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MBBS IV - Junior Clerkship WCS > JC09 (Medicine) - Exertional Heart Failure > Flashcards

JC09 (Medicine) - Exertional Heart Failure Flashcards

1
Q

Define heart failure

A

HF:

Unable to pump blood at a rate to match requirement of metabolizing tissues

Due to forward failure (adequate filling pressure) or backward failure (congestion with high filling pressure to distend myocardium for higher CO)

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2
Q

S/S low cardiac output/ forward heart failure

A
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3
Q

S/S of right heart failure (backward HF)

A
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4
Q

S/S of left heart failure

A
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5
Q

Describe the Frank Starling Law

A
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6
Q

Mechanism of Orthopnea/ PND

A
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7
Q

Mechanism of pulmonary edema in left heart failure

A
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8
Q

Symptoms/ Signs of HF

  • Which ones are the most specific/ sensitive?
A
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9
Q

Name two criteria for Dx of heart failure

A

Framingham criteria

Boston criteria

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10
Q

Name one criteria for severity of LV dysfunction

A
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11
Q

CXR Lung features of left heart failure

A

Upper lobe diversion/ Cephalization - pulmonary venous hypertension, pulmonary edema in the lower lobe compresses on lower lobe vessels and distends upper lobe vessels, exacerbated by hypoxia-vasoconstriction in lower lobe vessels

Kerley B lines (Septal lines) - Interstitial edema, develops at LA pressure > 15-20mmHg

Peribronchial cuffing - Interstitial fluid accumulate around bronchi causing thickening of bronchial wall, doughnut-like densities in parenchyma, LA pressure > 15-20mmHg

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12
Q

Biomarkers for heart failure

Levels for severities of HF

Physiological function of the marker

A

Brain Natriuretic Peptide (BNP) and NT-proBNP

Endogenous function: BNP from cardiomyocytes to resist fibrosis and myocardial hypertrophy by decreasing BP, sympathetic tone, RAAS activation

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13
Q

Cardiac causes of high BNP

A
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14
Q

Confounding/ Non-cardiac causes of high BNP

A
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15
Q

Surgical Treatment options for HF

A

Devices:

  • Cardiac Resynchronization therapy (CRT) (biventricular pacing)
  • Cardiac assist devices: Pacemaker
  • Implantable Cardioverter Defibrillator (ICD)

Revascularization:

  • Cardiac Transplant
  • CABG for ischemic cardiomyopathy
  • Valvular surgery
  • Left ventricular assist device (LVAD)
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16
Q

Outline history taking questions for HF (apart from S/S)

A

Symptoms of HF: Characterize all symptoms in detail

Past history of CAD, PVD, Stroke

Etiologies:

  • Risk factors of CVS: Smoking, Metabolic syndrome (HT, DM,HL)
  • Valvular diseases: CTD, Rheumatic fever…etc
  • Systemic diseases: Thyroid storm, Pheochromocytoma …etc
  • Cardiotoxic drugs: Chemo/RT, Substance abuse

Family history:

  • Sudden death at young age, FHx of myopathies, arrhythmias, premature CVD
17
Q

First-line investigations for HF ***

A

Blood:

  • CBC
  • Serum K, Ca, PO4, glucose
  • RFT, Serum Urea and Cr
  • TSH, fT4
  • BNP, Pro-BNP

Urine microscopy and urinalysis

CXR: Features of HF

ECG

Further confirmation: CT/ MRI, Nuclear scans e.g. MIBG, Exercise/ pharmacological stress testing, Cardiac catherization

18
Q

Outline the NYHA Functional Classification to stage HF

A
19
Q

Outline the clinical course of HF over time

A
20
Q

Causes of HF

A
21
Q

Myocardial disorders that cause HF

A
22
Q

Classes of HF according to ejection fraction

A

Heart failure with Reduced Ejection Fraction (HFrEF)/ Systolic HF - LVEF <40%

Heart failure with Preserved Ejection Fraction (HFpEF)/ Diastolic HF - LVEF >50%

Other classes: HFmrEF (41-49%), HFpEF (>40%)

23
Q

Compare HFrEF and HFpEF

  • Demographics
  • Risk factors
  • Difference in CXR
A
24
Q

Approach to Dx heart failure

A
  1. Clinical diagnosis by S/S and diagnostic criteria
  2. Unclear clinical diagnosis >> use BNP or Pro-BNP concentration with clinical context to Dx
25
Q

Causes of acute HF

A

Respiratory causes:

  • Acute respiratory failure
  • Pulmonary embolism

Circulation emergency:

  • Cardiogenic shock
  • Hypertension emergency/ Malignant hypertension

Cardiac causes:

  • Acute Coronary syndrome/ MI
  • Arrhythmia
  • Acute mechanical cause e.g. VHD, LVOTO

Systemic:

  • Anemia
  • Endocrine: e.g. thyroid storm, pheochromocytoma
  • Adverse drug effects
26
Q

Approach to treat hemodynamic profiles of heart failure *

A

Congestion (both left or right heart) (Yes or No) >> S3, peripheral edema, orthopnea and PND, high JVP, Pulmonary edema

Perfusion (Adequate or poor) >> low peripheral temp and pulse

HF with congestion (Wet profile)

  1. Adequate peripheral perfusion - Wet and Warm - Treat hypertension and congestion with Vasodilators, Diuretics
  2. Poor peripheral perfusion - Wet and Cold - Inotropes, Vasopressors, Diuretics for low SBP; Vasodilators, Diuretics for normal SBP

HF without congestion (Dry profile)

  1. Adequate peripheral perfusion - Dry and warm - Compensated HF, adjust medication
  2. Poor peripheral perfusion - Dry and cold - treat hypoperfusion with Fluid Challenge, Inotropic agent
27
Q

General management and monitoring metrics for acute HF

A

General:

  • Bed rest
  • O2 supplementation: NIV, NI-cPAP, Intubation, Mech. ventilation
  • Low salt diet
  • Fluid restriction

Monitor:

  • Vitals: Orthostatic BP, O2 saturation, HR
  • Fluid I/O, Weight
  • Clinical: signs of peripheral congestion, symptoms of HF
  • Electrolytes and renal function
28
Q

Drug management of acute HF

All options

A

BP Stable:

  • IV Frusemide (diuretic)
  • IV nitrate
  • Morphine (pain)

BP unstable or deterioration:

  • Moderate: Inotropes: Dopamine and Dobutamine
  • Severe: Intra-aortic balloon pump, ECMO
29
Q

Drug management for CHRONIC HF (HFrEF)

All options

A

4 main pillars:

  1. ACEi/ ARB + Beta Blocker
  2. Mineralocorticoid receptor antagonist
  3. Angiotensin receptor neprilysin inhibitor (ARNI), Ivabradine
  4. Surgical: e.g. Cardiac resynchronization therapy (CRT)

Additional:

  • Nitrate + Hydralazine if cannot tolerant ACEi and ARB
  • Diuretics for volume overload
  • Anti-coagulants, Digoxin, PCI for A-fib
  • CABG/ PCI for CAD
30
Q

Examples of ACEi and ARB

Indications for HF

A

ACEi - Captopril, Ramipril

Recommended for all HFrEF patients

ARB - Valsartan, Losartan

For ACEi refractory patients with intractable cough, angioedema

31
Q

Effect of Beta blocker in HF

A

Cardioprotective effect, block SNS stimulation

Short-term decrease contractility, increase EF gradually after 1-3 months of use

Increase the dose with time

Long-term symptomatic improvement

32
Q

Effect of MRA on HF

A

Spironolactone - reduce HF mortality and morbidity

Eplerenone - reduce MI, HF mortality with less hormonal side effects e.g. gynaecomastia

33
Q

Effect of Ivabradine on HF

A

Funny Channel blocker - reduces SA node firing frequency and slows HR

For patients intolerant to Beta-blockers

34
Q

Treatment options for CHRONIC HF HFpEF/ Diastolic HF**

A

SGLT-2 inhibitor + ACEi/ ARB = major drugs

Additional:

  • Slow HR, BP control: BB, CCB
  • Diuretics for volume overload
  • CAD - coronary revascularization

MBBS IV - Junior Clerkship WCS (131 decks)

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