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ILA Heart failure Flashcards

1
Q

Define heart failure

A

the inability of the heart to deliver blood and oxygen at a rate equivalent to the requirements of the metabolising tissues despite normal or increased cardiac filling pressures

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2
Q

What are the two types of heart failure?

A

HFREF - ejection fraction <40% (left ventricular systolic dysfunction)
HFPEF - ejection fraction >50% (diastolic heart failure)

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3
Q

Explain the pathophysiology of HFREF

A
  • Less blood is ejected from the ventricle so more blood remains
  • Starling’s law states there is a point of decompensation where CO decreases with increased diastolic volume
  • Heart tries to compensate by increasing HR and venous pressure, which leads to pulmonary congestion, hepatic enlargement and ascites
  • Reduced CO causes reduced perfusion of tissues
  • Higher left ventricular pressure due to lV failure leads to pulmonary congestion and fluid retention in the lungs

The 3 core pathways driving heart failure:

  1. Sympathetic nervous system
    - a failing ventricle activates the symp system by baroreceptors and this increases vascular resistance and worsens heart failure
  2. Renin-angiotensin-aldoesterone system
    - reduced renal perfusion activates the RAAS and causes Na+ and water retention
  3. Inflammation
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4
Q

What is BNP and where is it released from and why?

A

Brain Natriuretic Peptide
Produced from the stretched ventricles
Causes natriuresis

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5
Q

List 5 causes of heart failure

A
  1. ischaemic heart disease
  2. hypertension
  3. cardiomyopathy
  4. valvular disease
  5. arrythmias

Hypothyroidism/hyperthyroidism, sepsis and alcohol excess are to non-cardiac causes

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6
Q

What are the symptoms and signs of LEFT heart failure?

A

Breathlessness - on exertion, orthopnoea, PND
Bibasal crepitations and dullness to percussion at lung bases
Pulmonary oedema - pink frothy sputum
third heart sound/gallop

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7
Q

What are the symptoms and signs of RIGHT heart failure?

A

Peripheral oedema
raised JVP
Hepatomegaly
Ascites

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8
Q

What are the signs of heart failure on CXR?

A 
ABCDE
Alveolar oedema (batwing oedema) 
Kerly B lines 
Cardiomegaly 
Upper lobe venous dilation 
Pleural effusions
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9
Q

What aspects of physical examination would be done in heart failure?

A

o Cardiac exam - peripheral stigmata, auscultation of heart and carotid vessels for murmurs and bruit, auscultation of lung bases, pulse, feel for oedema peripherally
o Resp exam - auscultation of the lungs
o Abdo exam - hepatomegaly, ascites

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10
Q

Name a commonly used staging system for heart failure

A

New York Heart Association classification - NYHA

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11
Q

What are the functional categories of the NYHA?

A

Class I - no limitation of physical activity (asymptomatic)
Class II - slight limitation (mild HF) - comfortable at rest, exertion causes symptoms
Class III - marked limitation (Moderate HF) - less than ordinary activity causes symptoms
Class IV - inability to carry out any physical activity without discomfort (severe HF) - symptoms at rest

Symptoms limiting are: Fatigue, palpitations and dyspnoea

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12
Q

What are the objective categories of the NYHA?

A

Stage A - No objective evidence of cardiovascular disease.
Stage B - objective evidence of minimal cardiovascular disease.
Stage C - Objective evidence of moderately severe cardiovascular disease.
Stage D Objective evidence of severe cardiovascular disease.

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13
Q

What investigations would you do for heart failure?

A 
Bloods
o pro-BNP (the inactive component of BNP)
o FBC
o U+E
o LFT
o TFT (hypothyroidism and hyperthyroidism can cause heart failure)
o lipids
o HbA1c

ECG - ischaemia and arrythmia

Echo - chamber size, wall abnormalities, valvular problems, cardiomyopathy, ejection fraction calculation

Myocardial perfusion scan - ischaemia

CXR

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14
Q

What are the steps of managing heart failure? Is this for HFREF or HFPEF?

A
  1. risk factor reduction - including treat hypertension, dyslipidaemia, diabtes - diet, smoking, alcohol, exercise, statins, metformin
  2. ACEI or ARB
  3. beta blocker
  4. diuretic and digoxin
  5. cardiac resynchronisation if there is BBB - ie pacemaker
  6. revascularisation
  7. aldosterone antagonists eg spironolactone
  8. left ventricular assist device or heart transplant
  9. hospice

It is for HFREF

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15
Q

What are the treatment options for HFPEF?

A

Diuretics and then review - not many treatment options

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16
Q

What is the key prognostic indicator for heart failure?

A

Severity of symptoms and signs NOT ejection fraction

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17
Q

When someone presents with acute heart failure, how would you initially manage them?

A

Diuretics
Nitrates
Oxygen
Opiates

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18
Q

What is a hibernating myocardium?

A

A region of impaired cardiac contractility due to low coronary flow - revascularisation improves this

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19
Q

What are the complications of heart failure - ie what might cause an acute decompensation in heart failure?

A
  • AF
  • renal failure
  • Liver failure
  • DVT and PE
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20
Q

What might precipitate an acute decompensation of heart failure?

A
  • hypertension - flash pulmonary oedema
  • AF
  • infection
  • hyperthyroidism
  • excess alcohol
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21
Q

In general, not specifically left or right, what are the symptoms of heart failure?

A
  • SOB on exertion, lying flat, middle of the night
  • Fatigue
  • Ankle swelling
  • Pink frothy sputum
  • Lightheadedness, syncope
22
Q

In general, not specifically left or right, what are the signs of heart failure?

A
  • Tachycardia
  • Tachypnoea
  • Pleural effusion
  • Raised JVP
  • Displaced apex beat
  • Peripheral oedema
  • Pulmonary crackles
  • Hepatomegaly, pulsatile in tricuspid regurgitation
  • Third heart sound or gallop
23
Q

What are the other causes of a raised pro-BNP other than heart failure?

A

diabetes

renal impairment

24
Q

Other than medication, what are the other services available to hep patients with heart failure?

A

Specialist heart failure nurses

  • based in the community or in the hospital seeing in-patients
  • provide info and advice on heart failure and self-care
  • can take bloods at home and modify treatment

Cardiac rehabilitation - can be at home, in the community or in the hospital

Psychological support and peer support groups

Flu and pneumococcal vaccine

25
When would you consider a DNACPR for a pt with heart failure?
if symptoms are worsening despite optimum medical treatment | if it is felt that CPR is unlikely to be successful or is not appropriate due to the clinical outcomes
26
Name 5 steps for primary prevention of heart failure
- stop smoking - diet - reduce salt, increase fruit and veg, oily fish - reduce alcohol - lose weight - exercise - treat hypertension, diabetes, hypercholesterolaemia with antihypertensives and statins
27
Define primary prevention
Steps taken to prevent the onset of disease
28
Define secondary prevention
Steps taken to prevent an event from happening again, including early diagnosis and treatment
29
Define tertiary prevention
Steps taken to reduce long-term complications of disease and improve life expectancy
30
List approaches to secondary prevention in heart failure
Continue to monitor for risk factors eg hypertension, diabetes, high cholesterol Medications post MI - aspirin, clopidogrel, statins
31
List approaches to tertiary prevention in heart failure
Cardiac rehabilitation Regular visits from specialist heart failure nurse Revascualrisation eg CABG Pacemaker
32
What are the indications of statins?
primary and secondary prevention of CVD | Primary hyperlipidaemia
33
Give examples of statins
atorvastatin | simvastatin
34
What is the mechanism of action of statins?
Inhibit 3-hydroxyl-3-methyl-glutaryl coenzyme A (HMG CoA reductase) which is involved in cholesterol production
35
What are the side effects of statins?
muscle aches, rhabdomyolysis Headache GI disturbance
36
What are the cautions and CI of statins?
hepatic/renal impairment
37
What might interact with statins?
CYP450 inhibitors – amiodarone, macrolides, grapefruit juice etc Think of it as cholesterol is made in the liver so other drugs that act on the liver will cause problems
38
How do you take statins?
In the evening when dietary intake is at its lowest
39
What advice would you give to pts starting statins?
To seek medical attention if they get muscle symptoms eg pain or weakness
40
What monitoring would you do for statins as primary prevention?
- check lipids before treatment | - liver enzymes eg ALT at baseline, 3 and 12 months
41
What monitoring would you do for statins as secondary prevention?
- liver enzymes eg ALT at baseline, 3 and 12 months
42
What result on liver enzymes would make you discontinue statins?
A rise in ALT more than 3 times normal
43
List the drug classes used in heart failure
``` ACEIs ARBs Beta blockers Digoxin Thiazide and loop diuretics Aldosterone antagonist - Spironolactone Hydralazine and nitrate Sacubitril with valsartan Ivabradine ```
44
What are the indications for loop diuretics?
acute pulmonary oedema chronic heart failure oedema in liver or renal disease
45
Give examples of loop diuretics
Furosemide | Bumetanide
46
Describe the mechanism of action of loop diuretics
Act on the Loop of Henle Inhibit Na+/K+/2Cl- cotransporter, so reduces the reabsorption of these ions Venodilator - reduces preload in heart failure
47
Side effects of loop diuretics
Dehydration Hypotension Electrolyte depletion Hearing loss and tinnitus due to electrolyte imbalace
48
What are the cautions and contraindications for loop diuretics?
``` Hypovolaemia Dehydration Hypokalaemia Hyponatraemia Gout Hepatic encephalopathy ```
49
What are the interactions of loop diuretics?
Drugs that are also excreted by the kidneys – increase lithium and digoxin levels Can increase the ototoxicity and nephrotoxicity of aminoglycosides
50
How should diuretics be taken?
In the morning and not at night as will cause nocturesis

Phase 3a GP (7 decks)

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