Cardiac failure

Question 1

Acute left ventricular failure

Answer 1

Left ventricle unable to adequately move blood through the left side of the heart and out into the body

Question 2

Triggers

Answer 2

Iatrogenic (aggressive IV fluids in frail elderly patients with impaired LVF)

Sepsis

MI

Arrhythmias

Question 3

Symptoms of acute LVF

Answer 3

Rapid onset breathlessness
- exacerbated by lying flat and improves on sitting up

Looking/ feeling unwell

Cough (frothy white/pink sputum)

Question 4

Acute LVF on examination

Answer 4

Increased RR

Reduced O2 sats

Tachycardia

3rd heart sound

Bilateral basal crackles

Hypotension in severe cases

Question 5

Blood gas for acute LVF

Answer 5

Type 1 respiratory failure
- low oxygen without increase in carbon dioxide

Question 6

Signs/symptoms if they also have right sided failure

Answer 6

Raised JVP

Peripheral oedema

Question 7

BNP

Answer 7

Hormone released from the ventricles when the myocardium is stretched beyond the normal range

Question 8

Action of BNP

Answer 8

Relax smooth muscle in blood vessels

Reduces systemic vascular resistance making it easier for the heart to pump blood through the system

Acts on kidneys as a diuretic to reduce circulating volume and improve function of heart

Question 9

Other causes of raised BNP

Answer 9

Tachycardia

Sepsis

PE

Renal impairment

COPD

Question 10

Use of ECHO

Answer 10

To measure left ventricular function by the ejection fraction

Question 11

Normal ejection fraction

Answer 11

Above 50%

Question 12

Chest xray findings

Answer 12

Cardiothoracic ratio >0.5

Upper lobe venous diversion

Bilateral pleural effusions

Fluid in interlobular fissures

Fluid in septal lines (Kerley lines)

Question 13

Management of acute LVF

Answer 13

Pour SOD

Pour away (stop) their fluids

Sit up

Oxygen if <95%

Diuretics

Question 14

Other management if severe acute pulmonary oedema or cardiogenic shock

Answer 14

IV opiates (act as vasodilators but not routinely recommended)

NIV (CPAP helps open airways to improve gas exchange)

If NIV doesn’t work they made need full intubation and ventilation

Inotropes to strengthen force of heart contractions

Question 15

Presentation of chronic heart failure

Answer 15

Breathlessness worsened by exertion

Cough (frothy white/ pink sputum)

Orthopnoea

PND

Peripheral oedema

Question 16

Paroxysmal nocturnal dyspnoea

Answer 16

Waking and feeling short of breath with a cough and wheeze

Fluid settling across large surface area as lying flat

Respiratory centres in brain become less responsive so RR and effort doesn’t increase in response to reduced O2 like it would awake

Question 17

Causes of chronic heart failure

Answer 17

IHD

Valvular heart disease

HTN

Arrhythmias

Question 18

Additional management for chronic heart failure patients

Answer 18

One off pneumococcal vaccine

Annual flu vaccine

Stop smoking

Question 19

First line medical management of chronic HF

Answer 19

ACEi and beta blocker

Question 20

Second line treatment

Answer 20

Aldosterone antagonist

Need to monitor potassium

Question 21

Third line treatment

Answer 21

Ivabradine

Salcubitril-valsartan

Digoxin

Hydralazine combination with nitrate

Cardiac resynchronisation therapy

Question 22

Ivabradine criteria

Answer 22

Sinus rhythm >75bpm and LVF <35%

Question 23

Sacubitril-valsartan criteria

Answer 23

LVF <35%

Considered in HF with reduced ejection fraction who are symptomatic on ACEi or ARBs

Question 24

Digoxin use

Answer 24

Not been proven to reduce mortality in patients with HF

May improve symptoms due to inotropic properties

Strongly indicated if co-existant af

Question 25

Hydralazine indication

Answer 25

Afro-Caribbean patients

Question 26

Cardiac resynchronisation therapy indication

Answer 26

Widened QRS complex on ECG