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What is the management of type A descending aortic dissection?

Medical control of BP with beta blockers, with surgery or endovascular stent grafting for selected patients with an unfavourable outlook.


What are the stats like for out of hospital VF arrest and AEDs?

>25% for survival to hospital admission and survival at one year (inc w/o neurological impairment)

Time in interval between collapse and first shock achieves the highest survival rates.


Which drugs decrease preload?

preload reduction: diuretics, opioids, decrease intake, spironolactone


Which drugs decrease afterload?

afterload reduction: ACE-I, GTN, IABP


Which drugs increase contracitility?

increase contractility: milrinone, dobutamine, adrenaline, VAD


Which drugs degrease myocardial work?

decreased myocardial work: beta-blockers, IABP, VAD


What increases coronary perfusion and oxygenation?

increased coronary perfusion and oxygenation: O2, Hb, Stents, CABG, IABP


What is the role of assisted ventilation in heart failure


    CPAP: favourable effects on intrathoracic and left ventricular transmural pressure
    -> significant reduction in mortality and intubation rates
    BIPAP: reduction in intubation, trend to reduction in mortality
    invasive ventilation: associated with poor prognosis but can produce dramatic improvement


What is the role of TTE in heart failure?

All patients with suspected CHF should have an echocardiogram, the single most useful investigation in such patients. The echocardiogram can make the all-important distinction between systolic dysfunction (typically an LV ejection fraction < 40%) and normal resting systolic function, associated with abnormal diastolic filling, while alsexcluding correctable causes of CHF, such as valvular disease. 


What is the significance of anaemia in CHF?

Mild anaemia may occur in patients with CHF and is associated with an adverse prognosis


What happens to serum sodium in heart failure?

dilutional hyponatraemia, exacerbated by high-dose diuretic therapy


What happens to serum potassium in heart failure?

elevated plasma potassium in the presence of impaired renal function, or resulting from the use of potassium- sparing diuretics, ACEIs, or angiotensin II receptor antagonists and aldosterone antagonists.

 hypokalaemia is more common and is often secondary to
therapy, with thiazide or loop diuretics


What happens to serum magnesium in heart failure?

plasma magnesium levels may be reduced due to the
effects of diuretic therapy; magnesium replacement to
normal levels reduces ectopic beats and helps normalise
potassium levels


What happens to the LFTs in heart failure?

Congestive hepatomegaly results in abnormal liver function tests (elevated levels of aspartate transaminase (AST), alanine transaminase (ALT) and lactate dehydrogenase (LDH). 

Theremay be a rise in serum bilirubin, particularly in severe CHF.

In long-standing CHF, albumin synthesis may be impaired, resulting in hypoalbuminaemia. The latter finding may also indicate cardiac cirrhosis


What is an "angina equivalent"?

Dyspnoea on exertion is a frequent manifestation of inducible myocardial ischaemia, sometimes referred to as an ‘angina equivalent’.


What is a frequent manifestation of inducible myocardial ischaemia that isn't pain?  How is it assessed?

Dyspnoea on exertion is a frequent manifestation of inducible myocardial ischaemia, sometimes referred to as an ‘angina equivalent’.

Inducible ischaemia can be assessed with numerous stress
protocols, using either technetium-9m-labelled agents or
thallium-201. Many patients have limited physical activity
capacity and therefore pharmacological stress testing—e.g.
using dipyridamole or dobutamine—is more appropriate.
Stress echocardiography is another alternative using either
physical activity or dobutamine


What is the role of a right heart cath in heart failure?

heart failure appears refractory to therapy

the diagnosis of CHF is in doubt
diastolic heart failure is recurrent and difficult to confirm by other means


What are BNP levels useful for?

BNP levels have been demonstrated to be useful for differentiating dyspnoea caused by CHF from dyspnoea due to other causes.

This reduced both the time to initiation of the most appropriate therapy and the length of hospital stay.

BNP and N-terminal proBNP levels vary with age, gender and renal function. 


When are BNP levels less useful?

Better for systolic, not diastolic dysfunction.

In particular, BNP levels do not appear to discriminate well between elderly
female patients with diastolic heart failure—the most common patient group with this condition—and healthy age-matched controls. Furthermore, mildly raised levels can be due to other
causes, including corpulmonale and pulmonary embolism. 


What is the CSANZ recommendation for use of plasma BNP in patitens with recent-onset dyspnoea?

Plasma BNP or N-terminal pro-BNP measurement may be helpful in patients presenting with recent-onset dyspnoea; it has been shown to improve diagnostic accuracy with a high negative predictive value


What is the role of plasma BNP in therapy for CHF titration?

Repeated measurement of plasma BNP or N-terminal pro-BNP to monitor and adj ust therapy in CHF should be confined to patients with CHF and systolic dysfunction who are not doing well on conventional management. Further, more definitive trials are required to fully establish the role of hormone level measurement in guiding CHF treatment


When would you do an endomyocardial biopsy?

Endomyocardial biopsy may be indicated in patients with cardiomyopathy with recent onset
of symptoms, where CHD has been excluded by angiography, or where an inflammatory or
infiltrative process is suspected.


How do you delineate between systolic and diastolic heart failure?

Systolic dysfunction (LVEF < 40%)
Diastolic dysfunction (LVEF > 40%


Who are the high risk CHF patients?

age ≥ 65 years

NYHA Class III or IV symptoms

Charlson Index of Comorbidity Score of 2 or more

left ventricular ejection fraction (LVEF) ≤ 30%

living alone or remote from specialist cardiac services


language barrier (e.g. non-English speaking)

lower socioeconomic status (due to poorer compliance, reduced understanding of reasons for medicines, fewer visits to medical practitioners, high-salt diet in ‘take-awayfoods’, reduced ability to afford medicines, higher rates ofcigarette smoking, etc.)

significant renal dysfunction (glomerular filtration rate < 60 mL/min/1.73 m).


What type of exercise should be avoided in CHF?

Isometric physical activity with heavy straining should be avoided, as it may increase LV afterload.

Isokinetic muscle-strengthening physical activity has been used safely in patients with CHF.


Can patients with heart failure have sex?  Why?

Sexual activity is likely to be safe in patients who are able to achieve approximately six metabolic equivalents (MET) of exercise— that is, able to climb two flights of stairs without stopping due to angina, dyspnoea or dizziness.


Male patients with CHF frequently experience erectile dysfunction.  Would you give them viagra?  Why?

Male patients frequently suffer from erectile dysfunction.

Sildenafil is contraindicated in patients receiving nitrate therapy, or those who have hypotension, arrhythmias or angina pectoris


How do you manage fluid status in CHF?

Weight diary with daily morning weights
>2kg/ days --> see doctor ASAP, ditto with loss
No more than 2L fluid a day
1.5L / day if fluid retaining
Can self regulate diuretic dose based on weight monitoring and symptoms - can only ever double - drop back when dry weight/symptoms resolve
May need to have a bit more fluid in warmer weather esp if losing weight


What do you do about alcohol in CHF?

ETOH related disease --> abstain, can slow disease or even improve LVF

Other patients - 1-2 drinks a day

ETOH is a direct myocardial toxin and impairs contracitlity, also adds to fluid intake


What is the role of psychosocial support in heart failure?

LVEF <20% --> depression --> increased mortality
Depression --> impaired functional capacity and CHF sx with no relationship between the 2

CBT reduces depression in cardiac patients as does antidepressents but does not significantly reduce mortality