Heart Failure Flashcards
What are two ways of classifying heart failure?
Left/Right/Mixed (usually mixed)
Acute/Chronic
What is left sided heart failure mainly due to?
- IHD = MI’s
- Cardiomyopathy
- valvular disease
What is right sided heart failure due to?
- secondary to left heart failure
- cor pulmonale
- congenital heart disease
What are the clinical symptoms of left sided heart failure?
Dyspnoea on exertion/rest
Orthopnoea
Paroxysmal nocturnal dyspnoea
Pulmonary oedema
(sudden dyspnoea pink, frothy sputum)
What are the clinical signs of left sided heart failure?
Tachycardia
Fine crepitations
Pleural effusion
S3 (Gallop rhythm = S3 + Tachycardia)
What is seen on CXR for left sided heart failure?
Cardiomegaly
Bats wing shadows esp. lower zones
Interstitial fluid
What is the clinical symptom for right sided heart failure?
oedema
What are the clinical signs of right sided heart failure?
Oedema (ankle/sacral)
JVP elevated (>4cm above sternal angle)
Hepatomegaly
Ascites
What is seen on CXR for right sided heart failure?
normal
How is cardiac failure diagnosed?
B-type natriuretic peptide:
Refer patients with suspected heart failure and a BNP level above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml (236 pmol/litre) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks.
Refer patients with suspected heart failure and a BNP level between 100 and 400 pg/ml (29–116 pmol/litre) or an NTproBNP level between 400 and 2000 pg/ml (47–236 pmol/litre) to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks
Transthoracic Doppler 2D echocardiography:
-excludes important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts.
What is the standard medical treatment for CCF?
Diuretics to excrete retained fluid:
- furosemide
- thiazide for mild cases only
Angiotensin converting enzyme inhibitors:
-if cough used ARB
Beta Blockers (caution required):
- Can worsen CCF in long term
- start low go slow
- initial risks hypotension/worsening dyspnoea
Spironolactone (severe cases only):
- aldosterone receptor antagonist
- S/E hyperkalaemia/renal dysfunction/gynaecomastia
- add digoxin if AF
- other vasodilators such a nitrates/hydralazinefirst-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
second-line treatment is now either an aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate
if symptoms persist cardiac resynchronisation therapy or digoxin* should be considered. An alternative supported by NICE in 2012 is ivabradine. The criteria for ivabradine include that the patient is already on suitable therapy (ACE-inhibitor, beta-blocker + aldosterone antagonist), has a heart rate > 75/min and a left ventricular fraction < 35%
diuretics should be given for fluid overload
offer annual influenza vaccine
offer one-off** pneumococcal vaccine
What is the surgical treatment for CCF?
Implantable Cardiac Defibrillators
Cardiac Resynchronisation Therapy:
- only for prolonged QRS
- 3 pacemakers force LV and RV to contract together
Transplantation
when would ivabradine be used in CCF?
if fast HR despite BBlockers
What is the management of acute left ventricular failure?
- Sit up and 100% oxygen flow
- Do an ECG, FBC, U/E, Cardiac enzymes, ABG, CXR
- Sublingual 2 puffs nitrates or oral to enhance myocardial perfusion
- IV opiates [diamorphine 2.5-5mg] to reduce anxiety and preload
- IV furosemide 40-80mg i.v. to reduce fluid retention, hence pulmonary edema
- If Systolic>90 then give IV infusion isosorbide dinitrate 2-10mg/h, if Sys<90 then treat as cardiogenic shock
What are the investigations for a suspected heart failure with no previous MI?
measure serum natriuretic peptides (BNP)
if levels are ‘high’ arrange echocardiogram within 2 weeks
if levels are ‘raised’ arrange echocardiogram within 6 weeks
