Shortness of Breath Flashcards
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).
What are the common causes of a V/Q mismatch?
Pulmonary embolism
Pulmonary oedema
Pulmonary fibrosis
What are the four common cardiac causes for shortness of breath?
Heart failure
Constrictive pericarditis
Myocarditis
Cardiomyopathy
A pansystolic murmur on auscultation of the right sternal border is suggestive of what pathology?
Tricuspid regurgitation
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
What are the two types of anatomical heart failure?
Right and left-sided heart failure
What can are the cardiac complications of left-sided heart failure?
Congestive heart failure increased backflow pressure into the pulmonary veins.
What is the definition of a low-output state?
The heart fails to pump in response to normal exertion -There is low cardiac output.
What is the definition of a high output state?
The cardiac output is normal, however, there is increased metabolic demand (pregnancy, anaemia, hyperthyroidism).
What are the valvular causes of left-sided heart failure?
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
What are the muscular causes of left-sided heart failure?
Ischaemia (IHD)
Cardiomyopathy
Myocarditis
Arrhythmias (AF)
What are the systemic causes of left-sided heart failure?
Hypertension
Amyloidosis
Drugs (cocaine, chemo)
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
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
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
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
Which abnormal heart sounds are associated with LHF?
S3 ventricular gallop
S4 in severe HF
What are the symptoms of RHF?
Fatigue Reduced exercise tolerance Anorexia Nausea Nocturia
Which cardiac biomarker is raised in heart failure?
NT-pro-BNP
A raised NT-Pro-BNP in a patient with suspected HF, indicates which investigation to confirm the diagnosis?
Trans-thoracic echocardiogram (TTE)
What is the diagnostic investigation to confirm heart failure?
Trans-thoracic echocardiogram (TTE) coupled with doppler
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
What is a normal ejection fraction?
50-70%
What ejection fraction value is suggestive of reduced ejection fraction heart failure?
<40%
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
