M103 T3 L12 Flashcards
When does high output HF occur?
when the heart can’t provide for the unusually high demand for blood to organs with normal functioning
What conditions result in high output HF? (SATT.PAPP)
sepsis, acromegaly, thyrotoxicosis (SAT)
Profound anaemia, Pregnancy, Pagets disease (PAPP)
What are causative conditions of HF?
Cardiomyopathies Congenital Heart Disease Coronary Heart Disease Hypertensive Heart Disease Myocardial Disease Valvular Heart Disease
What are the causes of dilated cardiomyopathy?
alcohol, pregnancy systemic disease muscular dystrophies Drug toxicity (chemotherapy) Myocarditis – common viruses
What are the three types of cardiomyopathy? (DHR)
dilated
hypertrophic
restrictive
What is the main cause of restrictive cardiomyopathy?
amyloid
What does the activation of neurohormonal system involve?
the release of noradrenaline
the release of ANP / BNP
the activation of RAAS
Which compensatory mechanisms may successfully restore cardiac output but can also worsen HF?
vasoconstriction
Na and water retention
excessive tachycardia
What is excessive tachycardia caused by?
→ ↓diastolic filling time → ↓ventricular filling → ↓SV and CO
What are the clinical types of HF?
Left sided, right sided and biventricular Acute and chronic Compensated and decompensated Systolic and Diastolic High and Low out put
What happens during left sided HF?
blood backs up progressively from the left atrium to the pulmonary circulation
What conditions cause left sided HF? (VIM Him)
Valvular heart disease
Ischaemic heart disease
Myocardial disease
Hypertension
How does left ventricular HF cause heavy wet lungs?
pulmonary vein pressure is transmitted retrogradely to the capillaries and arteries
< pulmonary congestion and oedema < heavy wet lungs
What conditions cause heavy wet lungs?
dyspnoea exaggeration of the normal breathlessness that follows exertion
Orthopnoea
Paroxysmal nocturnal dyspnoea
How does left ventricular HF affect the kidneys?
Decreased cardiac output results in decreased renal perfusion
Activation of RAAS
Retention of salt and water with consequent expansion of interstitial fluid and blood volumes
What neurological conditions cause left ventricular failure?
Hypoxic encephalopathy
Irritability, Loss of attention, Restlessness
Stupor and coma
What conditions cause right sided HF?
usually left sided HF - congestive cardiac failure
cor-pulmonale
valvular heart disease
congenital heart disease
What is cor-pulmonale caused by?
increased resistance within the pulmonary circulation due to respiratory disease e.g. COPD or pulmonary emboli
leads to significant pulmonary hypertension
causes right HF
Which parts of the body does HF affect? (PASST)
Portal system, Abdomen, Spleen, Subcutaneous Tissue
the liver
the pleural and pericardial space
What conditions does right HF cause in the liver or in the portal system?
Congestive hepatomegaly
Centrilobular necrosis when severe
Cardiac cirrhosis
What abdominal condition is caused by right HF?
Congestive splenomegaly
How does right HF affect the subcutaneous tissue?
Peripheral oedema of dependent portions of the body esp. ankle and pretibial oedema
How does right HF affect the pleural and pericardial space?
effusions
What can cause biventricular failure?
the same pathological process on each side of the heart
left HF leading to volume overload of the pulmonary circulation and eventually the right ventricle
In patients with HF, what conditions does excess fluid accumulation cause? (HODA)
Hepatic congestion
Orthopnoea, Oedema
Dyspnoea, paroxysmal nocturnal dyspnoea
Ascites
In patients with HF, what does a reduction in HF cause?
Fatigue
Weakness
What are the different classes of HF?
Class I: No limitation of physical activity
Class II: Slight limitation of ordinary activity
Class III: Marked limitation, even during less-than-ordinary activity
Class IV: Severe limitation with symptoms at rest
What are the clinical signs of HF?
Cool, Ascites, pale (CAP)
Peripheral oedema, Displaced apex (PO.DA)
cyanotic extremities, Tachycardia (CET)
Hepatomegaly, Elevated jugular venous pressure (HEj)
the presence of an S3 sound
Crackles or decreased breath sounds at bases on chest auscultation
What clinical tests are used to pin point HF?
CXR, ECG
Blood investigations
Echocardiogram / Cardiac MRI or CT / CT-PET
CTCA / Coronary angiography
What are two examples of loop diuretics?
frusemide
bumetanide
What can potent loop diuretics lead to?
electrolyte abnormalities
hypovolaemia
diminished renal perfusion
How are loop diuretics administered?
iv / orally
How do loop diuretics work?
Inhibit Na+ re-absorption from the proximal tubule
K+ loss from distal tubule
What are two examples of Mineralocorticoid Receptor Antagonists?
EPLERENONE
SPIRONOLACTONE
How do Mineralocorticoid Receptor Antagonists work?
they promote Na+ excretion and K+ re-absorption
in distal tubule
What is the effect of Mineralocorticoid Receptor Antagonists?
they reduce hypertrophy and fibrosis
What are the main side effects of Mineralocorticoid Receptor Antagonists?
Gynaecomastia (esp. Spironolactone)
Electrolyte (K+ high) and renal function abnormalities
What are examples of ACE Inhibitors? (RECord Perilous Liars)
Ramipril Enalapril Captopril Perindopril Lisinopril
What do ACE Inhibitors act on?
the activated RAAS
How are ACE Inhibitors administered?
given orally in small doses with slow titration
How do ACE Inhibitors block the production of angiotensin?
Vasodilatation
BP lowering
Reduce cardiac work
What are the main side effects of ACE inhibitors?
cough
hypotension
renal impairment
What are three examples of beta blockers? (BCM - Back CAR MEeT)
BISOPROLOL
CARVEDILOL
METOPROLOL
How do beta blockers block the action of adr and noradr?
they slow the HR, which reduces BP
What is the function of beta blockers?
to block the action of adrenaline and noradrenaline on adrenergic b-receptors
How are beta blockers administered?
they are given orally in small doses with slow titration
treat arrhythmias
What are the two main side effects of beta blockers?
Bronchospasm
Claudication
What is an example of a SA node blockade?
ivabradine
How do SA node blockades work?
Slow HR, no effect on BP
How are SA node blockades administered?
Given orally with dose titration
What is the function of SA node blockades?
blocks the If channel within the SA node
What are the two main side effects of SA node blockades?
Visual aura
Bradycardia
What is the effect of digoxin?
it increases myocardial contractility
it slows conduction at the AV node
What conditions is digoxin used to treat?
acute HF, chronic HF
arrhythmias, AF
What happens to digoxin once it has made its way through the body?
it is excreted by kidney
What is an example of an ARNI?
SACUBITRIL VALSARTAN
What is the function of an ARNI?
it acts on the activated RAAS
it blocks the breakdown of ANP/BNP
it blocks the production of angiotensin
it promotes natriuresis
How do ARNIs block the production of angiotensin?
vasodilatation
lowers the bp
reduces cardiac work
What are the main side effects of ARNIs?
hypotension
renal impairment
How do ARNIs promote natriuresis?
sodium excretion
vasodilatation
reduce hypertrophy
fibrosis
What are other therapies for HF?
Cardiac Resynchronisation Therapy
Cardiac transplantation
Stem cell therapy
What is the difference between standard pacemakers and biventricular pacemakers?
standard - equipped with two leads that conduct pacing signals to specific regions of heart
biv - have an additional third lead designed to conduct signals directly into the left ventricle
What is an adv of biventricular pacemakers?
the combination of all three leads promotes synchronised pumping of ventricles
there is increasing efficiency of each beat
pumps more blood on the whole
What is the usual cardiac output at rest?
70mls/kg/min
What two things does the Frank Starling law relate to eachother?
Preload
Cardiac Output
What does the Frank Starling law state?
that an increase in volume of blood filling the heart stretches the heart muscle fibres causing greater contractile forces which, in turn, increases the stroke volume
Why is the Frank Starling law only true up to a certain point?
at some stage the fibres become over-stretched and the force of contraction is reduced
What is the effect of noradrenaline?
increases heart rate
increases myocardial contractility
causes vasoconstriction
What does the activated RAAS do and how?
it elevates blood volume by increasing Na and water reabsorption
What is the natriuretic peptide system activated by?
increased ventricular wall stretch
What is the effect of active BNP?
diuresis
vasodilationinhibits the RAAS and the sympathetic NS
What is the half life of active BNP in circulation?
20 mins - very short lived
What does high NT-proBNP indicate?
increased risk of HF
What are the effects of the natriuretic peptide system?
Increase GFR
decrease bp
increased water & sodium excretion in urine
What happens when the natriuretic peptide system is activated?
pro-BNP is released
is cleaved
What is pro-BNP cleaved into?
active BNP
NT-proBNP
From where is NT-proBNP excreted?
renally
What is the half life of NT-proBNP in circulation?
2 hrs
Why is sympathetic NS activity counter productive in a HF situation?
increased cardiac, vascular and renal sympathetic activity
Why is increased cardiac sympathetic activity counter productive in a HF situation?
myocytes hypertrophy
increased arrhythmia
increased ischaemic demand
Why is increased vascular sympathetic activity counter productive in a HF situation?
vasoconstriction mediated by the peripheral vascular circulation
Why is increased renal sympathetic activity counter productive in a HF situation?
causes sodium retention
further activates the RAAS - RAAS activates this sympathetic NS and vice versa
What happens during decompensated HF?
occurs when patients have ended up with worsening symptoms
often admitted to hospital
What causes decompensated HF?
an additional medical condition - puts extra pressure on the balance of their HF
disease progression / further cardiac insult
When is Cardiac Resynchronisation Therapy (CRT) offered to a HF patient?
when the patient is deemed to be at risk of sudden cardiac death
When is Dialysis & Ultrafiltration used on a HF patient?
when the patient become resistant to diuretics
What treatments are used on HF patients who are very unstable and extremely unwell with cardiogenic shock?
Ventricular Assist Device (LVAD/RVAD)
Intra-aortic balloon pump
What are the two types of defibrillator?
System ICD
Transveous ICD
How is the Transveous ICD positioned?
a lead inside the heart is connected to a pulse generator under the skin
How does a Transveous ICD work?
an electrical shock wave is passed through the heart from the generator to the lead and back
this reverts unstable ventricular arrhythmias back to sinus rhythm
What is an advs of using a Transveous ICD?
can be achieved completely subcutaneously
avoids the need for placing electrodes within the circulation or within the heart itself
How is the System ICD positioned?
the lead is placed to the left of the sternum
What is Cor pulmonale otherwise known as?
right-sided HF
What is cardiac cirrhosis caused by?
right sided HF
What is S3 otherwise known as?
the third heart sound
ventricular gallop
What is a displaced apex caused by?
LV enlargement
What medication may work for swelling when other medications have not?
bumetanide
What is frusemide used to treat?
hypertension
fluid build-up due to HF, cirrhosis, or kidney disease
What is bumetanide used to treat?
swelling (cardiac AAR of HF) and hypertension
What is Eplerenone used to treat?
HF, hyperaldosteronism
reduces the risk other heart problems / a stroke
Is Gynaecomastia benign?
usually but breast cancer can develop in about 1% of cases
What causes Gynaecomastia?
an imbalanced ratio of oestrogen and androgen activity
What causes high output HF?
when CO is higher than normal due to increased peripheral demand
What conditions an result from high output HF?
a circulatory overload
pulmonary oedema secondary
elevated diastolic pressure (left ventricle)
What is claudication usually a symptom of?
peripheral artery disease caused by atherosclerosis
When does claudication occur?
when there is too little blood flow to the limbs due to atherosclerosis
What is peripheral artery disease usually caused by?
atherosclerosis
What is a symptom of claudication?
pain in the limbs associated with walking or using the arms
What is the difference between angina and chest pain?
Not all angina is chest pain
angina is pain caused by narrowed coronary arteries
What conditions is ivabradine used to treat?
the symptoms of stable heart-related chest pain
HF not fully managed by beta blockers
What do the cardiac glycosides affect?
they ics the force of the heart and its rate of contractions
How do the cardiac glycosides work?
by acting on the cellular Na/K ATPase pump
What is digoxin used for?
to control some heart problems
How does neprilysin work to inactivate peptide-based hormones?
they cleave peptides at the amino side of hydrophobic residues
What are examples of peptide hormones that are inactivated by neprilysin? (GES NOB)
glucagon, enkephalins, substance P, neurotensin, oxytocin, and bradykinin.
When are ARNIs used?
when other treatments for HF aren’t working in certain cases / patients
Where is B-type natriuretic peptide made?
inside the pumping chambers of the heart
When is B-type natriuretic peptide made?
when pressure builds up from HF
What substance serves as an indicator of HF?
B-type natriuretic peptide
What does CRT involve?
implanting a small pacemaker just below the collarbone
three leads are connected to a device that monitors the heart rate to detect heart rate irregularities and emit tiny pulses of electricity to correct them
What gender(s) is androgen present in?
both genders
What is the role of androgen?
contributes to male traits and reproductive activity
What are the two main androgens?
testosterone and androstenedione
