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Medicine (Year 5) > Cardiology (Heart failure) > Flashcards

Cardiology (Heart failure) Flashcards

1
Q

classification of heart failure

A
  • Timeline
  • Ejection fraction
  • Systole/diastole
  • Site of heart involved
  • Symptoms
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2
Q

HF by timeline

A

Acute (decompensated):

  • Sudden worsening of signs and symptoms of heart failure
  • Can be due to decompensation of chronic heart failure due to intercurrent illness (e.g. myocardial infarction, arrhythmia, infection, severe hypertension, or drugs) or high-output heart failure (discussed below)

Chronic heart failure:

  • Long-term and controlled by managing symptoms
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3
Q

define LVEF

A

left ventricular ejection fraction : the percentage of blood pumped out during a single contraction

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4
Q

left ventricular ejection fraction (LVEF, the percentage of blood pumped out during a single contraction):

A

LVEF <40%: heart failure with reduced ejection fraction (HFrEF)

LVEF >50% but has symptoms of heart failure/raised levels of natriuretic peptides:** heart failure with preserved ejection fraction (HFpEF)**

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5
Q

left sided heart failure

A

Oxygenated blood from the lungs enters the left side of the heart and is pumped to the rest of the body.

Left-sided heart failure leads to a back up of blood in the lungs leading to pulmonary oedema characterised by:

  • Tachypnoea
  • Dyspnoea
  • Bilateral basal crackles
  • Orthopnoea – shortness of breath when lying down
  • Paroxysmal nocturnal dyspnoea – waking up short of breath at night, usually improved by sleeping upright
  • Laterally displaced apex beat – due to enlargement of the left ventricle
  • Additional heart sounds – S3 and S4
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6
Q

right sided heart failure

A

Deoxygenated blood from the body enters the right side of the heart to be pumped to the lungs. Right-sided heart failure is often caused by pulmonary diseases (such as pulmonary stenosis or pulmonary hypertension), leading to increased work on the right ventricle, hypertrophy, and subsequent right heart failure.

This leads to the accumulation of fluid in the systemic circulation characterised by:

  • Peripheral oedema (usually ankle/sacral oedema)
  • Raised jugular venous pressure
  • Hepatomegaly with or without splenomegaly
  • Due to liver congestion
  • This can lead to impaired liver function, jaundice, and coagulopathy due to impaired clotting factor synthesis
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7
Q

how can left sided HF lead to right sided HF

A

Failure of one side of the heart can lead to the failure of the other. Left-sided heart failure can lead to pulmonary congestion, which puts more strain on the right side of the heart, which can lead to right-sided heart failure.

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8
Q

The New York Heart Association (NYHA) classification of heart failure

A

Based on the severity of symptoms and limitation of physical activity:
Class I: asymptomatic

  • Ordinary physical activity does not cause breathlessness, fatigue, or palpitations

Class II: mild symptoms with moderate exertion

  • Comfortable at rest
  • Ordinary physical activity does cause breathlessness, fatigue, or palpitations

Class III: symptoms with minimal activity

  • Comfortable at rest
  • Less than ordinary physical activity does cause breathlessness, fatigue, or palpitations

Class IV: symptoms at rest

  • Unable to carry out any physical activity without symptoms
  • Discomfort worsens with physical activity
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9
Q

High-output heart failure

A

High-output heart failure describes when an intact heart cannot pump enough blood to meet the demands of the body. This can occur in scenarios where the metabolic rate of the body increases such as:

  • Anaemia
  • Sepsis
  • Hyperthyroidism
  • Paget’s disease of bone
  • Multiple myeloma
  • Arteriovenous malformation
  • Vitamin B1 (thiamine) deficiency
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10
Q

Left-sided heart failure suymptoms –

A

Due to pulmonary congestion:

  • Tachypnoea
  • Dyspnoea
  • Bilateral basal crackles
  • Orthopnoea – shortness of breath when lying down
  • Paroxysmal nocturnal dyspnoea – waking up short of breath at night, usually improved by sleeping upright
  • Laterally displaced apex beat – due to enlargement of the left ventricle
  • Additional heart sounds – S3 and S4
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11
Q

Right-sided heart failure presentation–

A

due to systemic congestion

  • Peripheral oedema (usually ankle/sacral oedema)
  • Raised jugular venous pressure
  • Hepatomegaly with or without splenomegaly
  • Due to liver congestion
  • This can lead to impaired liver function, jaundice, and coagulopathy due to impaired clotting factor synthesis
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12
Q

Biventricular failure (congestive) presentation

A

failure of one side of the heart can lead to failure of the over:

  • An overlap of the above signs and symptoms may be seen
  • Pleural effusions may occur – this can still happen in unilateral heart failure
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13
Q

define acute heart failure

A

Acute heart failure is either new-onset heart failure in people without a history of cardiac dysfunction, or an acute decompensation (worsening) of chronic heart failure.

Acute heart failure should be suspected in any patient with a sudden onset of:
- breathlessness
- ankle swelling, fatigue
- reduced exercise tolerance

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14
Q

acute heart failure symptoms are caused by

A

During acute heart failure, patients have volume overload with pulmonary and/or systemic oedema (congestion). This gives rise to the signs and symptoms seen.

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15
Q

causes of acute heart failure

A
  • Acute coronary syndrome
  • Hypertensive emergencies
  • Arrhythmia
  • Chest trauma
  • Pulmonary embolism
  • Infection e.g. myocarditis
  • Cardiac tamponade
  • Myocarditis
  • Causes of high-output heart failure (e.g. anaemia, sepsis, thyrotoxicosis)
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16
Q

Risk Factors for acute HF

A
  • History of heart failure
  • History of cardiovascular disease
  • Hypertension
  • Older age
  • Diabetes mellitus
  • Family history of cardiovascular disease
  • Family history of cardiomyopathy
  • Excess alcohol consumption
  • Smoking
  • History of arrhythmia
  • History of sarcoidosis or haemochromatosis
  • History of chemotherapy
  • Some drugs NSAIDs, corticosteroids, rate-limiting calcium channel blockers (diltiazem or verapamil)
  • Valvular heart disease
    *
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17
Q

investigations for acute heart failure

A

ECG
- may show arrhythmia or changes in wave morphology/duration

Chest x-ray
- pulmonary congestion
- pulmonary oedema
- pleural effusion
- cardiomegaly

Blood tests

  • NT-proBNP blood test: Elevated
  • Troponin: May be elevated
  • Full blood count: May identify anaemia or leukocytosis suggesting infection
  • Urea and electrolytes (U&Es)
  • Liver function tests (LFTs): To screen for liver pathology which can worsen heart failure or to screen for liver pathology due to heart failure
  • Thyroid function tests (TFTs): To screen for hypo- or hyperthyroidism
  • C-reactive protein: Non-specific marker of inflammation, may be elevated
  • D-dimer: If pulmonary embolism suspected

Echocardiography
This assesses the systolic and diastolic function of the ventricles

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18
Q

acute heart failure management: haemodynamically stable

A

stop b-blockers if HR <50, heart block or cardiogenic shock

  • Treat underlying cause
  • Sit the patient up
  • IV loop diuretic if there are signs and symptoms of congestion e.g. furosemide
  • If loop diuretic is insufficient and there are still signs and symptoms of congestion, consider an aldosterone antagonist e.g. spironolactone or eplerenone
  • Oxygen only if saturations are <90%
  • Consider CPAP if respiratory failure occurs (severe dyspnoea with or without acidaemia)
  • Consider invasive ventilation if respiratory failure occurs or there is reduced consciousness/physical exhaustion
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19
Q

acute heart failure management: haemodynamically unstable

A
  • Identify and treat the underlying cause
  • Request critical care
  • Vasoactive drugs – given in a specialist setting:
    1) Inotropes (e.g. dobutamine):
  • If there is severe left ventricular dysfunction with potentially reversible cardiogenic shock
    2) Vasopressors (e.g. noradrenaline):
  • Generally used if there is an insufficient response to inotropes and evidence of end-organ hypoperfusion
  • Oxygen only if saturations are <90%
  • Consider CPAP if respiratory failure occurs (severe dyspnoea with or without acidaemia)
  • Consider invasive ventilation if respiratory failure occurs or there is reduced consciousness/physical exhaustion
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20
Q

measures patients should take to prevent recurrence of acute heart failure

A
  • Restricting fluid and salt intake
  • Reducing alcohol intake
  • Continuing medication as prescribed
  • Regularly checking weight
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21
Q

how is chronic heart failure classified

A

Left ventricular ejection fraction (LVEF) *This is the amount of blood in the left ventricle that is pumped out with each heartbeat. The LVEF is measured using echocardiography. *

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22
Q

Heart failure with reduced ejection fraction (HFrEF):

A
  • Ejection fraction <40%
  • Patients usually have systolic dysfunction – impaired ventricular contraction during systole
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23
Q

Heart failure with preserved ejection fraction (HFpEF):

A
  • Ejection fraction >40%
  • Patients usually have diastolic dysfunction – impaired ventricular filling during diastole
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24
Q

most common causes of chronic heart failure

A
  • coronary heart disease
  • hypertension
  • valvular disease
  • cardiomyopathies
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25
Q

risk factors for chronic heart failure

A

Risk Factors

  • Previous cardiovascular disease
  • Previous myocardial infarction
  • Hypertension
  • Diabetes mellitus
  • Increasing age
  • Male
  • Family history
  • Arrhythmia e.g. atrial fibrillation
  • Obesity
  • Valvular heart disease
  • Sleep apnoea
  • Hypo- and hyperthyroidism
  • Anaemia
  • Connective tissue disorders
  • Same risk factors for acute heart failure
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26
Q

investigations for chronic heart failure

A

N-terminal pro-B-type natriuretic peptide (NT-proBNP)

  • a key initial test
  • Elevated
  • If >2000ng/L (high) – referral for specialist assessment and echocardiography within 2 weeks
  • If 400-200ng/L (raised) – referral for specialist assessment and echocardiography within 6 weeks

Full blood count (FBC):

  • May identify anaemia, which can worsen heart failure

Urea and electrolytes (U&Es):

  • May show hyponatraemia – heart failure can lead to increased water retention and dilution of serum sodium

ECG – may show:

  • Ventricular hypertrophy
  • Conduction abnormalities
  • Abnormal QRS duration

Chest x-ray – may show:

  • Pulmonary oedema – Kerley B lines
  • Cardiomegaly
  • Pleural effusions

Transthoracic echocardiogram:

Identifies systolic or diastolic ventricular dysfunction

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27
Q

management of chronic heart failure

A

First line

  • ACEi + beta-blocker (add b blocker once ACEi established)

Second line

  • aldosterone antagonist e.g. spironolactone/eplerenone

Additional treatment

  • Loop diuretic e.g. furosemide for symptomatic relief (do not improve survival but reduce symptoms of fluid overload)
  • SGLT-2 inhibitors

Third line: initiated by a specialist

  • If Afro-Caribbean: Hydralazine and isosorbide dinitrate
  • If heart rate >75bpm and ejection fraction <35%: Ivabradine
  • If reduced LVEF, especially for those with atrial fibrillation: Digoxin
  • If LVEF <35% and ACEi/ARB ineffective: Sacubitril-valsartan after ACEi/ARB washout period completed
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28
Q

general recomendations for all heart failure patients

A
  • Annual influenza vaccination
  • One-off pneumococcal vaccination

Patients should:

  • Regularly monitor their weight – assesses fluid overload
  • Restrict salt and fluid intake
  • Stop smoking
  • Limit alcohol intake
  • Have a balanced and healthy diet
  • Control blood pressure and diabetes
  • Exercise regularly and as much as tolerated
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29
Q

Complications of HF

A
  • Pleural effusion
  • Acute heart failure
  • Acute kidney injury
  • Chronic kidney disease
  • Anaemia (dilutional)
  • Cardiac arrest
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30
Q

Acute kidney injury secondary to HF

A

This could be due to poor perfusion due to heart failure itself or as a side effect of the medications e.g. ACE inhibitors, aldosterone antagonists etc.

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31
Q

Chronic kidney disease secondary to HF

A

Patients may develop a “cardiorenal syndrome” in which the dysfunction of the heart may lead to dysfunction of the kidneys and vice versa.

This is a difficult scenario as medications for heart failure often negatively impact the kidneys

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32
Q

what is cor pulmonale

A

the dysfunction of the right ventricle secondary to respiratory disease. This is due to the right ventricle working harder against pulmonary hypertension causing backflow of blood into the right atrium, the vena cava, and the systemic venous system.

33
Q

Pulmonary hypertension may be due to:

A

Chronic hypercapnia and respiratory acidosis leading to pulmonary vasoconstriction
Damage to the lung parenchyma itself e.g. pulmonary fibrosis/COPD
Increased blood viscosity due to the lung disease e.g. secondary polycythaemia

34
Q

risk factors for cor pulmonale

A

Risk Factors

  • COPD
  • Smoking
  • Pulmonary embolism
  • Interstitial lung disease
  • Primary pulmonary hypertension
  • Obstructive sleep apnea
35
Q

presentation of cor pulmonale

A

SoB

Other symptoms:

  • Worsening tachypnoea
  • Peripheral oedema
  • Shortness of breath on exertion
  • Syncope
  • Chest pain
  • Haemoptysis
  • Hepatic congestion – this is a late-stage feature which has:
  • Anorexia
  • Jaundice
  • Right-upper quadrant abdominal discomfort
36
Q

management of cor pulmonale

A

Management involves treating the underlying cause as well as possibly using long-term oxygen therapy.

37
Q

stage 1 hypertension

A

Clinic blood pressure ≥140/90mmHg
Ambulatory/home blood pressure ≥135/85mmHg

38
Q

stage 2 hypertension

A

clinic blood pressure of >160/100 mmHg

A/HBPM average blood pressure of >150/95 mmHg or higher.

39
Q

stage 3 hypertension

A

clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.

40
Q

malignant hypertension

A

severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve)

41
Q

Referral for same-day specialist assessment should be arranged for hypertensives with:

A
  • A clinic blood pressure of 180/120 mmHg and higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension) or life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
  • Suspected phaeochromocytoma, for example labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis.
42
Q

types of hypertension

A

Primary (essential) - no identifiable cause
Secondary

43
Q

secondary hypertension causes

A

Renal disease – most common cause of secondary hypertension

  • Examples are renovascular disease e.g. renal artery stenosis due to atherosclerosis or fibromuscular dysplasia

Endocrine disease:

  • Cushing’s syndrome
  • Hyperaldosteronism
  • Hyperthyroidism/hypothyroidism
  • Phaeochromocytoma
  • Acromegaly
  • Hyperparathyroidism

Obstructive sleep apnoea

Pre-eclampsia and pregnancy-induced hypertension

Some drugs/toxins:

  • Alcohol
  • Cocaine
  • Amphetamines
  • Antidepressants e.g. venlafaxine
  • Combined oral contraceptive pill
  • Glucocorticoids
44
Q

Risk Factors for hypertension

A
  • Increasing age
  • Sex – more common in men if <65, but higher in women between 65-74 years
  • Ethnicity – Black African/Hispanic people are at higher risk
  • Family history
  • Social deprivation
  • Smoking
  • Excess alcohol
  • Excess dietary salt
  • Obesity
  • Low exercise
  • Anxiety and emotional stress
45
Q

complications of hypertension

A
  • coronary artery disease
  • Stroke
  • HF
  • Hypertensive retinopathy
  • PAD
  • Aortic dissection
  • Malignant hypertension
46
Q

Assessment blood pressure

A
  • Blood pressure measurement on two or more occasions with the average recorded
  • Blood pressure should be measured in both arms. A difference in the arms may suggest aortic dissection
47
Q

if between 140/90mmHg and 180/120mmHg then offer

A

ambulatory/home blood pressure monitoring (ABPM/HBPM)

48
Q

Hypertension is diagnosed and staged if the two following criteria are met:

A
  • Clinic blood pressure of ≥140/90mmHg and
  • ABPM/HBPM ≥135/85mmHg
49
Q

Investigations for end-organ damage

A

ECGs:

  • May show left ventricular hypertrophy or signs of myocardial ischaemia
  • A normal result does not rule out coronary artery disease

Urine dipstick:

  • May show signs of renal disease e.g. haematuria/proteinuria

Urea and electrolytes (U&Es):

  • To check for renal disease which may cause or be a cause of hypertension

Thyroid function tests(TFTs):

  • Indicated if there are signs of hypo-/hypothyroidism

Lipid panel:

  • To check for dyslipidaemia

HbA1c:

  • To check for diabetes mellitus
50
Q

which hypertensives are offered antihypertensives

A

1) Have stage 2 hypertension
2) Under 80 years of age with stage 1 hypertension that have:
* Type 2 diabetes
* Chronic kidney disease
* End-organ damage
* QRISK score ≥10%

51
Q

first line antihypertensives for <55 or Type 2 diabetes

A

ACEi e.g. Ramipril or ARB e.g. Candesartan

switch to ARB is ACEi not tolerated

52
Q

Angiotensin-converting enzyme inhibitors (ACEi):

A

Examples: ramipril, lisinopril, enalapril
Mode of action: inhibits the conversion of angiotensin I to angiotensin II
Common side effects:

  • Dry cough
  • Postural hypotension
  • Acute kidney injury, especially in renal artery stenosis
  • Angioedema
  • Hyperkalaemia

Cautions:

  • Avoid in pregnancy
  • Renal function must be checked 2 weeks after starting as renal function may decline in people with renovascular disease e.g. renal artery stenosis
53
Q

Angiotensin II receptor blockers (ARB):

A

Examples: candesartan, valsartan
Mode of action: blocks the angiotensin II receptor and prevents its action
Common side effects:
* Hyperkalaemia
Cautions:
* Avoid in pregnancy
* Do not combine with ACEi

54
Q

first line for:
- >55 years and no type 2 diabetes
- Afro-caribbean and no type 2 diabetes

A

calcium channel blocker

55
Q

Calcium channel blockers (CCBs):

A

Examples: amlodipine, felodipine, nifedipine
Mode of action: block voltage-gated calcium channels and relax vascular smooth muscle and decrease the force of heart contractions
Common side effects:
* Ankle swelling
* Headache
* Dizziness
* Bradycardia
* Flushing

56
Q

second line anti hypertensives

A

A+C e.g. ACEi or ARB + CCB

or

A+ D
ACEi or ARB + Thiazide like diuretic

57
Q

Thiazide-like diuretics:

A

Examples: indapamide, chlortalidone
Mode of action: inhibit sodium absorption at the start of the distal convoluted tubule
Common side effects:
* Hyponatraemia
* Hypokalaemia
* Hypercalcaemia
* Hyperuricaemia
* Dehydration

Cautions:
* Can worsen diabetes, gout, and systemic lupus erythematosus
* Can cause erectile dysfunction in men

58
Q

third line

A

A + C + D

59
Q

fourth line

A

DEPENDS ON SERUM POTASSIUM

  • If K+ >4.5 - add alpha/beta blocker
  • ## If K+ <4.5 - add low-dose spironolactone
60
Q

alpha blockers

A

Examples: doxazocin and terazosin
Mode of action: inhibit post-synaptic alpha1-adrenergic receptors leading to vasodilation of the blood vessels
Common side effects:
* Dizziness
* Drowsiness
* Orthostatic hypotension

61
Q

beta blockers

A

Examples: carvedilol, metoprolol, bisoprolol
Mode of action: block beta-adrenergic receptors and lead to vasodilation and reduced heart contraction strength
Common side effects:
* Diabetes
* Impotence
* Bradycardia
* Fatigue
* Cold hands and feet
* Worsening psoriasis
Cautions:
* Contraindicated in asthma
* Contraindicated in 3rd-degree heart blocks

62
Q

Aldosterone antagonists:

A

Examples: spironolactone, eplerenone
Mode of action: bind to aldosterone receptors and reduces sodium absorption and promotes water excretion
Common side effects:
* Hyperkalaemia
* Spironolactone – gynaecomastia
Cautions:
* Contraindicated in hyperkalaemia or Addison’s disease

63
Q

treatment targets for HTN

A
64
Q

types of hypertensive crisis

A

Malignant hypertension
Hypertensive urgency

65
Q

Malignant (accelerated) hypertension:

A
66
Q

Hypertensive urgency:

A

Severe hypertension without end-organ damage

67
Q

RF for hypertensive emergecy

A
  • Inadequately treated hypertension
  • Renal artery stenosis
  • Chronic kidney disease
  • Renal transplant
  • Hyperaldosteronism
  • Cushing’s syndrome
  • Acromegaly
  • Hyperparathyroidism
  • Hyper-/hypothyroidism
  • Phaeochromocytoma
  • Pregnancy
  • Older age
  • Afro-Caribbean ethnicity
  • Male sex
68
Q

Presentation of hypertensive emergency

A

Blood pressure >180/120mmHg

Neurological symptoms:
* Vision changes
* Headaches
* Dizziness
* Seizures
* Weakness
* Gait problems

Cardiorespiratory symptoms:
* Chest pain
* Shortness of breath
* Palpitations
* Orthopnoea
* Paroxysmal nocturnal dyspnoea
* Oedema
* New murmurs
* S3
* Jugular venous distention

Oliguria

Fundoscopy signs:
* Retinal haemorrhages
* Retinal exudates
* Papilloedema
* Enlarged retinal veins

69
Q

examination for patients with hypertensive crisis

A

Blood pressure measurement from both arms and repeated after 5 minutes

  • If there’s a >20mmHg difference between the arms, aortic dissection may need to be considered

Fundoscopy which may show:

  • Papilloedema
  • Retinal haemorrhages
  • Retinal exudates

Cardiorespiratory examination

Neurological examination

70
Q

Investigations for patients with hypertensive crisis

A

Urea and electrolytes (U&Es)

  • May show acute kidney injury

Urinalysis and microscopy:

  • May show red cells and protein
    ECG:
  • May show myocardial infarction

Chest x-ray:

  • May show pulmonary oedema, or a widened mediastinum that may suggest aortic dissection
71
Q

malignant hypertensive same -day referral

A
  • Papilloedema/retinal haemorrhages
  • New-onset confusion
  • Chest pains
  • Signs of heart failure
  • Signs of AKI
  • Suspected phaeochromocytoma
72
Q

general management of hypertensive emergency

A

1st line: IV labetalol
2nd line: IV nicardipine
3rd line: IV fenoldopam

73
Q

orthostatic hypertension definition

A

a drop in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.

74
Q

causes of orthostatic hypertension

A

Normal ageing

Deconditioning due to prolonged bed rest

Hypovolaemia:

  • Dehydration
  • Excess diuretic use
  • Vasodilators

Drugs:

  • Beta-blockers
  • Sildenafil
  • Tricyclic antidepressants
  • MAO inhibitors
  • Alpha blockers
  • Levodopa and dopamine agonists

Neurological:

  • Parkinson’s disease
  • Alcoholic neuropathy
  • Guillain-Barré syndrome
  • Neurosyphilis
  • Multiple system atrophy

Cardiovascular:

  • Aortic stenosis
  • Arrhythmia
  • Myocardial infarction
  • Heart failure
  • Constrictive pericarditis
  • Cardiac tamponade

Haematological:

  • Anaemia
    Endocrine:
  • Diabetes mellitus
  • Primary hypoaldosteronism (Addison’s disease)
  • Phaeochromocytoma
75
Q

cause of fainting with orthostatic hypotension

A

The symptoms are a result of inadequate cerebral perfusion due to the blood pressure being too low as the body responds too slowly. They may experience:

  • Blurred vision
  • Light-headedness
  • Nausea
  • Weakness
  • Syncope or loss of consciousness

Patients may have aggravating factors:

  • Early morning – due to not drinking water overnight
  • Hot environments – due to vasodilation
  • Post-prandial – due to diversion of blood to the gut
  • During or after exercise – due to the diversion of blood to muscles
    *
76
Q

conservative management of orthostatic hypotension

A

prescription reveiw
increase water
salt ingestion

77
Q

if conservative management of orthostatic hypotension fails

A

fludrocortisone

78
Q
A

Medicine (Year 5) (34 decks)

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