Cardiology > Heart Failure > Flashcards

Heart Failure Flashcards

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1
Q

Pathophysiology of Heart Failure

Mechanisms of heart failure [3]

A

Systolic and diastolic failure
Left and right failure
High and low output failure

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2
Q

Explain systolic vs diastolic heart failure but note that they usually co-exist

A 
Systolic Heart Failure EF low
- Decreased pumping / CO and fluid backs up
- Eg IHD, MI, cardiomyopathy
Diastolic - preserved EF
- Hypertrophy so doesn't fill or relax 
- Fluid back up
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3
Q

Explain the difference between Left and Right sided Heart Failure

A

• Left sided failure:

  • Ax: IHD, valvular heart disease
  • Blood backs up to lungs > pulmonary congestion, hypertension
  • Decreased pulses

• Right sided failure:
- Ax: LVF, pulmonary stenosis, cor pulmonale
- Less blood goes to lungs
- Blood backs up to body tissues causing edema
Right-sided heart failure generally develops as a result of advanced left-sided heart failure

• Congestive cardiac failure: left and right failure

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4
Q

Describe low [4] and high [3] output failure

A

Low output failure

  • cardiac output reduced, normally increases with exertion
  • Pump failure
  • Excessive preload
  • Chronic excessive after load

High output failure (rare)

  • output normal or increased due to increased body requirements
  • but CO can’t meet these requirements
  • Anaemia, pregnancy, Paget’s disease, AV malformation
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5
Q

Causes of low output failure:
Pump failure [3]
Excessive preload [2]
Chronic excessive after load [2]

A
  1. Pump failure:
    - systolic and/or diastolic failure
    - reduced heart rate (post-MI, heart block, beta blockers), negatively ionotropic drugs (anti-arrhythmic agents)
  2. Excessive preload:
    - mitral regurgitation
    - fluid overload (NSAIDs causing excessive fluid retention, normal heart but renal impairment or fluids running too fast)
  3. Chronic excessive afterload:
    - aortic stenosis, hypertension
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6
Q

Presentation of RHF [6] and LHF [6]

A

RHF:

  • JVP elevated
  • peripheral oedema (sacrum, thighs, abdo wall), ascites
  • nausea, anorexia
  • venous engorgement
  • neck and face pulsation (tricuspid regurgitation)
  • epistaxis

LHF:

  • SOB, orthopnoea, PND, nocturnal cough (pink frothy sputum)
  • wheeze (cardiac asthma)
  • RV heave
  • poor exercise tolerance
  • fatigue
  • weight loss (cardiac cachexia; can be masked by “weight gain” due to oedema)
  • muscle wasting
  • cool peripheries, cyanosis
  • displaced apex beat
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7
Q

Investigations for heart failure [4]

A

N-terminal pro B type natriuretic peptide
TFTs- thyrotoxicosis may mimic HF, Haematinics
ECG
TTE
CXR

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8
Q

B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels are associated with a poor prognosis.

A

high (2000ng/L) = TTE in 2w
Natriuretic peptides are non-specific but
very sensitive and so a normal level virtually
excludes heart failure.

2. raised (400-2000ng/L) = TTE in 6w

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9
Q

Findings on ECG [5]

A

Ischemic changes
MI
Ventricular hypertrophy
- RVH = tall R wave in V1, deep S wave in V6
- LVH = deep S wave in V1, tall R wave in V6

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10
Q

TTE uses in ix heart failure [3]

CXR [5]

A
  • TTE: identify valve disease, systolic and diastolic ventricular function and cardiac shunts
  • CXR: ABCDE =
    Alveolar oedema (bat’s wings)
    Kerley B lines (interstitial oedema)
    Cardiomegaly
    Dilated prominent upper lobe vessels
    Pleural Effusion
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11
Q

Diagnostic criteria for HF

A

Framingham criteria for congestive cardiac failure

>2 major OR 1 major and 2 minor

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12
Q

What is part of the Framingham MAJOR criteria [9]

A

 PND
 Bibasal crackles
 Neck vein distension
 Hepatojugular reflux
 Acute pulmonary oedema
 S3 gallop
 Cardiomegaly (cardiothoracic ratio >50% on CXR)
 Increased CVP (>16cmH2O in right atrium)
 Weight loss >4.5kg in 5d in response to mx

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13
Q

What is part of the Framingham MINOR criteria [7]

A 
	Bilateral ankle oedema 
	Nocturnal cough 
	SOB on ordinary exertion 
	Hepatomegaly 
	Tachycardia (>120bpm)
	Pleural effusion
	Decrease in VC of 1/3 of maximum recorded
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14
Q

Increased BNP [12]

A 
Age
LVH, Ischaemia, Valve
Tachycardia, Overload
Hyperaemia inc PE
Low GFR, CKD
Sepsis
COPD
DM
Liver cirrhosis
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15
Q

What causes decreased BNP [4]

A

Obesity
ACEI
BB
Diuretic / aldosterone antagonist

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16
Q

What is the New York classification of HF

A

Class 1 = no limitation
Class 2 = mild limitation to exercise, none at rest
Class 3 = moderate limitation, not at rest
Class 4 = severe limitation at rest

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17
Q

Management modalities of HF [5]

A

Lifestyle modification
Vaccination
Monitoring
Rx
Definitive treatment

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18
Q

Mx HF: Lifestyle mods [4], Vaccination [2]

A

Lifestyle modification:
- Cardiac rehab
- Smoking cessation, reduce alcohol
- Salt and fluid moderation
- Avoid NSAIDs
Vaccination:
- annual influenza
- and one off pneumococcal vaccination (need 5y booster if asplenia or CKD)

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19
Q

Mx HF: monitoring, definitive

A
  • Monitoring: effective mx lowers BNP levels

* Cardiac transplantation: severe refractory symptoms or refractory cardiogenic shock

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20
Q

Acute heart failure

Etiology: describe two groups and their causes

A
  1. Acute on chronic HF: precipitated by ACS, hypertensive crisis, acute arrhythmia, valvular disease
  2. De-novo acute HF: viral myopathy, toxins , valve dysfunction
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21
Q

Signs of Acute heart failure [8]

A
  • distress, pallor, sweating, sitting forward
  • cyanosis, tachycardia
  • pulsus alterans
  • elevated JVP
  • displaced apex beat
  • bibasal crackles, wheeze
  • S3 heart sound (gallop rhythm),
  • BP usually normal*
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22
Q

What causes severe pulmonary oedema [6]

A

LVF post MI or IHD
Valve disease
HF
ARDS any cause
Fluid overload
Neurogenic
Infection

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23
Q

What causes peripheral oedema [6]

Study These Flashcards
A 
Heart failure = most common
Cellulitis
DVT
Lack of mobility
Chronic venous insuffinecy 
Lymphoedema
24
Q

Initial management of acute heart failure [8]

Study These Flashcards
A 
Stop fluids
Sit patient up 
100% O2 if sats <96 but careful in COPD 
IV access, bloods: FBC U&E, CRP, ABG, *BNP, troponin
ECG (MI, arythmias)
IVFurosemide 40-80mg
IV Diamorphine 1.25mg-5mg slowly
GTN 2 puffs sublingual (unless SBP<90)
25
Further management of acute heart failure [4]
o SBP >100: start ISOSORBIDE DINITRATE infusion (keep SBP>90)  Echocardiogram: identify underlying cause o SBP <100: treat for cardiogenic shock and refer to ICU
26
Mx of cardiogenic shock [6]
``` IV Opiates - act as vasodilator Vasodilator Inotropes - NA (often need CCU / ITU) NIV - CPAP Ultra filtration Mechanical circulatory assistance ```
27
Subsequent mx for acute heart failure [4]
- aim for weight loss of 0.5kg/day - repeat CXR - treat as CHF - consider for biventricular pacing or cardiac transplantation
28
You've given isosorbide nitrate for patient in acute heart failure SBP >100. However she continues to worsen, what do you do? [3]
Worsening symptoms: - more FUROSEMIDE - CPAP (recruits more alveoli and drives fluid back into vasculature) - NITRATES
29
What is Cor Pulmonale
Cor pulmonale is defined as an alteration in the structure and function of the right ventricle (RV) of the heart caused by a primary disorder of the respiratory system.
30
Causes of cor pulmonale [4]
Interstitial lung disease PE CF Pulmonary hypertension
31
Two groups of drugs used in heart failure therapy?
Diuretics | Drugs that reduce ejection fraction
32
What drugs reduce ejection fraction? [6]
1. ACEI 2. BB 3. Mineralocorticoid receptor antagonist or aldosterone antagonist or dapagliflozin (SGLT-2 inhibitors) 4. Ivabradine 5. Digoxin Sacubitril valsartan (angiotensin receptor neprilysin inhibitor)
33
What drugs improve survival [3] | What drugs improve symptoms and survival [2]
Improve survival only: BB Ivabradine Vasodilator Improve symptoms and survival: ACEI / ARB (but not if EF normal) Spirnolactone
34
Loop diuretics MOA Eg [2]
Loop of Henle - ascending Inhibit Na-K-Cl Furosemide - rapid IV Bumetanide - slower use in older people
35
What do you do if resistant to loop | Eg [2]
Use with thiazide (inhibit reabsorption of Na at DCT) Don't leave on for too long Indapamide / BDZ
36
What are adverse effects of loop diuretics? [7]
Dehydration, Dizzy, Hypotension Metabolic disturbances: low K, Ca, Na, Cl Hypochloraemic alkalosis Gout Impaired glucose tolerance Renal failure due to dehydration, Uraemia Ototoxicity
37
What do BB do [3] | Eg [2]
Block sympathetic hormonal changes in HF Can precipitate deterioration Only use by specalist when other therapy has been tried BISOPROLOL or CARVEDILOL
38
When are BB CI [4]
Asthma Hypotension AV block Verapamil - rate-liming CCB
39
When is morphine indicated [2] MOA SE
Anxious Use if restless and distressed Vasodilator as reduced sympathetic drive Can cause respiratory depression
40
What does Ivabradine do [2] and criteria of use
Inhibitor of SA Node Does not modify contractility Must be on standard therapy, including BB and HR >75, left ventricular fraction < 35%
41
What does digoxin do?
Inotrope properties Enhance cardiac function by increasing availability of cardiac Use if still symptomatic on therapy / or if AF
42
What are affects of digoxin [2] and how do you monitor
Arrythmia Confusion U+E - particularly K (if low = more toxic)
43
What are vasodilators | MOA
Hydralazine Nitrate - isosorbide denitrate MOA: Reduce preload and after load Use if intolerant to ACEI
44
What does ACEI do for heart failure
Prevents conversion of angiotensin I to II | Reduce preload and after load
45
What do you do if K >6
Stop ACEI immediate
46
What does (Sacubitril) do
Prevent metabolism of ANP and BNP
47
What anti-coagulant and when are they indicated?
DOAC or warfarin | If in AF
48
What do you do if spironolactone not tolerated
Eplerenone if not tolerated or if had MI | Aldosterone antagonist
49
What are SE of spironolactone [3]
Gynaecomastia HyperK Renal failure
50
What does morphine do in pulmonary oedema
Reduce preload
51
What do diuretics interact with [5]
NSAID Anti-hypertensives = hypo Vancomycin Lithium Aminoglycosides
52
Acute management [8]
oxygen IV loop diuretics opiates vasodilators inotropic agents CPAP ultrafiltration mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices
53
First line treatment [4]
1. ACEi and a BB (start one at a time) ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction 2. Diuretics for fluid overload 3. Offer annual influenza vaccine 4. Offer one off pneumococcal vaccine
54
Sacubitril-valsartan indications [2]
In heart failure with reduced ejection fraction who are symptomatic on ACEi or ARB Initiate following ACEi or ARB washout period
55
When is cardiac resynchronisation therapy indicated in heart failure?
Cardiac resynchronisation therapy (CRT) uses a pacemaker that can stimulate the left ventricle. This is a very effective means of improving HF, particularly where there is sinus rhythm and LBBB. Combining an ICD with a cardiac resynchronisation therapy-pacemaker (CRT-P) results in a cardiac resynchronisation therapy defibrillator (CRT-D).
56
Medication that may exacerbate heart failure [6]
thiazolidinediones- pioglitazone is contraindicated as it causes fluid retention verapamil - negative inotropic effect NSAIDs/glucocorticoids- should be used with caution as they cause fluid retention low-dose aspirin is an exception - many patients will have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks class I antiarrhythmics flecainide (negative inotropic and proarrhythmic effect)
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