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Flashcards in CARDIO: HF Deck (50)
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1
Q

Worst prognostic indicators for HF?

A
Severe fluid overload
very high NT-proBNP levels
severe renal impairment 
advanced age 
multi- morbidity 
frequent admissions with heart failure
2
Q

What is the purpose of Implantable cardiac defibrillators in HF?

A

Not to improve symptoms, but to prevent sudden cardiac death by delivering electroshock if pt in VT/VF

3
Q

Define Heart Failure

using BMJ BP / QUESBOOK

A
  • Heart failure (HF), also known as congestive heart failure (CHF) and congestive cardiac failure (CCF), is defined as the failure of the heart to generate **sufficient cardiac output **to meet the **metabolic demands **of the body.
4
Q

EPIDEMIOLOGY of HF?

A
  • elderly population average age of diagnossi is 75 yrs
  • in Europe / North America most common causes are coronary artery disease, HTN and valvular disease
  • Chagas disease is significant cause in Central/South America
5
Q

The pathophysiology of HF is diverse and depends on the cause of HF.

This is why it is classified in different ways e.g. acute or chronic.

List these classifications (will go into depth later)

A
  • Low-output HF vs. High-output HF
  • Systolic vs. Diastolic HF (ejection fraction)
  • Acute vs. Chronic HF
  • Severity of Symptoms (New York Heart Association classification of HF)

ways to think about HF and what is going on when someone presents

6
Q

HF can be classified as Low-output HF vs. High-output HF.

What does this mean ?
Which is more common ?

A

Low-output:
* More common
* Due to a primary problem with the heart that means the heart is unable to meet the bodys needs

High-ouput:
* a heart with normal cardiac output, but there is an increase in peripheral metabolic demands that the heart is unable to meet.

7
Q

Examples of causes for High- ouput HF?

AAPPTT mnemonic

A
  • Anaemia
  • Arteriovenous malformation
  • Paget’s disease
  • Pregnancy
  • Thyrotoxicosis
  • Thiamine deficiency (wet Beri-Beri)

All increase the peripheral metabolic demands - heart unable to meet.

8
Q

Compare Systolic (reduced ejection fraction) vs Diastolic (preserved ejection fraction) HF

A

Systolic dysfunction (reduced ejection fraction):
* impaired ventricular contraction.
* ventricles can fill well, but heart is unable to pump the blood sufficiently out of the ventricle due to impaired myocardial contraction during systole.

Diastolic (preserved ejection fraction)
* Inability of the ventricles to relax and fill normally
* heart is still able to pump well but pumps out less blood per contraction due to reduced diastolic filling.

9
Q

What is ejection fraction? what does it represent?

A

Ejection fraction is measured as a percentage of the total amount of blood in your heart that is pumped out with each heartbeat.

10
Q

HF with reduced ejection fraction (systolic HF) what are values to diagnose?

BMJ BP

A

(HFrEF): HF with left ventricular ejection fraction:
* ≤40%.

mildly reduced EF :
* 41% - 49%.

Preserved EF
* >50%

11
Q

HF with preserved ejection fraction (diastolic HF) what are values to diagnose?

A

HF with left ventricular ejection fraction:
* ≥50%.

12
Q

Causes of HF with Reduced ejection fraction ? (systolic dysfinction)

A
  • ischaemic heart disease
  • dilated cardiomyopathy, myocarditis
  • infiltration (haemochromatosis or sarcoidosis).
13
Q

Causes of HF with preserved ejection fraction ? (diastolic dysfunction)

A
  • uncontrolled chronic HTN (significant left ventricular hypertrophy reduces filling of the left ventricle)
  • hypetrophic cardiomyopathy
  • cardiac tamponade
  • constrictive pericarditis.
14
Q

Compare Acute vs Chronic HF (HF classed by time of onset)

A

Acute:
* new-onset of symptoms
* e.g Mitral regurgitation following MI
* Actue deterioriation in pt w/ chronic HF

Chronic:
* slow progression
* years to develop

15
Q

Outline the New York Heart Association (NYHA) Classification of HF

Good to use in OSCE to judge severity of HF

A
16
Q

Clinical features of LHF

why do you get the symptoms and signs? what is pathophysiology?

A

LHF, or left ventricular failure (LVF), causes pulmonary congestion (pressure builds up on the LHS of the heart and there is backpressure to the lungs) and there is systemic hypoperfusion.

17
Q

Clinical features of LHF : what are symptoms

A
  • Shortness of breath on exertion
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Nocturnal cough (¬± pink frothy sputum)
  • fatigue
18
Q

Clinical features of LHF : what are signs?

A
  • Tachypnoea
  • Bibasal fine crackles on auscultation of the lungs
  • Cyanosis
  • Prolonged capillary refill time
  • Hypotension

Less common signs:
* pulsus alternans (alternating strong and weak pulse)
* S3 gallop rhythm (produced by large amounts of blood striking compliant left ventricle)
* features of functional mitral regurgitation.

19
Q

Clinical features of right heart failure:

why do you get the symptoms and signs? what is pathophysiology?

A

Right heart failure causes venous congestion (pressure builds up behind the right heart)

and

pulmonary hypoperfusion (as reduced right heart output).

20
Q

Right heart failure:

symptoms:

A
  • Ankle swelling
  • Weight gain
  • Abdominal swelling and discomfort
  • Anorexia and nausea
21
Q

Right heart failure:
Signs

A
  • Raised JVP
  • Pitting peripheral oedema (ankle to thighs to sacrum)
  • Tender smooth hepatomegaly
  • Ascites
  • Transudative pleural effusions (typically bilaterally)
22
Q

What can you get both Left and Right sided HF symptoms and signs in the same pt?
whats this called?

A

Sometimes left sided heart failure can lead to pulmonary congestion which in turn also pushes the right ventricle into failure.

In these cases signs and symptoms of both left and right sided heart failure may be present.

This is congestive cardiac failure.

23
Q

Common causes of right heart failure:

A

cor pulmonale and pulmonary or tricuspid valve disease.

24
Q

Differencial Diagnosis for HF?

A
  • COPD
  • ARDS
  • Renal failure
  • Liver Failure
25
Q

Differencials for HF
what are the similarities and Differences of HF with COPD

A

Similarities:
* dyspnoea (and significant respiratory distress)
* fatigue.

Differences:
* HF- SOB worse on lying flat (orthopnoea) and may be accompanied by paroxysmal nocturnal dyspnoea and peripheral oedema.
* COPD - SOB worse on exertion and get symptoms e.g chronic productive cough, wheeze, significant smoking history.

26
Q

Differencials for HF
what are the similarities and Differences of HF with ARDS

A

Similarities:
* both present w/ SOB, tachypnoea and respiratory distress.
* Both - accumulation of fluid in the lungs and impaired gaseous exchange leading to hypoxaemia.

Differences:
* underlying pathology
* HF = raised pressures in pulmonary capillaries
* ARDS = increased pulmonary capillary pressure secondary to a large insult (e.g. pneumonia, aspiration, or trauma).
* They can be distinguished by taking pulmonary capillary wedge pressures.

27
Q

Differencials for HF
what are the similarities and Differences of HF with Renal Failure

A

Similarities:
* fluid retention
* peripheral overload.

Differences:
* renal Failure - uraemic symptoms (nausea, anorexia, uraemic flap)
* potentially signs of renal replacement therapy.

28
Q

Differencials for HF
what are the similarities and Differences of HF with Liver Failure

A

Similarities:
* fluid retention
* peripheral overload especially ascites.

Differences:
* liver failure - S&S incl. jaundice, hepatic encephalopathy and chronic liver disease signs (gynaecomastia, spider naevi, and excoriations).

29
Q

Investigations for HF: bedside:

A
  • 12-lead ECG

ECG may be normal or hint at underlying aetiology (ischaemic changes or arrhythmias).

30
Q

Investigations for HF:
Bloods:

A
  • NT-pro-BNP (released in response to myocardial stretch)
    > 2000ng/L - specialist + TTE <2 weeks
    > 400-2000ng/L - specialist + TTE in <6 weeks

Other bloods:
* FBC - anaemia
* U&Es - renal function for meds + hyponatraemia
* LTS - deranged? suggest hepatic congestion
* TFT’s - hyperthryroid + high output HF
* Glucose and lipid profile (modifiable CV RF)
* Ferritin and transferrin (Younger patients with possible haemochromatosis)

31
Q

Imaging invesitgations for HF
(name of investigations now - results later)

A
  • CXR
  • Transthoracic echocardiogram (TTE)
  • Cardiac MRI: May elaborate cause for heart failure as echo may miss right ventricle.
32
Q

Imaging for HF what will Transthoracic echocardiogram (TTE) show / do?

A

Echo- confirm the presence and degree of ventricular dysfunction.

  • EF <40% = HF with reduced ejection fraction ( systolic dysfunction).
  • EF >40% but with raised BNP = HF with preserved ejection fraction (diastolic dysfunction).
  • EF 50-70% with normal BNP = normal.

Below i think Sandiland detail but can ignore:
Possibly: dilated poorly contracting left ventricle (systolic dysfunction) ; stiff, poorly relaxing, often small diameter left ventricle(diastolic dysfunction); valvular heart disease; atrial myxoma; pericardial disease

33
Q

Imaging for HF: CXR what expect to see ?

ABCDEF mnemonic

A
  • A: Alveolar oedema (with ‘batwing’ perihilar shadowing)
  • B: Kerley B lines (caused by interstitial oedema)
  • C: Cardiomegaly (cardiothoracic ratio >0.5)
  • D: upper lobe blood diversion
  • E: Pleural effusions (typically bilateral transudates)
  • F: Fluid in the horizontal fissure
34
Q

Conservative management for HF?

A
  • Weight loss if BMI >30.
  • Smoking cessation
  • Salt and fluid restriction - improves mortality
  • Supervised exercise-based group rehabilitation programme for people with heart failure.
  • annual influenza and one-off pneumococcal vaccinations for patients diagnosed with heart failure.
35
Q

Medical Management of Heart Failure:

A

Symptom management (no mortality benefit)
* For fluid overload : loop diuretics (e.g. furosemide or bumetanide).

Mortality benefit:
* 1st line: ACE-I and beta-blocker
* ARB if intolerant to ACE-I.
* hydralazine if intolerant to ACE-I/ARB.

36
Q

You have a pt with HF, you have started them on:
1. Furesomide (for symptoms)
2. ACEi and Beta-blocker

Their symptoms persist and you work out they are a NYHA class 3 / 4 (symptom severity)

What can you add?

rough idea of next steps i think is all needed

A
  • Aldosterone antagonists = spironolactone or eplerenone.
  • Hydralazine and a nitrate for Afro-Caribbean patients.
  • Ivabradine if in sinus rhythm >75/min and impaired EF.
  • Digoxin = useful in those with AF. This worsens mortality but improves morbidity.
  • NICE advises to seek specialist guidance for prescribing SGLT2 inhibitors (dapagliflozin or empagliflozin).
37
Q

What are some surgical / interventional management options for HF?

A
  • Cardiac resynchronisation therapy
  • Implantable cardioverter defibrillator (ICD) - depends on QRS interval and other criteria
38
Q

Adverse effects of heart medication :

  1. Beta blockers
  2. ACE i
A
  1. Beta blockers:
    * Bradycardia
    * hypotension
    * fatigue
    * dizziness
  2. ACE inhibitors:
    * Hyperkalaemia
    * renal impairment
    * dry cough
    * lightheadedness,
    * fatigue,
    * GI disturbances
    * angioedema
39
Q

Adverse effects of heart medication :
1. Sprinonlactone
2. Furesomide

A
  1. Spironolactone:
    * Hyperkalaemia
    * renal impairment
    * gynaecomastia
    * breast tenderness/hair growth in women
    * changes in libido
  2. Furosemide:
    * Hypotension,
    * hypoatraemia
    * hypokalaemia,
40
Q

Adverse effects of heart failure medications:

  1. Hydralazine/nitrate:
  2. Digoxin:
  3. SGLT-2 inhibitors:
A
  1. Hydralazine/nitrate:
    * Headache
    * palpitation
    * flushing
  2. Digoxin:
    * Dizziness
    * blurred vision
    * GI disturbances
  3. SGLT-2 inhibitors:
    * Thrush
    * UTIs,
    * DKA in patient with pre-existing diabetes
41
Q

Prognosis of HF

A

It is estimated that >50% of people diagnosed with HF will survive after 5 years.

Approximately 35% will be alive in 10 years.

42
Q

Recap: what is Acute Left ventricular failure?

A
  • acute event results in the left ventricle being unable to move blood efficiently through the left side of the heart and into the systemic circulation.
  • Cardiac output is the product of stroke volume x heart rate.
43
Q

Triggers for Acute Left Ventricular Failure?

A
  • OFTEN decompensated chronic heart failure.
  • Iatrogenic (e.g., aggressive IV fluids in a frail elderly patient with impaired left ventricular function)
  • MI
  • Arrhythmias
  • Sepsis
  • Hypertensive emergency (acute, severe increase in blood pressure)
44
Q

How would a pt with Acute left ventiruclar failure look on inspection?

A
  • Patient looks acutely unwell- pale and grey
  • Cold clammy peripheries ? cyanosis
  • Frothy white / blood stained sputum in sputum pot
  • Orthopnoeic using accessory muscles
  • May have wheeze (cardiac asthma)
45
Q

Acute left ventricular failure on examination: signs?

A
  • Raised RR
  • reduced 02 sats
  • Sinus tachycardia or atrial fibrillation
  • Systolic hypotension (severe sign - cardiogenic shock)
  • Signs of cardiomegaly
    (displaced apex, signs of valve disease)
  • Third and fourth heart sounds
  • Right sided or bilateral pleural effusions
  • bilateral bibasal crackles

Signs relating to an underlying cause:
* chest pain - MI
* Fever in sepsis
* Palpitations w/ arrythmias

may also be signs of RSHeart failure too

46
Q

Assessment on pt with acute left ventricular failure?

A

)Hx/ Exam/ A-E)
Bedisde:
* ECG to look for ischaemia and arrhythmias

Bloods:
* anaemia, infection, kidney function, BNP, and consider troponin if suspecting MI
* Arterial blood gas (ABG)

Imaging:
* Chest x-ray
* Echocardiogram

47
Q

BNP is sensitive but not specific - helps rule out HF but can be +ve in what other conditions?

A
  • Tachycardia
  • Sepsis
  • Pulmonary embolism
  • Renal impairment
  • COPD
48
Q

Management of Acute Left ventriuclar failure

SODIUM

A
  • Admit
  • (severe pulmonary oedema / cardiogenic shock - HDU/ITU)

SODIUM
* S – Sit up
* O – Oxygen
* D – Diuretics
* I – stop IV Fluids
* U – Treat underlying cause (e.g. MI)
* M – Monitor fluid balance

49
Q

What might severe cases of acute left ventiruclar failure require? (further management)?

A

(guided by specialist):

  • IV opiates (e.g. morphine) which act as vasodilators
  • IV nitrates act as vasodilators -considered in severe HTN or ACS
  • Inotropes, (dobutamine) to improve cardiac output
  • Vasopressors, (noradrenalin) to improve BP
  • Non‑invasive ventilation
    Invasive ventilation (involving intubation and sedation)
50
Q
A

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