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TCD Cases > Heart Failure > Flashcards

Heart Failure Flashcards

1
Q

Define heart failure

A

The inability of the heart to pump adequate amounts of blood to meet the metabolic demands of the body

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2
Q

Give 6 factors that can potentially decrease BNP levels seen clinically

A
  1. Obesity
  2. Diuretics
  3. ACE inhibitors
  4. Beta blockers
  5. Angiotensin 2 receptor blockers
  6. Aldosterone antagonists
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3
Q

Recall the components of the first line treatment of chronic heart failure (ABAL)

A
  1. A - ACE inhibitor
  2. B - Beta blocker
  3. A - Aldosterone antagonist
  4. L - Loop diuretic
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4
Q

What are the 4 main potential causes of chronic heart failure?

A
  1. Ischaemic heart disease
  2. Valvular heart disease
  3. Hypertension
  4. Arrhythmias
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5
Q

What is the most common valvular heart disorder that can cause chronic heart failure?

A

Aortic stenosis

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6
Q

What is the most common arrhythmia leading to chronic heart failure?

A

Atrial fibrillation

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7
Q

What are the 5 key features of a patient presenting with chronic heart failure?

A
  1. Dyspnoea
  2. Cough
  3. Orthopnoea
  4. Paroxysmal nocturnal dyspnoea
  5. Peripheral oedema
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8
Q

In what subgroup of patients with chronic heart failure should ACE inhibitors be avoided in without specialist supervision?

A

Those with valvular heart disease

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9
Q

When would an aldosterone antagonist be indicated in the treatment/ management of chronic heart failure?

A

When there is a reduced ejection fraction and symptoms are not controlled by a ACE inhibitor and beta blocker.

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10
Q

Briefly outline the 3 factors which are thought to contribute to the precipitation of PND at night

A
  1. Fluid shift when the patient lies flat i.e. covering a larger surface area of the lungs
  2. Less reactive respiratory centre during sleep
  3. Less circulating adrenalin during sleep
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11
Q

Suggest the 4 main causes of de novo acute heart failure

A
  1. Ischaemia
  2. Viral myopathy
  3. Toxins
  4. Valve dysfunction
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12
Q

What are the 4 main symptoms associated with acute heart failure?

A
  1. Breathlessness
  2. Reduced exercise tolerance
  3. Oedema
  4. Fatigue
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13
Q

What are the 6 main clinical signs associated with acute heart failure?

A
  1. Cyanosis
  2. Tachycardia
  3. Elevated JVP
  4. Displaced apex beat
  5. Bibasal crackles (may also have a wheeze)
  6. S3 heart sound
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14
Q

What are the 4 main components of the diagnostic work up for patients with acute heart failure?

A
  1. Bloods - checking for anemia, electrolyte abnormalities and infection
  2. CXR
  3. Echo
  4. BNP
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15
Q

Suggest 3 potential finding on CXR for patient with acute heart failure

A
  1. Pulmonary venous congestion
  2. Interstitial oedema
  3. Cardiomegaly
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16
Q

What 2 conditions can potential be identified on echo in patient with acute heart failure?

A
  1. Pericardial effusion

2. Cardiac tamponade

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17
Q

Define cardiomegaly

A

A cardiothoracic ratio greater than 50%

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18
Q

Recall the 5 main features of heart failure that can be seen on CXR

A
  1. Pulmonary oedema/ congestion
  2. Septal/ Kerley B lines
  3. Cardiomegaly
  4. Upper lobe vessel enlargement
  5. Pleural effusion
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19
Q

What are the 3 factors that determine how fluid moves between the capillaries and the interstitium?

A
  1. Hydrostatic pressure
  2. Oncotic pressure
  3. Capillary permeability
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20
Q

What is the most common cariogenic cause of pulmonary oedema?

A

Left sided heart failure

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21
Q

Suggest 4 non cariogenic causes of pulmonary oedema

A
  1. Pulmonary infections
  2. Inhalation of toxic substances
  3. Trauma to the chest
  4. Sepsis
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22
Q

Give 2 medical conditions that lead to a low oncotic pressure, which may in turn lead to pulmonary oedema

A
  1. Liver Failure

2. Nephrotic syndrome

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23
Q

What are the most common valve dysfunctions caused secondary to heart failure?

A

Functional mitral and tricuspid regurgitations

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24
Q

Suggest 3 potential causes of diastolic heart failure

A
  1. Pericardial disease
  2. Restrictive cardiomyopathy
  3. Tamponade
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25
Q

Recall the Major Framingham diagnostic criteria for congestive heart failure (SAW PANIC)

A

S - S3 heart sound (gallop)
A - Acute pulmonary oedema
W - Weight loss of more than 4.5 kg in 5 days once treated

P - Paroxysmal nocturnal dysponea 
A - Abdominojugular reflux 
N - Neck Veins distended (raised JVP)
I - Increased cardiac shadow on CXR (cardiomegaly) 
C - Crackles in lungs
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26
Q

Recall the Minor Framingham diagnostic criteria for congestive heart failure (HEART ViNo)

A 
H - Hepatomegaly 
E - Effusion, pleural 
A - Ankle oedema bilaterally
R - exeRtional dyspnoea 
T - Tachycardia

Vi -Vital capacity decreased by a third of maximal volume
No - Nocturnal cough

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27
Q

Define the 4 grades of the NYHA Classification of heart failure

A

Grade 1 - No limitation of function

Grade 2 - Slight limitation of function. Moderate exertion causes symptoms but no symptoms at rest.

Grade 3 - Marked limitation. Mild exertion causes symptoms but no symptoms at rest

Grade 4 - Severe limitation. Any exertion causes symptoms. May also have symptoms at rest (but not always).

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28
Q

Give 4 contraindications for the use of beta blockers in the treatment of heart failure

A
  1. Asthma
  2. 2nd or 3rd degree heart block
  3. Sick sinus syndrome
  4. Sinus bradycardia (<50 bpm)
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29
Q

Name the calcium channel blocker that is recommend for use in the management of heart failure

A

Amlodipine

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30
Q

Suggest 7 drug types to avoid in patients with heart failure

A
  1. Felcanide
  2. Verapamil and Diltiazem
  3. Tricyclic antidepressants
  4. Lithium
  5. NSAIDS
  6. Corticosteroids
  7. Drugs shown to prolong the QT interval e.g. erythromycin
31
Q

Suggest 7 drug types to avoid in patients with heart failure

A
  1. Felcanide
  2. Verapamil and Diltiazem
  3. Tricyclic antidepressants
  4. Lithium
  5. NSAIDS
  6. Corticosteroids
  7. Drugs shown to prolong the QT interval e.g. erythromycin
32
Q

What causes the A wave of the jugular venous wave form?

A

Caused by right atrial contraction

33
Q

What causes the C wave of the jugular venous wave form?

A

Bulging of the tricuspid valve into the right atrium during ventricular systole

34
Q

What causes the V wave of the jugular venous wave form?

A

Occurs in late systole, Increased blood in the right atrium from venous return

35
Q

What causes the X descent of the jugular wave form?

A

Combination of atrial relaxation, downward movement of the tricuspid valve and ventricular systole.

36
Q

What causes the Y descent in the jugular venous wave form?

A

Tricuspid valve open and blood flows into the right ventricle

37
Q

Define a Grade 1 murmur

A

The murmur is heard only on listening intently for some time

38
Q

Define a Grade 2 murmur

A

A faint murmur that is heard immediately on auscultation

39
Q

Define a Grade 3 murmur

A

A loud murmur with no palpable thrill

40
Q

Define a Grade 4 murmur

A

A loud murmur with a palpable thrill

41
Q

Define a Grade 4 murmur

A

A loud murmur with a palpable thrill

42
Q

Which electrolyte imbalance is most commonly seen in patients with heart failure?

A

Hyponatraemia

43
Q

What are the 3 main clinical characteristics of left ventricular free wall rupture?

A
  1. Raised JVP
  2. Pulsus paradoxus
  3. Diminished heart sounds
44
Q

Name 2 drugs that can precipitate heart failure

A

Verapamil and Diltiazem

45
Q

Name a drug that is contraindicated in patients that have heart failure due to the risk of fluid retention

A

Pioglitazone

46
Q

Define heart failure with a reduced ejection fraction

A

Heart failure with an LV ejection fraction < 40%

47
Q

Give 4 drug classes that can potentially lead to heart failure

A
  1. Beta -blockers
  2. Calcium antagonists
  3. Anti-arrythmics
  4. Cytotoxics
48
Q

Suggest 5 toxins that can cause heart failure

A
  1. Alcohol
  2. Cocaine
  3. Mercury
  4. Cobalt
  5. Arsenic
49
Q

Give 5 infiltrative diseases that can cause heart failure

A
  1. Sarcoidosis
  2. Amyloidosis
  3. Haemochromatosis
  4. Loffler’s eosinophilia
  5. Connective tissue disease
50
Q

Suggest 2 infections that can cause heart failure

A
  1. HIV

2. Chaga’ disease

51
Q

Outline 7 causes of high output cardiac failure

A
  1. Anemia
  2. Pregnancy
  3. Sepsis
  4. Hyperthyroidism
  5. Paget’s disease of bone
  6. Arterovenous malformations
  7. Beriberi
52
Q

Tender, pulsatile hepatomegaly can be indicative of what form of valvular abnormality?

A

Severe tricuspid regurgitation

53
Q

Excluding heart failure, suggest 10 other conditions in which an elevated BNP may be observed

A
  1. LVH
  2. Ischaemia
  3. Tachycardia
  4. Hypoxemia
  5. Renal dysfunction
  6. Age > 70
  7. Liver cirrhosis
  8. Sepsis
  9. COPD
  10. Diabetes
54
Q

Give 3 circumstances in which BNP levels may be reduced

A
  1. Obesity
  2. Afro-carribean ethnicity
  3. Certain medications e.g. ACE inhibitors and beta blockers
55
Q

Suggest 2 endocrine causes of heart failure

A
  1. Thyrotoxicosis

2. Phaeochromocytoma

56
Q

Name 2 drugs/ toxins that can cause heart failure

A
  1. Alcohol

2. Doxorubicin

57
Q

What are the 6 key clinical features associated with heart failure?

A
  1. Pulmonary oedema/ pleural effusion
  2. Raised JVP
  3. Pitting oedema
  4. Ascites
  5. Tachycardia
  6. S3 Gallop
58
Q

List the 3 types of evidence used to demonstrate structural or functional cardiac abnormalities at rest in the context of heart failure patients

A
  1. Cardiomegaly
  2. S3 hear sound
  3. Echocardiographic abnormalities
59
Q

What blood tests are required for the investigation of potential heart failure? (5)

A
  1. FBC
  2. U and E
  3. Haematinics
  4. TFTs
  5. Glucose
60
Q

What is BNP?

A

Brain natriuretic peptide - 32 amino acid polypeptide secreted by the ventricles of the heart in response to excessive stretching of the heart wall muscle.

61
Q

Give 3 reasons why ACE inhibitors are particularly useful in the treatment of heart failure

A
  1. Inhibit left ventricular hypertrophy and remodelling
  2. Inhibit vasoconstriction thereby lowering arterial constriction and increasing venous capacity
  3. Decrease salt and water retention
62
Q

Which beta blocker is NOT licensed for the treatment of heart failure?

A

Atenolol

63
Q

Approximately what % of heart failure patients will have significant electrical and mechanical desyncrony?

A

15%

64
Q

Outline the 3 leads of a CRT device

A
  1. Atrial lead
  2. Right ventricular lead
  3. Left ventricular lead is passed through the coronary sinus and into one of the vessels on the outside lateral wall of the heart
65
Q

Suggest 4 potential causes of Cor Pulmonale

A
  1. COPD
  2. Pulmonary fibrosis
  3. Recurrently pulmonary emboli
  4. Primary pulmonary hypertension
66
Q

What causes physiological mitral valve regurgitation?

A

Dilatation of the left atrium

67
Q

What occurs during phase 0 of the cardiac action potential?

A

Influx of Na +

68
Q

What are the 3 major criteria that make up the Duke criteria for the diagnosis of infective endocarditis?

A
  1. Positive blood culture
  2. Evidence of endocardial involvement
  3. Positive echo findings
69
Q

Suggest 4 potential echo findings which could indicate infective endocarditis

A
  1. Oscillating intra-cardiac mass on valve/ supporting structure (i.e. a vegetation)
  2. Abscess
  3. New partial dehiscence of a prosthetic valve
  4. New valvular regurgitation
70
Q

Recall the 7 minor criteria that make the up the Duke criteria for the diagnosis of infective endocarditis

A
  1. Predisposing heart condition or intravenous drug use
  2. Fever
  3. Vascular phenomena
  4. Immunological phenomena
  5. Microbiological phenomena
  6. Broad range PCR of 16S
  7. Supportive Echo finding (but do not satisfy major criteria)
71
Q

Outline the vascular phenomena that can be associated with infective endocarditis (6)

A
  1. Major arterial emboli
  2. Septic pulmonary infarcts
  3. Mycotic aneurysm
  4. Intracranial haemorrhage
  5. Conjunctival haemorrhage
  6. Janeway lesions
72
Q

Outline the immunological phenomena that can be associated with infective endocarditis (4)

A
  1. Glomerulonephritis
  2. Osler’s nodes
  3. Roth’s spots
  4. Rheumatoid factor
73
Q

Adrenaline pushes the Frank Starling Curve in which direction?

A

Shifts the curve to the left

TCD Cases (25 decks)

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