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Y3 Medicine: Cardiovascular > HFrEF > Flashcards

HFrEF Flashcards

1
Q

What is heart failure (HF)?

A

Heart failure is a complex syndrome in which the ability of the heart to maintain the circulation of blood is impaired as a result of a structural or functional impairment of ventricular filling or ejection.

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2
Q

How does the ejection fraction (EF) differ in HFpEF and HFrEF?

A

There is no agreement on what level should be used to separate normal from abnormal left ventricular ejection fraction (LVEF). The definition of reduced ejection fraction varies in clinical trials between a LVEF of less than or equal to 35 to 40%.

  • Heart failure with reduced ejection fraction (HF-REF): just over half of people with heart failure have evidence of reduced LVEF on echocardiography
  • Heart failure with preserved ejection fraction (HF-PEF): nearly half of people with heart failure have preserved LVEF on echocardiography
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3
Q

How does acute and chronic HF differ?

A

Acute and chronic heart failure are terms used to define the rate of onset and duration of symptoms:

  • Acute heart failure may be a new presentation of heart failure or may be a deterioration or ‘decompensation’ in a person with existing chronic heart failure.
  • There is no agreed definition of the timescale of chronic heart failure although stable heart failure is a term used to describe a person with treated heart failure and symptoms which are unchanged for at least a month
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4
Q

Briefly describe the The New York Heart Association (NYHA) functional classification of heart failure based on severity of symptoms and limitation of physical activity

A

Class I- no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness, or palpitations.

Class II- slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class III- marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class IV- unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken discomfort is increased.

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5
Q

Briefly describe the pathophysiology of HFrEF

A

Inability for the ventricle to contract normally, resulting in reduced cardiac output. Ejection fraction is <40%.

Also known as systolic heart failure.

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6
Q

How do the symptoms of right and left HF differ?

A

Right sided HF: peripheral oedema (up to thighs, sacrum and abdominal wall), ascites, nausea, anorexia, facial engorgement and epistaxis.

Left sided HF: dyspnoea, poor exercise tolerance, fatigue, paroxysmal nocturnal dyspnoea (PND), nocturnal cough (+/- pink frothy sputum), wheeze, nocturia, cold extremities and weight loss.

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7
Q

What are the causes of HFrEF?

A
  • Ischemic heart disease
  • Myocardial infarction
  • Cariomyopathy
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8
Q

What risk factors are associated with HFrEF?

A
  • Female sex
  • >70 years
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9
Q

What are the signs of HFrEF?

A
  • Tachycardia
  • Respiratory signs such as tachypnoea, basal crepitations and pleural effusions
  • Jugular venous distension
  • Hypertension
  • Hepatojugular reflux
  • Congestive hepatomegaly
  • Lower extremity oedema
  • Laterally displaced apical impulse
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10
Q

What are the symptoms of HFrEF?

A
  • Exertional dyspnoea
  • Orthopnea
  • Paroxysmal nocturnal dyspnoea
  • Fatigue
  • Lightheadedness
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11
Q

What investigations should be ordered for HFrEF?

A
  • Serum electrolytes
  • Renal function tests
  • Brain-natriuretic peptide (BNP) or N-terminal prohormone brain natriuretic peptide (NT-pro-BNP)
  • FBC
  • ECG
  • CXR
  • Doppler echocardiography
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12
Q

Why investigate using serum elecrolytes? And what may this show?

A
  • Hypervolaemic hyponatraemia is common in severe heart failure due to expansion of extracellular volume
  • May also show hypokalaemia
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13
Q

Why investigate using renal function tests? And what may this show?

A
  • Renal failure may be the aetiology of fluid overload, or chronic kidney disease may be a risk factor leading to diastolic dysfunction
  • Increased creatinine, decreased estimated glomerular filtration rate
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14
Q

Why investigate using BNP or NT-pro-BNP? And what may this show?

A
  • BNP or NT-pro-BNP are raised in patients with heart failure, with concentrations rising in line with the severity of symptoms (New York Heart Association class). In patients presenting with dyspnoea, natriuretic peptide biomarkers should be measured to help diagnose or exclude heart failure.
  • Elevated
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15
Q

What factors can increase BNP?

A
  • Age over 70 years
  • Left ventricular hypertrophy, myocardial ischaemia or tachycardia
  • Right ventricular overload
  • Hypoxia.
  • Pulmonary hypertension
  • Pulmonary embolism
  • Chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73 m2)
  • Sepsis
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes mellitus
  • Liver cirrhosis
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16
Q

Why investigate using FBC? And what may this show?

A
  • Full blood count with iron levels (transferrin saturation) and ferritin is recommended. Anaemia can contribute to the patient’s symptoms.
  • Ferritin <100 ng/mL or 100-300 ng/mL if transferrin saturation is <20%
17
Q

Why investigate using ECG? And what may this show?

A
  • May reveal evidence of prior myocardial infarction, conduction defects, and arrhythmias common to HFrEF, such as atrial fibrillation. Increased QRS voltage may infer the presence of left ventricular hypertrophy; low QRS voltage can suggest infiltrative cardiomyopathy.
  • Left ventricular hypertrophy, atrial fibrillation and infiltrative cardiomyopathy
18
Q

Why investigate using CXR? And what may this show?

A
  • The finding of cardiomegaly is helpful in the diagnosis. Chest x-ray also helps evaluate for pulmonary causes of dyspnoea. In the presence of fluid overload, pulmonary oedema or pleural effusion is a typical finding.
  • Cardiomegaly, pulmonary oedema and pleural effusion
19
Q

Why investigate using Doppler echocardiography? And what may this show?

A
  • Investigation that may indicate the cause (e.g. MI or valvular heart disease)
  • Reduced LV systolic function (ejection fraction <40%)
20
Q

What features can be seen on a CXR of congestive heart failure?

A

A- alveolar oedema (bat wing opacities)

B- Kerley B lines

C- cardiomegaly

D- dilated upper lobe vessels

E- pleural effusion

21
Q

Briefly describe the treatment for patients with chronic HFrEF

A
  • Management of risk factors
  • Adjunct: diuretic
22
Q

Briefly describe diuretic treatment for chronic HFrEF

A

Prescribe a loop diuretic- up to 80 mg furosemide (or equivalent), if necessary, to relieve symptoms of fluid overload.

23
Q

Give examples of drugs that worsen HFrEF

A
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Calcium channel blockers (CCBs)
  • Antiarrhythmic drugs (except class III)
24
Q

What treatment is given to patients with chronic HFrEF and hypertension?

A

ACE inhibitors or angiotensin-II receptor antagonists are considered an important element of the treatment of HFpEF in patients with co-existing hypertension.

25
Q

What is the benefit to using beta-blockers in chronic HFrEF?

A

Beta-blockers may be added to ACE inhibitors or angiotensin-II receptor antagonists. Use in the chronic setting may cause regression of LV hypertrophy, reversal of adverse remodelling, and improved LV relaxation and distensibility. Also decrease mortality in HF.

26
Q

What are the complications of HFrEF?

A
  1. Sudden cardiac death
  2. Acute pulmonary oedema
27
Q

What differentials should be considered in HFrEF?

A
  1. Diastolic HF (HFpEF)
  2. Obstructive lung disease
  3. Idiopathic pulmonary arterial hypertension
28
Q

How does systolic (HFrEF) and diastolic (HFpEF) heart failure differ?

A
  • Differentiating signs and symptoms: no differentiating signs or symptoms
  • Differentiating investigations: cardiac imaging has a pivotal role in measuring the left ventricular ejection fraction
29
Q

How does HFrEF and obstructive lung disease differ?

A
  • Differentiating signs and symptoms:
    • Dyspnoea and orthopnoea may be present, but usually not paroxysmal nocturnal dyspnoea
    • Usual precipitants are allergens, environmental triggers, and respiratory infection
  • Differentiating investigations: pulmonary function testing will show an obstructive lung disease pattern, with or without improvement after using bronchodilators
30
Q

How does HFrEF and idiopathic pulmonary arterial hypertension differ?

A
  • Differentiating signs and symptoms: can present with heart failure symptoms. Blood pressure usually very elevated or history of high blood pressure. Right heart symptoms are peripheral oedema, hepatic congestion, and raised jugular venous pressure.
  • Differentiating investigations:
    • Pulmonary pressures may be indirectly measured by Doppler echocardiography. On echocardiography, left ventricular function is normal
    • The established standard for diagnosis of pulmonary hypertension is right heart catheterisation

Y3 Medicine: Cardiovascular (31 decks)

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