what would they show?
- CXR: pericardial calcification
- Echo: increased pericardial thickness – differentiate from restrictive cardiomyopathy
- Cardiac CT/MRI
What investigations would you do for constrictive pericarditis and what would they show?
- CXR: pericardial calcification (not specific)
- Echo: increased pericardial thickness – differentiate from restrictive cardiomyopathy
- Cardiac CT/MRI
restrictive cardiomyopathy vs constrictive pericarditis mangement
constrictive pericarditis can be cured with pericardectomy however cardiomyopathy cannot be cured
define myocarditis
Inflammation of the myocardium
- Inflammatory cardiomyopathy
Causes of myocarditis
Infectious- Coxsackie B virus is the most common cause of myocarditis in Europe. Can progress to cardiomyopathy
Drugs - cocaine
Metals
Radiation
Signs and symptoms of myocarditis
Flu-like prodrome
Chest pain (worse when lying down)
SOB
Palpitations
Investigations for myocarditis
ECG: non-specific ST and T wave changes
Cardiac biomarkers: CK and troponin elevated- different to constrictive pericarditis where it is normal
Endomyocardial biopsy: diagnostic but not routinely performed unless refractive to treatment
Aston was a 33-year-old male who suddenly collapsed on stage. Although the doctors attempted “love CPR”, the patient died, and the post-mortem revealed a hypertrophic heart.
What was the most likely cause of death?
A. Obstructed flow of blood from the heart
B. Arrhythmia
C. Reduced pumping of blood due to stiff myocardium
D. Stroke
E. Sub-arachnoid haemorrhage
arrhythmia
Even though HOCM can occur- would be warning symptoms eg SOB
normally people die due to arrhythmia due to impaired conduction through thickened muscle
presents with breathlessness and he says that he experienced a fever recently. His CK and troponin are elevated, so a presumptive diagnosis of myocarditis is made.
What other signs or symptoms would be consistent with this diagnosis?
A. Kussmaul’s sign
B. Ankle oedema
C. Ascites
D. Jaundice
E. Chest pain
chest pain
Marvin presents with a 4-month history of increasing breathlessness and ankle swelling. On examination, he has ascites and Kussmaul’s sign is elicited.
What would be the most useful diagnostic investigation?
A. Echocardiography B. ECG C. Endomyocardial biopsy D. Abdominal X-ray E. CK
A. Echocardiography
Allows differentiation between restrictive cardiomyopathy and constrictive pericarditis
B. ECG
Non-specific signs – not the most useful
C. Endomyocardial biopsy Pericardial biopsy might be useful – but highly invasive
D. Abdominal X-ray
Chest X-ray would be useful to look for pericardial calcifications, but these are not specific to constrictive pericarditis
E. CK
May be mildly elevated in both constrictive pericarditis and restrictive cardiomyopathy – not that helpful
JB is a 34-year-old male, with a history of infective endocarditis, complaining that he’s tired all the time and struggles to run as far as he used to. He also says that his ankles and face feel more swollen than before.
On examination, he has a raised JVP, breathing rate and heart rate. You also hear a pansystolic murmur on auscultation.
What is the most likely diagnosis?
A. Left heart failure secondary to mitral regurgitation
B. Left heart failure secondary to cocaine abuse
C. Right heart failure secondary to tricuspid regurgitation
D. Myocardial infarction
E. High output heart failure
Right heart failure secondary to tricuspid regurgitation
Signs of RHF, pansystolic murmur, infective endocarditis
No breathlessness symptoms – LHF unlikely
No mentioned condition like anaemia or hyperthyroidism
2 causes of acute HF
One of two:
- ACS
- Decompensation of chronic HF
what is congestive HF?
RHF + LHF
LHF backs up pressure into pulmonary circulation and into right heart, leading to RHF
High output versus low output HF
HIGH OUTPUT: CO is normal but higher metabolic needs e.g. pregnancy, anaemia, hyperthyroidism
LOW OUTPUT: Heart fails to pump in response to normal exertion -> low CO
Valvular causes of LHF
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Muscular causes of LHF
Ischaemia (IHD)
Cardiomyopathy
Myocarditis
Arrhythmias (AF)
Systemic causes of LHF
Hypertension (high afterload)
Amyloidosis
Drugs (e.g. cocaine, chemo)
Causes of RHF
LUNGS
- Pulmonary hypertension (cor pulmonale)
- Pulmonary embolism
- Chronic lung disease e.g. interstitial lung disease, cystic fibrosis
VALVULAR
- Tricuspid regurgitation
- Pulmonary valve disease
LHF -> CHF
What are the RF for chronic high output cardiac failure? (NAP MEALS)
Nutritional (B1/thiamine deficiency) *Anaemia *Pregnancy Malignancy *Endocrine- hyperthyroidism increases BMR AV malformations Liver cirrhosis Sepsis
Only specific symptom of RHF
nocturia
How do clinical diagnoses of LHF and RHF differ?
LHF = relies on respiratory symptoms (SOB) RHF = relies on signs of systemic fluid overload (oedema)
How do clinical diagnoses of LHF and RHF differ?
LHF = relies on respiratory symptoms (SOB) RHF = relies on signs of peripheral fluid overload (oedema)
Questions to ask possible HF patients
Assess SOB- number of stairs , how long can walk without stopping
Assess orthopnoea: “Have you noticed anything making the SOB worse? What about lying down, standing up?”
Assess PND: ”Do you ever wake up at night gasping for air? How many pillows do you sleep with at night? Has this changed recently?”
2 uses of TTE with doppler in HF
- Visualise the structure and function of the heart -> may show the cause of HF
- Can calculate ejection fraction (EF): % of the blood present in the LV that gets pumped during systole – normal = 50-70%
What would you see on CXR in a patient with pulmonary oedema? (A-E)
Alveolar oedema B-lines (Kerley) Cardiomegaly Dilated upper lobe vessels + Diverted upper lobe Effusion (Transudative pleural effusion)
State the criteria used to diagnose HF clinically
Framingham Criteria
2+ majors OR 1 major and 2 minors
Major Framingham criteria
Paroxysmal nocturnal dyspnoea Bibasal crepitations S3 gallop Cardiomegaly Increased central venous Pressure Weight loss Neck vein distension Acute pulmonary oedema Hepatojugular reflux
Minor Framingham criteria
bilateral ankle oedema dyspnoea on ordinary exertion tachycardia decrease in vital capacity by 1/3 nocturnal cough hepatomegaly pleural effusion
What is the general structure of management of chronic HF?
Chronic heart failure can’t really be “cured” without a heart transplant – goal of treatment is prolonging life and alleviating symptoms
- treat cause
- treat exacerbating factors
- lifestyle modifications
- Drugs ABD - ACE inhibitors, beta-blockers, diuretics
Name an ACE inhibitor and alternative if not tolerated
Rampiril (give to all patients with LV dysfunction)
Losartan = ARB if ACEi cause cough
Role of BB in chronic HF (give 2 examples)
reduce O2 demand on the heart
Bisoprolol, carvedilol
2 types of diuretic used in chronic HF
Use if evidence of fluid retention
- Loop diuretics e.g. furosemide
- Aldosterone antagonists e.g. spironolactone
What drugs may be considered in afro-carribean patients with chronic HF?
Hydralazine + nitrates
Name a drug used in chronic HF that improve symptoms but not mortality
Digoxin
positive inotrope
What therapy may be available to help patients in chronic HF?
Cardiac resynchronization therapy – aims to improve timings of contraction of atria and ventricles
