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Phase 3a GP > ILA Heart failure > Flashcards

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
Q

When would you consider a DNACPR for a pt with heart failure?

A

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
Q

Name 5 steps for primary prevention of heart failure

A
  • 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
Q

Define primary prevention

A

Steps taken to prevent the onset of disease

28
Q

Define secondary prevention

A

Steps taken to prevent an event from happening again, including early diagnosis and treatment

29
Q

Define tertiary prevention

A

Steps taken to reduce long-term complications of disease and improve life expectancy

30
Q

List approaches to secondary prevention in heart failure

A

Continue to monitor for risk factors eg hypertension, diabetes, high cholesterol
Medications post MI - aspirin, clopidogrel, statins

31
Q

List approaches to tertiary prevention in heart failure

A

Cardiac rehabilitation
Regular visits from specialist heart failure nurse
Revascualrisation eg CABG
Pacemaker

32
Q

What are the indications of statins?

A

primary and secondary prevention of CVD

Primary hyperlipidaemia

33
Q

Give examples of statins

A

atorvastatin

simvastatin

34
Q

What is the mechanism of action of statins?

A

Inhibit 3-hydroxyl-3-methyl-glutaryl coenzyme A (HMG CoA reductase) which is involved in cholesterol production

35
Q

What are the side effects of statins?

A

muscle aches, rhabdomyolysis
Headache
GI disturbance

36
Q

What are the cautions and CI of statins?

A

hepatic/renal impairment

37
Q

What might interact with statins?

A

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
Q

How do you take statins?

A

In the evening when dietary intake is at its lowest

39
Q

What advice would you give to pts starting statins?

A

To seek medical attention if they get muscle symptoms eg pain or weakness

40
Q

What monitoring would you do for statins as primary prevention?

A
  • check lipids before treatment

- liver enzymes eg ALT at baseline, 3 and 12 months

41
Q

What monitoring would you do for statins as secondary prevention?

A
  • liver enzymes eg ALT at baseline, 3 and 12 months
42
Q

What result on liver enzymes would make you discontinue statins?

A

A rise in ALT more than 3 times normal

43
Q

List the drug classes used in heart failure

A 
ACEIs 
ARBs 
Beta blockers 
Digoxin 
Thiazide and loop diuretics 
Aldosterone antagonist - Spironolactone 
Hydralazine and nitrate
Sacubitril with valsartan 
Ivabradine
44
Q

What are the indications for loop diuretics?

A

acute pulmonary oedema
chronic heart failure
oedema in liver or renal disease

45
Q

Give examples of loop diuretics

A

Furosemide

Bumetanide

46
Q

Describe the mechanism of action of loop diuretics

A

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
Q

Side effects of loop diuretics

A

Dehydration
Hypotension
Electrolyte depletion
Hearing loss and tinnitus due to electrolyte imbalace

48
Q

What are the cautions and contraindications for loop diuretics?

A 
Hypovolaemia 
Dehydration 
Hypokalaemia 
Hyponatraemia 
Gout 
Hepatic encephalopathy
49
Q

What are the interactions of loop diuretics?

A

Drugs that are also excreted by the kidneys – increase lithium and digoxin levels
Can increase the ototoxicity and nephrotoxicity of aminoglycosides

50
Q

How should diuretics be taken?

A

In the morning and not at night as will cause nocturesis

Phase 3a GP (7 decks)

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