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ICL Block Year 3 > Week 4 - heart failure, infective endocarditis, symptomstic aortic stenosis > Flashcards

Week 4 - heart failure, infective endocarditis, symptomstic aortic stenosis Flashcards

1
Q

what does diaphoretic mean ?

A

sweating

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2
Q

What does the medical abbreviation PRN mean ?

A

take the drug as/when required

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3
Q

What are the investigations for suspected heart failure ?

A
  • ECG
  • ECHO
  • CXR
  • bloods (FBC, CRP, BNP, Liver/renal/thyroid function tests, glucose)
  • ABG
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4
Q

Why is a BNP done in suspected heart failure ?

A

BNP is a cardiac neurohormone marker which is secreted from the heart when under stress

a normal result would exclude HF

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5
Q

What is the immediate treatment for suspected heart failure ?

A

furosemide (diuretic)
digoxin (glycoside)

then treat the underlying cause of the heart filaure e.g AF…

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6
Q

Why does heart failure cause a raised pulse rate

A

baroreceptors in carotids and aorta notice a decreased stretchdue to faulty ventricular action, so they relay to the medulla to increase heart rate in order to get blood around the body

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7
Q

Why does heart failure increase blood pressure ?

A
  • The left ventricle is not working well
  • causes back flow through the heart and lungs, dropping BP
  • receptors notice this drop in BP and cause vasoconstriction to counter this
  • this increases arterial pressure and venous return to the heart

this correction of BP happens within 30s

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8
Q

How is the RAAS system involved in correcting heart failure ?

A
  • baroreceptors in kidney sense dropped BP
  • kidneys release renin
  • causes vasoconstriction
  • as well as salt and water retention hence why you give furosemide in HF
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9
Q

How does heart failure cause oedema ?

A

backflow of pressure in the heart/lungs causes a drop in BP which is registered by receptors and counteracted = vasoconstriction, increasing capillary pressure so fluid leaks out of capillaries

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10
Q

Why is it common to see oedema in the ankles?

A

gravity causes the majority of fluid to pool in the legs

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11
Q

What is orthopnoea ?

A

breathlessness worsening when lying down

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12
Q

What causes orthopnoea in heart failure ?

A

lying down increases venous return to heart which increases blood flow to the pulmonary circulation and the left ventricle is unable to compensate for this (as in normal physiology) which causes pooling in pulmonary circulation and therefore fluid leakage into alveoli = pulmonary oedema

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13
Q

Why is JVP raised in heart failure ?

A

back flow of pressure in the heart causes increased pressure in right atrium which increases pressure in the JVP

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14
Q

Can you see the JVP in a healthy person ?

A

no !

only if pressure is raised in right atrium or pressure is places on the liver (hepatojugular reflex)

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15
Q

What can cause a raised JVP ?

A
  • right ventricular failure
  • tricuspid stenosis/regurgitation
  • pericardial effusion
  • constructive pericarditis
  • superior vena cava obstruction
  • volume overload (CHF, renal failure…)
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16
Q

How many grades of heart murmur are there ?

A

4 grades of murmur

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17
Q

What is a grade 1 heart murmur ?

A

murmur is heard only when intently listening for some time

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18
Q

What is a grade 2 heart murmur ?

A

a faint murmur heard immediately on auscultation

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19
Q

What is a grade 3 heart murmur ?

A

a loud murmur with no palpable thrill

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20
Q

What is a grade 4 heart murmur ?

A

a loud murmur with palpable thrills

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21
Q

What type of murmur is heard in mitral regurgitation?

A

pan systolic murmur

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22
Q

What type of murmur is heard in aortic stenosis ?

A

ejection systolic murmur

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23
Q

What type of murmur is heard in aortic regurgitation?

A

blowing decrescendo diastolic murmur

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24
Q

What type of murmur is heard in pulmonary regurgitation?

A

early diastolic decrescendo murmur

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25
Q

What type of murmur is heard in mitral stenosis ?

A

mid-diastolic low, rumbling murmur

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26
Q

What type of murmur is heard in tricuspid stenosis ?

A

mid- diastolic murmur

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27
Q

What type of murmur is heard in tricuspid regurgitation?

A

pan systolic murmur

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28
Q

What are the risk factors for heart failure ?

A
  • increasing age
  • smoking
  • hypertension
  • diabetes
  • dyslipidaemia
  • obesity
29
Q

What are the main causes of heart failure ?

A
  • ischaemia (MI, coronary artery disease)
  • hypertension
  • diabetes
  • valve defects
  • uncontrolled AF
  • drug/toxin induced (drugs, meds, alcohol)
  • endocrine (thyroid)
  • infective (viral myocarditis)
  • genetic (HOCM)
30
Q

What are the symptoms of heart failure ?

A
  • breathlessness (on exertion, orthopnoea, PND)
  • loss of energy/fatigue
  • pulmonary oedema/effusion
  • pitting oedema
  • raised JVP
  • ascites
  • tachycardia
  • S3 gallop
31
Q

How is heart failure different to an average diagnosis?

A

heart failure is the syndrome not the diagnosis, you then have to find the cause of the heart failure

32
Q

How do levels of BNP in blood help diagnose heart failure ?

A
  • normal levels = NOT heart failure
  • high levels indicate heart failure
  • higher levels = worse prognosis
33
Q

What is echocardiography ?

A

an ultrasound scan of the heart

34
Q

What is normal ejection fraction of the heart ?

A

approx. 60%

normal range 55-70%

35
Q

How does echocardiography help the diagnosis of heart failure ?

A
  • assess ejection fraction
  • observe left ventricular function
  • help define aetiology (valve defects, chamber sizes etc)
36
Q

What are the two categories of heart failure patients based on ejection fraction (EF) ?

A
  1. HF with preserved left ventricular function EF >45%
  2. HF with impaired systolic function EF <45%
37
Q

What treatment do you give someone with ‘Heart failure with preserved left ventricular function’ ?

A
  • diuretics (e.g furosemide)
  • treatment of the underlying cause/comorbidity (e.g hypertension meds etc)
38
Q

What treatment do you give someone with ‘Heart failure with impaired systolic function’ ?

A
  • diuretics (e.g furosemide)
  • ACE inhibitors (e.g rampiril)
  • beta blockers *(e.g bisoprolol)
  • aldosterone receptor antagonists (e.g spirinolactone)
  • devices (e.g pacemaker)
39
Q

What do ACE inhibitors do?

A

block the conversion of angiotensin 1 into angiotensin 2

40
Q

What is a common side effect of ACE inhibitors ?

A

a dry cough

in this case usually give the patient beta blockers instead

41
Q

Which beta blocker is NOT licensed for use in heart failure ?

42
Q

What level of heart failure indicates the use of angiotensin receptor antagonist drugs ?

A

treatment of severe left ventricular dysfunction (EF <35%)

43
Q

What are the ABCDE signs of heart failure on a CXR ?

A

A = alveolar oedema (bat-wing opacity)
B = kerley B lines
C = cardiomegaly
D = dilated upper lobe vessels
E = pleural Effusion (often bilateral)

44
Q

What do kerley B lines look like on a CXR ?

A

short horizontal peripheral lines at the lung bases

kinda look like staples or lots of dashes groups together

45
Q

What is ejection fraction ?

A

the measure of how much blood is pumped out the heart with each beat

46
Q

What are the top 2 most common causes of heart failure in the UK ?

A
  • coronary heart disease
  • hypertension
47
Q

What is the CHADS2VASc score used for ?

A

to predict the likelihood of an AF patient having a stroke

48
Q

What are the 7 risk factors used in the CHADS2VASc score ?

A

C = CHF
H = hypertension
A = age
D = diabetes
S = sex
S = stroke/TIA/VTE
Vasc = vascular history (previous MI, peripheral vascular disease etc)

49
Q

When would you add an SGLT-2 drug to a Heart Failure patients medications ?

A
  • symptomatic HF
  • reduced ejection fraction despite optimal therapy

reduces risk of re-admission and death

50
Q

What are some cardiovascular causes of collapse ?

A
  • aortic stenosis
  • arrhythmia
  • acute coronary syndrome
  • aortic dissection
  • postural hypotension
51
Q

What are some neurological causes of collapse ?

A
  • stroke
  • TIA
  • epilepsy
  • subarachnoid haemorrhage
  • muscle weakness
  • neuropathy
  • vasovagal
52
Q

What are some respiratory causes of collapse ?

A
  • pneumothorax
  • PE
  • asthma attack
  • pneumonia
  • hypoxia
53
Q

What are some haematological causes of collapse ?

A
  • blood clot (stroke, TIA, PE…)
  • haemorrhage
  • anaemia
54
Q

What are some endocrine causes of collapse ?

A
  • adrenal insufficiency
  • hypothyroidism
  • diabetic complication (DKA, hypoglycaemia, peripheral neuropathy, autonomic dysregulation)
55
Q

What are some surgery-related causes of collapse ?

A
  • post-operative sepsis
  • haemorrhage
  • acute abdomen
56
Q

What should be a top differential in patients with new clinical presentation of heart failure and murmur, especially if there’s a recent history of surgery?

A

infective endocarditis

57
Q

What are some classics peripheral signs of infective endocarditis ?

A
  • petechiae - pinpoint red spots on the skin/mucosa
  • subungual (splinter) haemorrhages
  • osler nodes - tender red nodules on distal pads of fingers/toes
  • janeway lesions - non-tender red spots on palms and soles
  • roth spots - retinal haemorrhages with small, clear centres (rare, seen in 5%)
58
Q

What criteria is used to diagnose Infective endocarditis?

A

Modified Duke Criteria

59
Q

What is the Modified Duke criteria split into ?

A
  • major criteria
  • minor criteria
60
Q

What classes as infective endocarditis on the Modified Duke criteria ?

A
  • 2 major criteria
  • 1 major, 3 minor criteria
  • 5 minor criteria
61
Q

What are the major criteria on the Modified Duke Criteria for infective endocarditis (IE) ?

A
  1. blood culture positive for IE from 2 separate sites
  2. evidence of endocardial involvement (via echocardiogram/PET/CT)
62
Q

What are the minor criteria on the Modified Duke Criteria for infective endocarditis (IE) ?

A
  1. predisposition (e.g IV drug use)
  2. fever temperature >38
  3. vascular phenomena (e.g aterial emboli, septic pulmonary infarcts, intercranial haemorrhage, janeways lesions…)
  4. immunologic phenomena (e.g glomerularnephritis, osler’s nodes, roth spots, rheumatoid factor)
  5. microbiological evidence (e.g positive blood culture that doesn’t meet a major criterion, evidence of IE related active infection)
63
Q

Which microorganisms are consistent with infective endocarditis?

A
  • staphylococcus aureus
  • viridans streptococci
  • streptococcus bovis
  • HÁČEK group
  • community acquired enterococci
  • coxiella burnetii
64
Q

What would be seen on an echocardiogram showing infective endocarditis ?

A
  • vegetation (masses on the valves)
  • abscess, psuedoaneurysm, intracardiac fistula
  • valvular perforation or aneurysm
  • new partial dehiscence of prosthetic valve (splitting/bursting of valve)
65
Q

What is the management for infective endocarditis ?

A
  • early identification
  • blood cultures from 3 separate sites *before antibiotic administration *
  • transthoracic echo (TTO) (first line imaging for IE)
  • transoesophageal echo (TOE) (used when IE suspected but TTO wasn’t confirmatory)
  • referral to endocarditis MDT
  • assessment of embolic complications
  • surgery incase of valvular repair/replacement
66
Q

How might a patient with severe aortic stenosis present ?

A
  • fluid overload (SOB, orthopnoea, peripheral oedema)
  • exertional syncope
  • chest pain
  • murmurs
67
Q

What is aortic stenosis ?

A

thickening of the aortic valve, causing restricted opening and subsequent obstructed blood flow out the LV

68
Q

What is the treatment for aortic stenosis ?

A
  • diuretics to improve symptoms
  • surgical valve replacement
  • TAVI (transcatheter aortic valve insertion)

ICL Block Year 3 (4 decks)

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