Cardiovascular 3

Question 1

In the chronic management of heart failure with a reduced ejection fraction, what are the two first line medications?

Answer 1

ACE inhibitor PLUS a Beta Blocker

Question 2

In the chronic management of heart failure with a reduced ejection fraction, if an ACE inhibitor is contraindicated or not tolerated, what other medication can be combined with the Beta Blocker?

Answer 2

Angiotensin Receptor Blocker (ARB)

Question 3

In the chronic management of heart failure with a reduced ejection fraction, if ACE/ARB + Beta Blocker aren’t tolerated, what is the next first line option?

Answer 3

Hydralazine + Nitrates

Question 4

What class of diuretics are used to treat fluid overload in heart failure? What other class may be used in addition to these?

Answer 4

Loop Diuretics, e.g. Furosemide. Although you can add in Thiazide-like diuretics if overload is severe

Question 5

In the chronic management of heart failure with a reduced ejection fraction, what is the MOA of Ivabradine?

Answer 5

Reduces heart rate by inhibiting SA node current and does not reduced contractility.

Question 6

According to NICE guidance, what are the (3) prescribing considerations for Ivabradine?

Answer 6

NYHA Class II-IV + Systolic dysfunction + LVEF <35%
Must be in sinus rhythm with HR >75 BPM
Stable on standard therapy for at least 4 weeks

Question 7

In the chronic management of heart failure with a reduced ejection fraction, what is the MOA of Sacubritril Valsartan (brand name Entresto)?

Answer 7

Sacubritril inhibits enzyme that breaks down ANP, BNP and Bradykinin. Increased levels of ANP and BNP stimulate sodium and water excretion, promote myocardial relaxation and stimulates vasodilation.

Valsartan is an ARB which is blocking the effect of Angiotensin II.

Question 8

In the chronic management of heart failure with a reduced ejection fraction, what is the MOA of Hydralazine + Nitrates?

Answer 8

Hydralazine = Arterial vasodilator
Nitrates = Venous vasodilator

decreasing TPR, and thus afterload, and decreasing venous return and thus preload

Question 9

In the chronic management of heart failure with a reduced ejection fraction, what is the MOA of Digoxen?

Answer 9

Na/K ATPase pump inhibitor. Increases force of contraction, but slows heart rate.

Question 10

In the ACUTE management of heart failure, what should be administered?

Answer 10

Oxygen (if required) + IV Furosemide

Question 11

In the ACUTE management of heart failure, according to NICE what (3) medications are NOT recommended for routine administration?

Answer 11

Opioids, Nitrates, Inotropes/Vasopressors

Question 12

Common side effects of loop diuretics, e.g. Furosemide

Answer 12

Dehydration, Hypotension, AKI, Electrolyte Imbalances, Hearing loss/tinnitus (same co-transporter regulates endolymph in ear)

Question 13

What medications have the potential to worsen heart failure?

Answer 13

Steroids, NSAIDs, CCBs, Metformin/Poiglitazone.

Question 14

Name the atrioventricular vavles:

Answer 14

Mitral and Tricuspid valves

Question 15

Name the semilunar valves

Answer 15

Aortic and Pulmonary valves

Question 16

How many leaflets/cusps does each valve have?

Answer 16

Mitral has 2 leaflets (bicuspid), Pulmonary, Tricuspid and Aortic valves have 3 leaflets.

Question 17

What is the name of the structure that connects the atrioventricular valves (mitral and tricuspid) to the papillary muscles on the inner wall of the ventricles?

Answer 17

Chordae Tendineae

Question 18

What (6) conditions can cause heart valves to become insufficient/Regurgitate?

Answer 18

Congenital Abnormalities - Prolapse or Bicuspid Aortic valve.

Inflammation - Rheumatic fever

Infective causes - Infective endocarditis

Ischaemic Events - Increase likelihood of traumatic rupture of chordae tendineae

Hypertrophy and Dilation

Question 19

What is meant by valvular stenosis?

Answer 19

Stiffened, thickened or hardened cusps/leaflets,

causing faster and more turbulent flow of blood.

Question 20

What is meant by valvular regurgitation?

Answer 20

Loose, floppy cusps/leaflets, Increased stagnation of blood. Valve remains open throughout cycle
causing constant drip flow and
backflow of blood.

Question 21

(7) Common causes of heart failure

Answer 21

CAD, previous MI

HTN

AF

Valvular Heart Disease

Excess Alcohol

Infection

Cardiomyopathy of unknown cause

Question 22

What is another name for systolic heart failure?

Answer 22

Heart failure due to reduced ejection

fraction (HFrEF)

Question 23

What is Systolic Heart Failure/HFrEF due to?

Answer 23

Due to

left ventricular systolic dysfunction.

Question 24

In Systolic Heart Failure/HFrEF, what is the ejection fraction?

Answer 24

<40%

Question 25

What is another name for diastolic heart failure?

Answer 25

Heart failure with preserved ejection | fraction (HFpEF)

Question 26

In Diastolic Heart Failure/HFpEF, what is the ejection fraction?

Answer 26

>50%. Although this may decline over time.

Question 27

What is the main pathophysiology/mechanisms behind Diastolic Heart Failure/HFpEF?

Answer 27

Delayed relaxation of the left ventricle and as a result, impaired left ventricle filling. The ventricular myocardium becomes thickened, increasing the stiffness.

Question 28

Define the Frank-Starling Mechanism

Answer 28

``` Defines the normal relationship between the length and tension of the myocardium. The greater the stretch on the myocardium before systole (preload), the stronger the ventricular contraction. ```

Question 29

What will the Frank-Starling Curve look life in heart failure?

Answer 29

In HF, the Frank–Starling curve is moved down (flattened) because more venous return and filling pressure is required to increase contractility and stroke volume.

Question 30

Presenting symptoms of Left Sided Heart Failure?

Answer 30

SOB, Cough, Wheeze, Blood in sputum, Fatigue, Waking up being breathless at night (PND)

Question 31

Findings of Left Sided Heart Failure on examination?

Answer 31

Increased RR Tachycardia Rales/crackles in lung bases (pulmonary oedema) Cool extremities at rest Cyanosis Laterally displaced apex beat (LV Hypertrophy) Gallop Rhythm

Question 32

Findings of Right Sided Heart Failure on examination?

Answer 32

Peripheral Oedema, Sacral Oedema, Raised JVP, Parasternal Heave, Ascites, Hepatosplenomegaly, Jaundice

Question 33

Name of the blood test used when suspecting heart failure?

Answer 33

B-Type Natriuretic Peptide (BNP) (Levels go up when heart failure develops)

Question 34

What is B-Type Natriuretic Peptide (BNP)?

Answer 34

A hormone produced by the heart in response | to changes in pressure inside the heart. Levels goes up when heart failure develops

Question 35

What BNP level(s) should a patient have in order to be referred to have transthoracic echocardiography?

Answer 35

Between 400 and | 2,000 pg/L

Question 36

Describe where each valve is located when doing a cardiovascular examination

Answer 36

``` Aortic = 2nd ICS, right sternal edge Pulmonary = 2 ICS, left sternal edge Tricuspid = 4th ICS, left sternal edge Mitral = 5th ICS, MCL ```