Lecture 31 Flashcards
Why has heart failure increased?
Heart failure has increased in NZ, because our technology and drugs have become so good that we can treat people as soon as they have a heart attack and mortality risks of a heart attack decrease, however these people tend to develop heart failure. When they get heart failure the outcome is not good (try and manage, can’t cure). Heart failure is 50:50 male and female. Big disparities in the stats. The decline for males has been since the 1980s, where as females decline hasn’t worked that well until the 2000s. ACE inhibitors worked well for men but not that well for women. ARB had a little bit of effect on both. One of the reasons for there was a disparity between women and men in terms of CVD deaths; was that because 9% of the proportion of clinical trial population comprised of women. No it is up to 41%. When we talk about heart failure, we choose people with obvious sign of heart failure (typically male); we also put age limits on studies. Women tend to get heart failure around 80-90years old.
What is the definition of heart failure?
It is complex clinical syndrome.
1. Shortness of breath.
2. Exercise limitations and fatigue.
3. Clinical signs of peripheral and or pulmonary congestion.
Hard initial signs to track down - do they have pneumonia or COPD or a stomach illness. There needs to be some sort of cardiac abnormality.
In the world the definition is a reduction in CO/and ejection fraction.
Why do some heart failure patients show brain decline?
This is because their brain is not getting enough oxygen. They’re also coping with high sympathetic nerve activity which makes them feel stressed.
What happens if the patient has high right heart sided failure?
High jugular pressures.
What are the symptoms of heart failure?
- Dilated pupils.
- Pale, grey of cyanotic skin colour.
- Dyspnea, orthopnea, crackles, wheeze and cough.
- Decreased blood pressure.
- Nausea and vomiting - this is due to gut being full of fluid.
- Ascites.
- Dependent, pitting oedema.
- Anxiety.
- Falling oxygen saturation.
- Confusion.
- Jugular vein distension.
- Infarct.
- Fatigue.
- Tachycardia.
- Enlarged spleen and liver.
- Decreased urine output.
- Weak pulse and fast.
- Cool and moist skin.
Describe left-sided heart failure?
- Lung “crackles”
- Tachycardia.
- Low SpO2.
- Paroxysmal nocturnal dyspnea.
- GI symptoms: nausea, bloating, constipation.
- Cool/cold/pale/cyanotic extremities.
- Weight gain.
Describe right-sided heart failure?
- Jugular venous distension.
- Liver engorgement.
- Ascites.
- Peripheral edema.
- Weight gain.
Describe the physical findings in HF?
- Tachycardia, irregular pulse.
- Elevated jugular venous pressure.
- A third heart sound.
- Peripheral oedema.
Investigations: - Blood test looking for BNP - stretch of the heart causes an increase in BNP.
- ECG - might see atrial fibrillation; useful to do ECG to rule out other causes.
- Chest XRAY.
- Echo - try and get a cross section to get a good indication of the heart. Sternal view - trying to get the length of the heart mostly focused on the LV. You can see the LV, LA, Aortic valve and RV. 5th intercostal space - just getting the bottom of the mitral valve, LV and RV. 4-chamber view from the apex - apex and LV (right side) and RV are at the top.
What are the types of heart failure?
- Reduced ejection fraction - systolic heart failure. Less blood pumped out of ventricles. Weakened heart muscles (but large heart) but can’t squeeze as well. (HFrEF) - EF 50%. Atrial fibrillation, renal dysfunction. Increase of stiffening of the heart (and increase in collagen of the heart). LV end-diastolic pressure increases. Thickening of the myocytes and less chance for heart to fill in the first place. Increase of the preload and inability of the heart to relax. The wall gets thicker and thicker to reduce tension but at the expense of filling. Increased wall thickness so increased ejections and impaired filling of the heart (smaller ventricle).
What is ejection fraction?
The amount of blood pumped out of the ventricle divided by the total amount of blood in the ventricle.
Describe the viscous cycle of heart failure?
Myocardial injury -> decrease in ventricular performance -> decrease in cardiac output -> activation of neurohumoral system (so an increase in sympathetic activity) -> vasoconstriction so there will be sodium and water retention -> increase demand on the heart. Peripheral vasoconstriction makes the system worse.
What happens in decompensated heart failure?
It doesn’t matter how much fluid you put in there, as you cannot increase the output.
How can we manage heart failure?
Most treatment is trying to manage the symptoms - get rid of shortness of breath. The key is trying to reduce the heart work load i.e. diuretics, ACE inhibitors, and beta blockers. If there is a bad rhythm you try and fix the rhythm. Quality of Life rather than quantity of life. You want to try and manage their weight (fluid balance).
What are other options for heart failure?
- ICD or cardiac resynchronisation therapy.
- Assist devices - younger people who could be a good candidate.
- transplant - younger people who could be a good a good candidate.
