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Year 3 TCD > 9. Congestive Cardiac Failure > Flashcards

9. Congestive Cardiac Failure Flashcards

1
Q

What is systolic heart failure?

A

It is when there is impaired left ventricular contraction

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2
Q

What is diastolic heart failure?

A

It is when there is impaired left ventricular relaxation

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3
Q

What symptoms will someone with chronic heart failure present with?

A
  • Breathlessness worsened by exertion
  • Loss of Energy / Fatigue
  • Cough
  • Orthopnoea
  • Paroxysmal Nocturnal Dyspnoea
  • Peripheral oedema (swollen ankles)
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4
Q

What is orthopnea?

A

The sensation of shortness of breath when lying flat (it is relieved by sitting or standing).

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5
Q

What is paroxysmal nocturnal dyspnoea?

A

This is the experience of waking up at night with a severe attack of shortness of breath and cough

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6
Q

What clinical signs could someone with congestive heart failure have?

A
  • Pulmonary oedema / pleural effusion
  • Raised JVP
  • Pitting oedema
  • Ascites
  • Tachycardia
  • S3 Gallop
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7
Q

What is the difference between pulmonary oedema and pleural effusion?

A

Pulmonary oedema is when there is fluid WITHIN the lung (ie. in the alveoli).

Pleural effusion is when there is fluid OUTSIDE the lung and in the pleural cavity instead.

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8
Q

What question can you ask in a history to check for orthopnea?

A

How many pillows are they needing to sleep? Or if its really bad, are they having to sleep whilst sat up in their chair?

Ask if they have always needed that or progressively add more and more pillows over time?

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9
Q

What question can you ask in a history to check for paroxysmal nocturnal dyspnoea?

A

Have you ever woke up at night with shortness of breath?

They might have to open a window in an attempt to get air

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10
Q

What 3 mechanisms are there behind paroxysmal nocturnal dysopnea?

A
  1. Fluid settling across a large surface area of the lungs when lied on back
  2. The respiratroy centre has reduced activity whilst sleeping, so you are at more of a hypoxic state.
  3. There is less adrenalin in circulation whilst asleep, meaning the heart muscles are more relaxed, and there is less output
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11
Q

What are the main categories of causes of heart failure?

A
  • Myocardial Disease (CAD, Hypertension, Cardiomyopathies)
  • Valvular Heart Disease (AS, MR)
  • Pericardial Disease
  • Congenital Heart Disease
  • Arrhythmias (AF)
  • High Output States (anaemia, thyrotoxicosis, sepsis etc.)
  • Volume overload
  • Obesity
  • Drugs (alcohol, cocaine, NSAIDS, beta-blockers, calcium-channel blockers)
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12
Q

What are some types of myocardial disease that can cause heart failure?

A
  • CAD
  • Hypertension
  • Cardiomyopathies (Familial, Infective, immune-related, toxins, pregnancy, infiltrative)
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13
Q

What are some risk factors for congestive heart failure?

A
  • Myocardial infarction (MI) is the most potent risk factor, increasing the risk by 15x
  • Diabetes mellitus - increases risk up to 5x
  • Dyslipidaemia
  • Old age
  • Male
  • Hypertension
  • Left ventricular dysfunction
  • Cocaine abuse
  • Alcohol abuse
  • Exposure to cardiotoxic agents
  • Left ventricular hypertrophy
  • Renal insufficiency
  • Valvular heart disease (such as aortic stenosis or mitral regurgitation)
  • Uncontrolled atrial fibrillation
  • Family history
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14
Q

What should you ask about in a history to investigate heart failure?

A
  1. Ask about typical symptoms
    - Breathlessness (on exertion, at rest, orthopnea, nocturnal cough, paroxysmal nocturnal dyspnoea)
    - Fluid retention (ankle swelling, bloated feeling, abdominal swelling, weight gain)
    - Fatigue, decreased exercise tolerence, or increased recovery time post exercise
    - Light headedness or history of syncope
  2. Ask about risk factors
    - CAD / MI
    - Hypertension
    - AF
    - Diabetes Melllitus
    - Drugs including alcohol
    - Family history of heart failure or sudden cardiac death under the age of 40
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15
Q

What physical examinations should you do for someone in which you suspect heart failure?

A

Examine for;

  • Tachycardia (heart rate over 100 beats per minute) and pulse rhythm.
  • A laterally displaced apex beat, heart murmurs, and third or fourth heart sounds (gallop rhythm).
  • Hypertension.
  • Raised jugular venous pressure.
  • Enlarged liver (due to engorgement).
  • Respiratory signs such as tachypnoea, basal crepitations, and pleural effusions.
  • Dependent oedema (legs, sacrum), ascites.
  • Obesity.
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16
Q

When should you arrange hospital admission for someone with heart failure?

A
  • If they have severe symptoms
  • If they are pregnant
  • If they have given birth in the last 6 months

If there is uncertainty, seek specialist advice

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17
Q

If you suspect someone has heart failure, which diagnostic tests will you need to do?

Hint: need to do

A
  • Measure their NT-proBNP
  • Arrange a 12 lead ECG
  • Echocardiography (done after first 2 have been done)
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18
Q

What is the timing of how urgently the echocardiography dependent on?

A

The levels of NT-proBNP

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19
Q

Aside from the main 3 tests, what other tests would you want to do in someone with suspected heart failure?

A
  • Chest X-ray (rules out other conditions and can show pulmonary oedema)
  • Urine Dipstick for blood and protein
  • Lung function tests (peak flow and spirometry)
  • Bloods (FBC, U&Es, eGFR, TFT, LFTs, HbA1c, Fasting Lipids, Troponins, Haematinics)
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20
Q

Why would you want to do fasting lipids and HbA1c tests in someone with suspected heart failure?

A

To rule out the possibility of them having a hypo- or hyperglycaemic event which has caused the symptoms

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21
Q

What are haematinics? What are they?

A

They are the nutrients required by the body for erythropoesis. They are;

  • Vitamin B2, B3, B6, B12
  • Vitamin A
  • Vitamin C
  • Vitamin E
  • Iron
  • Folic Acid
  • Copper
  • Cobalt
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22
Q

Once you have confirmed that they have heart failure, aside from treatment, what do you need to do next and why?

A

You need to work out the underlying cause of the heart failure.

This is because heart failure is a syndrome, and not a diagnosis.

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23
Q

What is BNP?

A

It is secreted from the ventricles in response to excessive stretching of heart muscle cells.

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24
Q

How useful are normal levels of BNP? How useful are high levels of BNP?

A

Normal levels can rule out heart failure

High levels just indicate that it could be heart failure (but it could be other things as well)

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25
Q

Using a patients BNP levels, what management plan will they need?

Ie. X amount of BNP requires A, B and C etc.

A
  • If the NT-pro-BNP level is above 2000 pg/mL, refer urgently for specialist assessment and echocardiography to be seen within 2 weeks.
  • If the NT-pro-BNP level is between 400–2000 pg/mL, refer for specialist assessment and echocardiography to be seen within 6 weeks.
  • If NT-pro-BNP is less than 400 pg/mL, be aware that a diagnosis of heart failure is less likely. Consider discussion with a physician with subspeciality training in heart failure if a clinical suspicion of heart failure persists.
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26
Q

What BNP level indicates heart failure with reduced ejection fraction? What about for preserved ejection fraction?

A

Trick question. BNP is not able to differentiate this.

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27
Q

Why are ECGs useful to perform in someone with heart failure?

A
  • Its quick to do
  • Its easy to set up
  • Its relatively cheap
  • You can do it anywhere
  • It provides information about the cause of heart failure (ie. CAD, arrhythmias, LVH, hypertension etc.)
28
Q

What are some differential diagnoses to heart failure?

A
  1. Conditions causing breathlessness such as:
    - Chronic obstructive pulmonary disease.
    - Asthma.
    - Pulmonary embolism.
    - Lung cancer.
    - Anxiety.
  2. Conditions causing peripheral oedema such as:
    - Prolonged inactivity or venous insufficiency causing dependent oedema.
    - Nephrotic syndrome.
    - Drugs (for example dihydropyridine calcium-channel blockers, nonsteroidal anti-inflammatory drugs).
    - Hypoalbuminemia (from renal or hepatic disease).
    - Pelvic tumour.
  3. Other conditions such as:
    - Obesity.
    - Severe anaemia or thyroid disease.
    - Bilateral renal artery stenosis.
29
Q

What 3 ways are used to categorise heart failure?

A
  1. Severity (Ejection Fracture)
  2. Symptomatically (NYHA)
  3. Time course
30
Q

How can the ejection fraction be categorised in heart failure?

A
  • Heart failure with reduced ejection fraction (HFrEF) - LVEF <40%.
  • Heart failure with mid-range ejection fraction (HFmrEF) - LVEF 40% to 49%
  • Heart failure with preserved ejection fraction (HFpEF): LVEF >50%
31
Q

In order to diagnose HFmrEF or HFpEF, what criteria do you need?

A

They need to have EF within the specific range (40-49% for mrEF and >50% for pEF)

Then, A must also be present, and 1 of either B or C

A. Elevated natriuretic peptides (NT-pro-BNP >125 nanograms/L)
B. Relevant structural heart disease (ie. LVH or LA enlargement)
C. Diastolic dysfunction.

32
Q

What is the normal range for ejection fraction of the left ventricle?

A

50-70%

33
Q

How can you symptomatically categorise heart failure?

A

By using NYHA grading

34
Q

What does NYHA 1 mean?

A

No symptoms and no limitation in ordinary physical activity

35
Q

What does NYHA 2 mean?

A

Mild symptoms and slight limitation during ordinary physical activity

36
Q

What does NYHA 3 mean?

A

Marked limitation in activity due to symptoms, even during less-than-ordinary
activity

37
Q

What does NYHA 4 mean?

A

Severe limitations. Experiences symptoms even while at rest

38
Q

What is the time difference between acute vs chronic heart failure?

A

There is no agreed definition of the timescale of chronic heart failure

Acute heart failure may be a new presentation of heart failure or may be a deterioration or ‘decompensation’ in a person with existing chronic heart failure.

39
Q

What is stable heart failure?

A

Stable heart failure is a term used to describe a person with treated heart failure and symptoms which are unchanged for at least a month

40
Q

What are some complications of heart failure?

A
  • Cardiac Arrhythmias
  • Depression
  • Cachexia
  • Chronic kidney disease
  • Sexual dysfunction
  • Sudden cardiac death
41
Q

What are the common cardiac arrhythmias after getting heart failure? How common are they?

A

Atrial fibrillation is the most common arrhythmia in people with heart failure. The prevalence increases with the severity of heart failure, increasing from about 10% in people with mild to moderate heart failure (New York Heart Association [NYHA] classes II and III) to 50% in people with severe heart failure (NYHA class IV)

They can also get ventricular arrhythmias, more common in those with dilated left ventricle and rEF.

42
Q

How common is depression in those with heart failure?

A

20% of people with heart failure get it

43
Q

How common is cachexia in those with heart failure?

A

Up to 10-15% of people with heart failure can get it.

44
Q

What is cachexia defined as?

A

The loss of 6% or more of total body weight within the previous 6-12 months

45
Q

What is the mechanism behind cachexia in those with heart failure?

A

The mechanism behind this is unknown, but thought to be because both the absorption of nutrients is harder in heart failure due to fluid build up, and that it takes increased effort to perform basic tasks like breathing.

46
Q

When diagnosing someone with heart failure, who do you need to speak to?

A
  1. Need to speak with the patient themsevles, and give a careful discussion and explanation of the condition
  2. Need to speak to someone more senior. If NT-proBNP is greater than 2000, then its an urgent referral
  3. Need to get input from specialist nurse for advice and support
47
Q

Aside from medical and surgical management of heart failure, what additional management will the patient require?

A
  • Yearly flu jab and once only pneumococcal vaccine
  • Stop smoking
  • Optimise treatment of comorbidities
  • Exercise as tolerated
  • Screen for depression and anxiety
  • Assess nutritional status
48
Q

Which medication is indicated in all heart failure patients?

A

Loop Diuretics

49
Q

Aside from diuretics, which other medication can be given to people in heart failure? Which types of patients get this medication?

A 
ABAL
A- Ace Inhibitor
B- Beta Blocker
A- Aldosterone Antagonist
L- Loop Diuretic

This is offered to any heart failure patient which an ejection fraction less than 45%. If they have greater than 45% then you just treat the co-morbidities and give diuretics

50
Q

Which beta blocker is not licensed for use in treating heart failure?

A

Atenolol

51
Q

When would you give an angiotensin receptor blocker to a heart failure patient?

A

When they have an ejection fraction under 45% and are not tolerating an ACE inhibitor

52
Q

In which type of heart failure patients do you need to avoid giving ACE inhibitors?

A

Those with valvular heart disease

53
Q

If starting a heart failure patient on medication, which order do you give them in?

A

1st: Give diuretics
2nd: Give either ACE inhibitor or beta blocker
3rd: Titrate the dose up until the effective dose or if not, most they can tolerate
4th: Start them on the other drug, and titrate up.
5th: If they are still symptomatic, then you start them on the aldosterone antagonist
6th: Assess whether they need an anti-platelet drug and/or a statin

54
Q

If someone is on diuretics, ACE inhibitors and/or aldosterone antagonists, what do you need to do?

A

Regularly check their U&Es as electrolyte disturbances are common

55
Q

What percentage of heart failure patients have electrical/mechanical dyssynchrony? What does this actually mean?

A

15%

It means that there is no longer the controlled contraction and relaxation of the heart. For example, the 2 ventricles could contract at different times.

56
Q

Why are you worried if someone has been in AF for more than 48 hours?

A

There is a fairly significant chance that a clot has formed in the atrium as the blood now pools here and is relatively stagnant.

57
Q

When would you not cardiovert a patient? Why?

A

When they have been in atrial fibrillation for more than 48 hours, or you do not know how long they have been in AF for.

This is because there is a risk that a clot has formed, and by cardioverting them, you would dislodge the clot and cause an embolic stroke.

58
Q

If someone in has been in AF for 10 days, how would you go about controlling it?

A

You do not want to cardiovert due to the chance of causing an embolic stroke.

Therefore, you aim to control the rate with medication, and anti-coagulate the patient. If approriate, cardioversion can be attempted at a later date once the patient is fully anti-coagulated, and an echo has excluded the presence of thrombi.

59
Q

What is cardioverting someone?

A

You place electrodes on someones chest, and it sends electrical impulses at specific moments in order to turn someones arrhythmia into normal sinus rhythm.

60
Q

What are the 2 devices we can use in those with heart failure?

A
  • Cardiac Resynchronization Therapy (CRT)

- Implantable Cardiac Defibrillators (ICD)

61
Q

What does cardiac resynchronisation therapy involve?

A

This consists of 3 leads

  • Atrial lead
  • Right ventricular lead
  • Left ventricular lead

They improve cardiac function by improving the synchronicity between the LV and RV and within the LV.

62
Q

How common is sudden cardiac death among heart failure patients?

A

It accounts for 50% of heart failure related mortalities

63
Q

In patients with heart failure, what is sudden cardiac death the result of?

A

It is most likely the result of ventricular arrhythmias, such as

  • Ventricular Fibrillation (VF)
  • Ventricular Tachycardia (VT)
64
Q

How does an implantable cardiac defibrillator work? Which group of heart failure patients is it effective in?

A

It detects ventricular arrhythmias when they happen, and can automatically shock them.

They are used in those with HFrEF as they have been shown to reduce mortality in this group mainly.

65
Q

What is the prognosis like for those with heart failure?

A
  • Mortality rate is 30% 1 year after diagnosis
  • Mortality rate goes to 50% after 5 years from diagnosis
  • 30-50% chance of re-hospitalisation as a result of decompensated heart failure

Year 3 TCD (36 decks)

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