Shortness of Breath Flashcards by Harroop Bola

What are the three categories for shortness of breath?

Not enough oxygen reaching the lungs (Asthma, anaphylaxis, COPD)
Not enough oxygen getting into the blood - V/Q Mismatch
Not enough oxygen reaching the rest of the body (Anaemia, shock).

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What are the common causes of a V/Q mismatch?

Pulmonary embolism
Pulmonary oedema
Pulmonary fibrosis

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What are the four common cardiac causes for shortness of breath?

Heart failure
Constrictive pericarditis
Myocarditis
Cardiomyopathy

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A pansystolic murmur on auscultation of the right sternal border is suggestive of what pathology?

Tricuspid regurgitation

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What is the definition of heart failure?

The failure of the heart to maintain the cardiac output required to meet the physiological demands

-not enough oxygen reaching the rest of the body

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What are the two types of anatomical heart failure?

Right and left-sided heart failure

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What can are the cardiac complications of left-sided heart failure?

Congestive heart failure increased backflow pressure into the pulmonary veins.

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What is the definition of a low-output state?

The heart fails to pump in response to normal exertion -There is low cardiac output.

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What is the definition of a high output state?

The cardiac output is normal, however, there is increased metabolic demand (pregnancy, anaemia, hyperthyroidism).

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What are the valvular causes of left-sided heart failure?

Aortic stenosis
Aortic regurgitation
Mitral regurgitation

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What are the muscular causes of left-sided heart failure?

Ischaemia (IHD)
Cardiomyopathy
Myocarditis
Arrhythmias (AF)

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What are the systemic causes of left-sided heart failure?

Hypertension
Amyloidosis
Drugs (cocaine, chemo)

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What are the chronic causes of right-sided heart failure?

Pulmonary hypertension (Cor Pulmonale)

Pulmonary embolism

Chronic lung disease (interstitial lung disease, cystic fibrosis)

Tricuspid regurgitation
Pulmonary valve disease

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What are the causes of high-output heart failure (NAP Meals)?

Nutritional (B1/Thiamine deficiency)
Anaemia
Pregnancy
Malignancy
Endocrine (Hyperthyriodism increases the BMR). 
AV malformations 
Liver cirrhosis 
Sepsis

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What are the signs of left-sided heart failure?

Fluid accumulates in the lungs - respiratory symptoms

Dyspnoea - Paroxysmal nocturnal dyspnoea (PND) - Episodic at night

Orthopnoea - SOB when lying flat

Exertional dyspnoea

Nocturnal cough (Pink frothy sputum)

Fatigue

Pulsus alternans
Displaced apex beat
S3 gallop
S4 in severe heart failure
Murmur (AS,MR, AR)

Pulmonary oedema - Crackles at lung bases

Wheeze - cardiac asthma

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What are the signs of right-sided heart failure?

Fluid accumulates in the peripheries - Swelling signs, raised JVP, Dyspnoea, ankle oedema, sacral oedema

Ascites

Hepatomegaly

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Which abnormal heart sounds are associated with LHF?

S3 ventricular gallop

S4 in severe HF

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What are the symptoms of RHF?

Fatigue
Reduced exercise tolerance
Anorexia
Nausea
Nocturia

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Which cardiac biomarker is raised in heart failure?

NT-pro-BNP

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A raised NT-Pro-BNP in a patient with suspected HF, indicates which investigation to confirm the diagnosis?

Trans-thoracic echocardiogram (TTE)

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What is the diagnostic investigation to confirm heart failure?

Trans-thoracic echocardiogram (TTE) coupled with doppler

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What does a TTE with doppler visualise?

Visualises the structure and function of the heart

Calculates ejection fraction (EF): % of blood present in the left ventricle that gets pumped during systole.

EF = SV/EDV x 100

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What is a normal ejection fraction?

50-70%

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What ejection fraction value is suggestive of reduced ejection fraction heart failure?

<40%

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What does reduced ejection fraction heart failure suggest?- Systolic

Indicates an inability of the ventricle to contract normally

Which value suggests a preserved ejection fraction heart failure? - Diastolic

>50% - indicates an inability of the ventricle to relax and fill normally.

What chest X-ray findings are evident in heart failure?

``` A: Alveolar odema B-lines - kerley Cardiomegaly Dilated upper lobe vessels Diverted upper lobe Effusion (Transudative pleural effusion). ```

Which criteria is used for the clinical diagnosis of Heart failure?

Framingham Criteria

What are the major symptoms of the Framingham criteria?

``` Paroxysmal noctural dyspnoea bibasal crepitations S3 gallop Cardiomegaly Increased central venous pressure Weight loss Neck vein distension Acute pulmonary oedema Hepatojugular reflux ```

What are the minor signs and symptoms of the Framingham criteria?

``` Bilateral ankle oedema Dyspnoea Tachycardia Decrease in vital capacity by 1/3 Nocturnal cough Hepatomegaly Pleural effusion ```

Which drugs are used for the treatment of heart failure?

ABD Ace inhibitors Beta blockers Diuretics

Which ace inhibitors are prescribed for the management of left ventricular dysfunction?

Enalipril, perindopril, ramipril

Which beta-blockers are indicated in reducing oxygen demand on the heart?

Bisoprolol | Carvedilol

How do ace inhibitors manage heart failure?

Reduce afterload and hypertension - supports left ventricular failure A low CO , activates the RAS, and sympathetic nervous system which makes HF worse

Which beta-blockers are indicated in reducing oxygen demand on the heart?

Bisoprolol | Carvedilol

How do ace inhibitors manage heart failure?

Reduce afterload and hypertension

Which diuretics are commonly used in the management of heart failure?

Loop diuretics - furosemide | Aldosterone antagonists - Spironolactone

What is digoxin?

Positive inotrope that improves symptoms not mortality

What is the acute management for heat failure?

``` DMONS Diuretics Morphine (IV diamorphine 2.5-5mg) Oxygen (60-100%) Nitrates (GTN infusion) Sit-up ``` IV furosemide 40-80mg

Which diuretic and dose is given to a patient with an acute HF?

IV furosemide 40-80 mg

Once oxygen and the patient is sat upright which drug should be administered in a patient presenting with acute HF?

IV diamorphine 2.5-5mg

What are the complications of heart failure?

Respiratory failure Renal failure due to hypoperfusion Acute exacerabtions Death

In cardiomegaly what comment can be made for the cardio-thoracic ratio on a chest radiograph?

There is an increased ratio

Which lung lobes are diverted in heart failure?

Upper lobes

What are the two types of cardiomyopathy?

Dilated- Dilated ventricle, thin walls, reduced ventricular pressure - systolic Hypertrophic - Muscle wall hypertrophies inwards, more rigid, obstruction (HOCM) - Diastolic Restrictive - Same amount of muscle but rigid - does not pump well (Systolic)

What is cardiomyopathy?

A group of diseases in which the myocardium becomes structurally and functionally abnormal -In the absence of CAD

What is the pathophysiology of dilated cardiomyopathy?

Ventricles enlarge and become dilated Walls thin and weaken - Cannot contract effectively Law of Laplace - An increase in radius = reduced ventricular pressure

What are the risk factors of dilated cardiomyopathy?

Alcohol, Post viral, Haemochromatosis, Genetic

What is the presentation of dilated cardiomyopathy

Displaced apex beat Signs and symptoms of heart failure TR/MR murmur S3 sound

On a CXR, how does dilated cardiomyopathy represent?

Globular heart

What is the pathophysiology of hypertrophic cardiomyopathy?

Thickened myocardium internally Increased stiffness of the muscle affects pumping Disrupts electrical conduction and causes arrythmias HOCUM- Obstructs the outflow of blood

What is the familial inheritance pattern for HOCM?

Autosomal dominant

What is the presentation of HOCM?

Sudden cardiac death | Angina, dyspnoea on exertion, palpitations, syncope

What are the signs of HOCM?

Ejection systolic murmur Jerky carotid pulse Double apex beat but not displaced S4

LVH by voltage criteria?

Deep S wave in V1 and V2 Tall R wave in V5/V6 S in V1 + R in V5 or V6 > 7 large squares

What are the ECG findings for HOCM?

Q waves, left axis deviation, signs of left ventricular hypertrophy

What is the pathophysiology of restrictive cardiomyopathy?

Ventricles become abnormally rigid and lose flexibility Impaired ventricular filling during diastole Reduced preload --> Reduced blood flow + backing up of blood.

What are the causes of restrictive cardiomyopathy?

Sarcoidosis, amyloidosis Haemocrhomatosis Familial Idiopathic

What is constrictive pericarditis?

Chronic inflammation of the pericardium (outer sac) with thickening and scarring

What are the causes of constrictive pericarditis?

Idiopathic Infectious (TB, bacterial, viral) Acute pericarditis Cardiac surgery and radiation

What are the signs and symptoms of constrictive pericarditis?

Right heart failure presentation (Raised JVP, oedema) | Kussmaul's sign

What is myocarditis?

Inflammation of the myocardium

Which virus is associated with myocarditis?

Coxsackie B virus

What are the signs and symptoms of myocarditis?

Flu-like prodrome Chest pain SOB Palpitations

What are the diagnostic investigations of myocarditis?

Endomyocardial biopsy

What are the main causes of valvular disease?

Infective endocarditis Rheumatic fever Calcification Myocardial infarction

What murmur is associated with tricuspid regurgitation?

Pansystolic

What murmur is associated with tricuspid stenosis?

Mid-late diastolic

What mumur is associated with pulmonary regurgtiation?

Early diastolic

Murmur with aortic regurtitation?

Early diastolic

Aortic stenosis murmur?

Ejection systolic

Mitral regurgitation murmur?

Pansystolic

Mitral stenosis murmur

Mid-late diastolic