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Year 2 PBL > u12w4: heart failure > Flashcards

u12w4: heart failure Flashcards

1
Q

What are the key features of left-sided heart failure?

A

Dyspnea - SOB
Orthopnoea - dyspnoea on lying down
Paroxysmal noturnal dyspnea -
Pulmonary congestion and odema = basal crackles
Exercise intolerance

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2
Q

What are the key features of right sides heart failure?

A

Odematous swelling of feet, ankles, legs
Hepatomegaly - enlarged, palpable, tender liver (nutmeg appearance on gross and microscopic examination)
Ascities
Escessive nocturnal urination (when body absorbed excess fluid and converts into urine)
Raised jugular venous pressure
Exercise intolerance.

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3
Q

What is the kep epidemiology of heart failure?

A

Annual incidence of 10% in over 65yrs
The long term outcome is poor and approximately 50% of patients are dead within 5 years.

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4
Q

What are the three main causes of heart failure?

A
  1. Ishcemic heart disease (35-40%)
  2. Cardiomyopathy-dilated (30-34%)
  3. HTN (12-20%)
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5
Q

What are some less common causes of heart failure?

A

1.Cardiomyopathy-hypertrophic (disatolic dysfunction) or restrictive (stiff-non compliant ventricles)
2. valve disease
3. Congenital (ASD, VSD)
4. Alcohol and chemo (imatinib)
5. Hyperdynamic circulation (anaemia, thyrotoxicosis, Pagets disease)
6. RtHF - from RV infarct, pulmonary hypertension, COPD
7. Severe brady/tachycardia (AF, CHB, SSS)
8. Pericardial disease (constrictive pericarditis)
9. Infections (myocarditis)

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6
Q

What blood tests are ordered to investigate someone with heart failure as a differential diagnosis?

A

FBC - rule out anemia
Creatinine and electrolytes - kidney damage as cause of fluid retention
LFTs - nutmeg liver, liver congestion
Troponini - I most specific for MI
BNP - ventricular strain
Thyroid function - cause of heart failure

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7
Q

What investigations should be ordered for a patient with heart failure as a differential?

A

Blood tests
Chest XR
ECG
Echo and stress echo
Nuclear cardiology
MRI
Coronary catherisation
Biopsy
Cardiopulmonary testing
Ambulatory 24-hour ECG monitoring

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8
Q

How are the heart sounds altered in heart failure?

A

Third and fourth heart sounds may appear
THird heart sound - rapid passive ventricular filling during diastole, can indicate a distened ventricle (Dilated cardiomyopathy)
Fourth heart sound - occurs in late diastole, resistance to ventricular filling, active ventricular filling, indicates a stiffned ventricle.

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9
Q

What are the different sings of heart failure?

A

Tachycardia
Elevated JVP
Cardiomegaly
Third and fourth heart sounds
Bi-basal crackles
Pleural effusion
Peripheral ankle oedema
Ascites
Tender hepatomegaly.

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10
Q

What is the simple pathophysiology of heart failure?

A

Heart fails - decreased cardiac output
Compensatory mechanisms (RAAS and SNS) attempt to maintain cardiac output and peripheral perfusion - affects venous, return, outflow resistance, contractility of myocardium and salt/water retention.
Mechanisms are overwhelmed no longer beneficial- tend to increase preload and afterload increasing cardiac work and causing myocyte damage.
In particular adrenergic stimulation a) incr contractility/HR in cardiac work
b) direct cardiotoxicity through myocyte damage.
Increase energy consumption
Structural remodelling of the heart

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11
Q

What are some of the pathophysiological changes seen in heart failure?

A

Ventricular dilation
Myocyte hypertrophy
Increased collagen synthesis
Altered myosin gene expression
Altered sarcoplasmic Ca2+ ATP density
Increased atrial natiuretic peptide secretion
Salt and water retention
Sympathetic stimulation
Peripheral vasoconstriction

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12
Q

What is myocardial remodelling in heart failure?

A

Process of progressive alteration of ventricular size, shape and function due to mechanical, neurohormonal and genetic factors.

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13
Q

What ventricular remodelling occurs after MI leading to heart failure?

A

Initial infarct
The infarct will expand over hours to days - this region of tissue has died so becomes thinner and stretched.
Wall stress increases - leading to progressive dilation of the infarcted area
Other areas in the wall may become hypertrophied due to increased wall stress.
Fibrosis develops in areas of remodelling - not enough oxygen and nutrients so cardiac myocytes die.
Over days to months the global remodelling occurs and the heart function is lost.

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14
Q

What ventricular remodelling occurs in systolic and diastolic heart failure?

A

Normal heart - undergoes uneccessary strain e,g tachycardia from arrhythmia or increased afterload.
Leads to hypertrophied heart due to increased workload - diastolic heart failure
This and other methods are poor compensation to increase CO leads to Insufficient oxygen delivered to tissue to reach demand, this causes death of tissue resulting in a dilated heart with fibrosis - systolic heart failure.
THis is progressive ventricular hypertrophy and dilation - does not require infarction.

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15
Q

What is the New York Heart Association classification of symptoms severity in heart failure?

A

Class 1 - no limit of physical activity, ordinary PA does not cause fatigue, palpitation, dsypnea (aka can play baseball, jogging)
Class 2 - slight limitation in pa, comfortable ar rest, but ordinary activity causes f,p,d. (walk and gardening)
Class 3 - marked limitation of physical activity, comfortable at rest, less than ordinary pa cause f,o,d. (can shower and get dressed)
Class 4 - unable to do pa, symptoms of heart failure at rest, discomfort worsens in pa. (no activity without discomfort)

Orindary activity - walking or climbing staris
Less than ordinary - yoga, gentle stretching

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16
Q

What criteria are required to be diagnosed with HF-REF?

A
  1. Symptoms typical of heart failure
  2. Signs typical of heart failure
  3. Reduced LV ejection fraction
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17
Q

What criteria are required to diagnose of HF-PEF?

A

Symptoms typical of heart failure
Signs typical of heart failure
Normal or only mildly reduced LV ejection fraction and LV not dilated
Relevant structural heart disease (LV hypertrophy/left atrial enlargement or diastolic dysfunction)

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18
Q

What is the relationship between diastolic and systolic heart failure and ejection fraction?

A

Systolic - reduced ejction fraction, loss of contractility - tends to be dialted ventricle due to thinning and weakening of wall

DIastolic - ejection fraction remains, volume of filling decreases, cardiac hypertrophy (e.g from hypertension), reduces filling but contractility remains the same.

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19
Q

What are the three parameters used to describe the function of the ventricles?

A
  1. Stroke volume - the volume of blood ejected by the ventricle in one beat
  2. Ejection fraction - the fraction of the EDV ejected in one stroke volume
  3. Cardiac output - the total volume ejected by the ventricle per unit of time.

This all influences EDV which correlates with venous return.

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20
Q

What factors affect stroke volume?

A

Preload - intrinsic to the heart, affects the resting ventricular muscle fibre length hence the force generated by contraction.

Contractility - ionotropic effect, extrinsic to the heart, does not affect reting muscle fibre length

Afterload - changes aortic pressure, external to the heart, changes the amount of pressure the ventricles must generate before the aortic valve will open.

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21
Q

How do you calculate ejection fraction?
What is it an indicator of?

A

Stroke volume/EDV
Is an indicator of contractility.

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22
Q

How do you calculate cardiac output?
What is the average value?

A

SV * HR
Approximately 500ml/min in a 70Kg person (70ml sv and 72 bpm)

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23
Q

What on a chest x-ray can indicate heart failure?

A

Cardiomegaly - by cardiothoracic ratio above 50%
Pulmonary congestion - vascular opacity towards upper lobes (pulmonary odema), with upper lobe diversion (dilation of veins), fluid in fissures and Kerley B lines (horizontal white lines less than 2cm long in bases of lungs represent interseptal oedema)

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24
Q

What can be seen on an ECG that is indicative of heart failure?

A
  1. Ischemia - pathological Q waves
  2. Ventricular hypertrophy - Increase QRS amplitude, convex ST segment
  3. Arrhythmia (lack of P waves or A fib -due to cardiac dysfunction)
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25
Q

What can be seen on a echocardiography that is indicative of heart failure?

A

Abnroaml cardiac chamber dimension
Poor systolic and diastolic function
Regional wall motion abnormalities
Valvular disease - such as regurgitation or stenosis
Cardiomyopathies

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26
Q

What is a nuclear cardiology investigation?
And how might it indicate heart failure?

A

Radionucleotide angiography - radioactive tracer injected into blood vessels tracked through heart and vessels - ventricular ejection fraction.
SPECT or PET - demonstrate myocardial ischemia and viability in dysfunctional myocardium.

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27
Q

What is a cardiac MRI?
And how might it indicate heart failure?

A

Assess cardiac structure and function and viability in dysfunctional myocardium
Use dobutamine for contractile reserve (difference in contractility at rest compared to physiological stress) or use gadolinium for delayed enhancement which identifies fibrotic tissue (infarct imaging)

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28
Q

What is cardiac catheterisation?
How can it be used to indicate heart failure?

A

Coronary angiogram is an example
Uses iodine contrast dye to visualise blood vessels on x-ray images
Diagnosis - ischaemic HF and suitability for revascularization
Catheter often has a pressure sensor at the tip so can measure pulmonary artery pressure, left ventricular ED pressure and left atrial (wedge) pressure.

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29
Q

What is the use of a cardiac biopsy in heart failure patient?

A

Diagnose cardiomyopathies such as amyloid
And follow up transplanted patients to assess rejection

Only takes a small tissue from heart often myocardium via a catheter then may use certain dyes to look for certain features.

30
Q

What is the use of cardiopulmonary exercise testing in congestive heart failure?

A

Measure peak oxygen consumption - predictive of hospital admission and death in heart failure
Also have a lower anaerobic threshold
May use a 6 minute walk instead of a bike protocol

31
Q

What is the purpose of a ambultory 24 hour ECG monitoring (Holter) in a patient with suspected congestive heart failure?

A

Used in patients with suspected arryhtmias and may be used in severe heart failure or inherited cardiomyopathy to determine is a defibrillator is appropriated for non-sustained ventricular tachycardia.

32
Q

What is the use of a stress echocardiography in a patient with suspected congestive heart failure?

A

Assess viability in dysfunctional myocardium when at physiological stress (exercise or medication induced)
Dobutamine reserve in stunned or hibernating myocardium

33
Q

What are the three essential tests that should be ordered in all patients with suspected congestive heart failure?

A

Chest x-ray
ECG
Echo.

34
Q

What is the algorithm for the diagnosis of congestive heart failure?

A

Is heart failure is suspected because of signs and symptoms assess cardiac disease by an ECG, CXR and natiuretic peptide measurement (rule out point)
If abnormal order a echocardiogram (rule out)
If abnormal - assess aetiology, degree, precipitating factors and type of dysfunction - use additional tests when appropriate
Choose and being treatment

35
Q

What general lifestyle advice should be given to a patient with congestive heart failure?

A

Education - family and patients, particularly on weight monitoring and dose adjustment of diuretics - prevent hospitalisation
Dietary modification - salt restriction, fluid restriction in severe cases (may need to weight daily)
Stop smoking
Ecnourage physical activity, exercise training and rehabilitation - norm low level endurance 5 times a week
Vaccination - flu and pneumonia
Sexual activity - if taking nitrates such not take PDE5 inhibitors (Viagra)
Driving - vary based on person and symptoms, LVEF less than 40 cannot drive buses or large lorries.

36
Q

What should be involved in the long term monitoring of a patient with congestive heart failure?

A

Functional capacity - by NYHA functional class, exercise tolerance test or echocardiography
Fluid status - body weight, serum creatinine and electrolytes
Cardiac rhythm - ECG or holter rhythm

37
Q

What MDT approach may be used in patients with CHF?

A

Integrated approach
Cardiologist or physician with a specialist interest in heart failure
Heart failure nurse
Dietician
Pharmacist
Occupational therapist
Physiotherapist
Palliative care adviser.

38
Q

What precautions should be taken with certain medications in congestive heart failure?

A
39
Q

What are the different stages of heart failure?

A

Stage A - high risk but with no symptoms
Stage B - structural heart disease, no symptoms
Stage c - structural disease, previous or current symptoms norm adequately managed with medical treatment
Stage D - refractory symptoms requiring specialist intervention

40
Q

What interventions tend to be used at different stages of heart failure?

A

A - risk factor reduction, ACEi or ARA norm to treat hypertension, DM, dyslipidemia
B - ACEi or ARB in all patients, beta-blockers in selected patients
C - beta blocker in all, dietary sodium restriction, diuretic, digoxin, cardiac resynchronization, revascularization, mitral valve surgery, alsoterone antagnoist
D - inotropes, VAD, transplant, hospice.

41
Q

How does the ejection fraction in congestive heart failure relate to the symptoms the patient may experience?

A

Normal EJ - 50% plus - usually comfortable during ordinary activity
Partially/borderlines 41-49% - symptoms noticeable during activity
Reduced - 40% or below - noticeable at rest.

42
Q

What are some of the electrophysiological changes in chronic heart failure during cardiac remodelling?
(cellular changes**)

A
  1. Loss of t-tubles - uncoupling of ryanodine receptors from L-type calcium ion channels in SR - inefficient excitation contraction coupling
  2. Decreased expression of SR Ca2+ ATPase pump so less reuptake of CA2+ during diastole - impaired myocyte relaxation and ventricular filling
  3. Ryanodine recpeotrs become kealy - reduce SR Ca2+ content
  4. Upregulated Na+/Ca2+ exchanger on the surface of the myocyte leads to increased Ca2+ loss into ECF.
  5. Overall less release of Ca2+ into cytoplasm during sytole - impaired action on troponin - leads to impaired contractile function
  6. Downregularion of B1 adrenoreceptors due to sympathetic overactivity leads to impaired contractile reserve.
43
Q

What is the law of laplace?

A

The tension in a vessel or heart chamber wall is equal to:
Pressure in that chamber * radius of the chamber
Divided by
2 * wall thickness

44
Q

How does the law of laplace underpin the process of cardiac remodelling in CHF?

A

WP = RP/2h
During chronic stress on the heart such as pressure overload (afterload) in hypertension ventricular pressure increases - resulting in increased wall stress
To compensate - inc wall thickness and decrease radius - hypertrophy and fibrotic remodelling in lef ventricle to decrease wall stress.
However, this compensatory mechanism leads to wall stiffness and reduced compliance (reduced relaxation and filling)
This becomes maladaptive and the ECM degrades leading to chamber dilation and wall thinning - this increases wall tension.

45
Q

What are the different hospice care support teams in heart failure patients?

A

Community palliative care nurse specialists
Day hospice
Hospice at home
Palliative care inpatient unit

46
Q

What is the role of a community palliative care nurse specialist?

A

Visit patient at home
Give advice on symptom control medication
Provide support to patient and family
Work collaboratively with GP and heart failure specialist nurse

47
Q

What is the function of a day hospice?

A

Patients attend weekly
Social interaction
Access to physiotherapy and relaxation which may help breathlessness
Acess to psychological support
Review by palliative care nurses and doctors if required
Provides respite one day a week for informal carers in the home

48
Q

What is the role of a hospice at home?

A

Health care assistances provide shifts in patinets home in last days/weeks of life
Support patient to die at home when this is there wish

49
Q

What are the three different elements of advanced care planning?

A

Can make a advanced statement of wishes and preferences of what you want to happen to you
Advanced Decision to Refuse Treatment ADRT - what you do not want to happen to you
Proxy or Lasting power of attorney - who will speak for you

This must all be done in terms with the UK Mental Capacity Act to assess if the patient is competent.

THe purpose is to encourage patients to think ahead, realist what is important to them, then discuss and record this with their family, friends and the health care department.

50
Q

What information must be included on a DNAR form?

A

Patient details - name, DOB, address, NHS number etc
Reason why form completed.
Who the discussion has taken place with, either the patient or a relative
Must be signed and dated by two medical professionals.
Must fill out date on form, and identify a review date.

51
Q

What are the four reasons on a DNAR form why it may be filled in?

A

Attempting CPR is unlikley to restart the patients heart and breathing
There is no benefit in restarting patients heart and breathing
The expected benefit of treatment is outweighed by burdens
Attempted resuscitation is against the competent patients expressed wishes.

52
Q

What is the impact of chronic condition on the patient and their family?

A

Must adjust fron seeing the purpose of healthcare from curative to care, this challenges the biomedical model of healthcare.
Chronic condition is not just biological affects it also affects the social life of the person, referred to a negotiated reality - can be difficult to manage the chronic illness with little compromise on their social life.
Face discredited, discreditable, enacted and felt stigma.

53
Q

What are the key sociology ideas of living with a chronic illness?

A

Diagnostic limbo - high levels of uncertainity
Biographical disruption - destabilisation, questioning and reorganisation of identity after diagnosis.
Narrative reconstruction - how people make sense of their illness in the context of their lives

54
Q

What are the three different strategies to manage stigma?

A

Passing - concealing or hiding characteristic in certain scenarios, can give short term relief but in long term increases stigma by reinforcing idea that certain people do not fit in certain groups.
Covering - downplaying or minimising an aspect of their identity in order avoid stigma
Withdrawing - no attending social events and keeping to themselves, in order to avoid people who may stigmatise them.

55
Q

What are the different ECG changes in heart block?

A

If the R is far from P then you have a first degree
Longer, longer, longer, drop! Then you have a wenckebach
Is some Ps don’t get through then you have a mobitz 2
Is Ps and Qs don’t agree, then you have a third degree.

56
Q

What are the causes of impaired cardiac contractility?**

A

NS - downregulation of beta adrenergic receptors due to overstimulation by SANS
RAAS - increase fluid retention, increase preload and afterload reduce stroke volume and EDV.
ANP/BNP - decrease fluid retention - should improve contractility, however effect is overwhelmed by that of the ANS and RAAS

Lead to cardiac remodelling and ventricular dysfunction.

57
Q

What are the effects of natiuretic peptides on the contractility of the heart?**

A

ANP - released from atrial myocytes in response to stretch
BNP - released from ventricles during wall stress
Causes diuresis, natruiresis (dilation of afferent arteriole), vasodilation (acts at guanylyl cyclase receptor) and suppression of RAAS (via increase in renal blood flow) –> decrease preload and afterload inc contractility.

58
Q

What are the three different types of cardiomyopathy?

A

Hypertrophic
Dilated
Restricted

59
Q

What is a hypertrophic cardiomyopathy?**

A

Increased ventricular wall thickness, reflects changes from increased loading. - most common cause in long standing hypertension.
Disease of the sarcomere. Can be gentic in cause with abnormal sarcomeric proteins thickening wall and impairing filling.
Can lead to HFpEF

60
Q

What is dilated cardiomyoopathy?

A

Dilated left ventricle with poor systolic function.
Often has dilated ventricles (left more than right), thin stretched chamber walls and a hypo-contractile myocardial muscle.
Can lead to HF-rEF.
Common cause - MI or infectious myocarditis.

61
Q

What is restrictive cardiomyopathy?**

A

Abnormal stiffness of the myocardium results in impaired ventricular filling during diastole, reducing diastolic and systolic volumes.
With normal ventricular wall thickness.
Causes by infiltration of the myocardium by disease process such as amyloidosis, scleroderma, sarcoidosis.
Can result in high atrial pressure and atrial hypertrophy - resulting in atrial dilation and atrial fibrillation with pulmonary and systemic congestion as a consequence.
Can lead to HFpEF.

62
Q

What are the cellular changes in cardiac remodelling?**

A
  1. Thickening and increase in number of cardiac myocytes - increase protein expression
  2. Thinning and apoptosis of cardiac myocytes
  3. Fibroblast proliferation to help heal the tissue
63
Q

What are the extracellular changes in cardiac remodelling?**

A

Fibrosis - increased collagen and ECM deposition and synthesis - replaces functional myocardium with scar tissue, this can impair conductivity and inc stiffness of the myocardium
Change the proportions of collagen and elasting - lead to stiffness or dilation of the heart chamber wall
Increase MMPs - promote ECM remodelling by degrading existing matrix.
Chronic remodelling can promote chronic remodelling.

64
Q

What is a gallop rhythm as a sign in heart failure?
How does it link to the pathophysiology of heart failure?**

A

Gallop rhythm - an abnormality in heart sounds on auscultation of the chest, normally an additional sound (not just S1 and S2)
S3 (ventricular gallop)- caused by rapid ventricular filling, due to fluid overload, often in a dilated or hypertrophied ventricle, results from increased ventricular filling pressure or impaired relaxation of the ventricles - indicates ventricular dysfunction which can be seen in heart failure
S4 (atrial gallop)- heard in late diastole, caused by atrial contraction forcing blood into a stiffened or non-compliant ventricle. May be due to hypertrophy cardiomyopathy or fluid overload.

65
Q

How should atrial fibrillation be diagnosed in a heart failure patient?

A

ECG (either a 12 lead or a 24 hour ambulatory ECG monitor) - irregularly irregular rhythm with no p waves, tachycardia, no isoelectric base line
Feel an irregular and fast pulse on the patient.

66
Q

Why is the link between HF and arrhythmias significant?**

A

Most comon arrythmia is A.fib
Combined increase the risk of stroke, hospitalisation and death. Should assess the risk of stroke in all patients with A flutter - may require anti-coagulation therapy.

67
Q

What is the link between heart failure and arrhythmias? **

A

Bidirectional relationship - unsure what is a causative but strong link between the pathophysiology of both conditions.
A fib - reduced cardiac output activates compensatory mechanisms RAAS and SANA - vicious cycle - tachycardia-induced cardiomyopathy due to increased cardiac stress
HF - increased atrial pressure - promotes fibrosis and scarring - damage conduction system = A.fib. Also alteres gene expression and causes atrial structural remodelling.

68
Q

What is the role of a heart failure specialist nurse?

A

Work across primary, secondary and tertiary care teams improving communication and integrated care for the patient - advocate for patient needs.
Educate patients/family and check understanding of condition, treatment, self monitoring and what to do if they have a problem.
Provide emotional support
Act as a point of contact for patients - refer to consultant(needed MDT member), offer advice or reassurance as needed.
Medication management - monitor for side effects and adjust doses (sometimes)
Lifestyle counselling - such as diet, exercise and smoking cessation.

69
Q

What is a role of heart failure clinic in the NHS?

A

Specialist outpatient clinic
Referred to by GP if blood tests indicate sign of weakness of strain on heart.
Patients are triaged and sent appointment date. Initial appointment - testing for diagnosis (ECho and ECG minimum)
May organise medication, community or hospital support teams and cardiac rehabilitation for the patient.
Will recieve a personalised plan with a focus on managing symptoms and improving quality of life. May be offered regular follow-up appointments if needed.
Encourage patient education and self-management when possible.

70
Q

What is an LVAD and what is its purpose in a heart failure patient?

A

Left Ventricular Assistive Device - mechanical pump implanted in chest, connected o the left ventricle and the aorta, continuously moves blood from LV into A improving blood flow. Connects to an external controlled via an LVAD line on the abdomen, controller manages speed and function of pump and can be adjusted by healthcare professional as needed, requires an external power source connected through a power cord. Reachargeable batteries.
Purpose - bridge to transplant, imporve symptoms and quality of life, hemodynamic support (ensure adequate blood supply yo organs), destination therapy (until death)

71
Q

What is the use of a heart transplant in a heart failure patient?
What is a heart transplant?

A

Heart transplant - recipient recives a new undamaged heart from a donor.
Offered to patients with refractory cardiogenic shock organised by NHS blood and transplant.
Tends to be given to younger patients who are otherwise healthy, when they have severe treatments that are not effectively managed by other treatments.
Is relatively rare due to lack of donors, age of patients and severity of procedure
Benefit - heart with no cardiomyopathy, reverse damage, remove structural and functional abnormalities of heart.
Increase life expectancy and blood flow (average gain of 14 yrs from all transplant)

72
Q

What end of life care tends to be offered to patients with heart failure?

A

Oxygen - may have at home portable oxygen cylinder - carry 3 hours worth of oxygen each - weight 2-3kg and fit inside a small backpack. Often requires fire risk assessment, should not smoke or have open flames or certain electricals near flames
May also be given morphine to help with dyspnea - reduce respiratory rate and improve inspiratory capacity.
Pain - WHO analgesic ladder: (paracetamol, codeine, morphine)
Fatigue - beta blocker, iron supplement
Anxiety - CBT+, antidepressants
Nausea/vomitting - anti-sickness medication.

Year 2 PBL (27 decks)

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