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Year 3 > Case 9 - Cogestive Cardiac Failure > Flashcards

Case 9 - Cogestive Cardiac Failure Flashcards

1
Q

What is the NYHA classification for heart failure?

A

New York Heart Association classification of heart failure:
Class 1 - no symptoms or limitation
Class 2 - mild symptoms, fatigue in ordinary activity
Class 3 - moderate symptoms, fatigue in less than ordinary activity
Class 4 - severe symptoms, unable to carry any activity without discomfort, symptoms present at rest

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2
Q

What are the guidelines for treatment of heart failure?

A

1st line - ACE inhibitor and beta blocker
2nd line - add aldosterone antagonist, or hydralazine in combination with nitrate
3rd line - add cardiac resynchronisation therapy or digoxin, can also add ivabradine if the patient has a heart rate >75 and EF <35%

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3
Q

What are the drugs that are shown to improve mortality in patients with heart failure?

A

ACE inhibitors
Spironolactone
Beta blockers
Hydralazine with nitrates

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4
Q

What is the first line investigation for suspected heart failure?

A

BNP test (regardless if had MI or not)

  • if levels are ‘high’ arrange echo for 2 weeks
  • if levels are ‘raised’ arrange echo for 6 weeks

All patients with suspected heart failure should have 12 lead ECG

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5
Q

What are the normal, raised and high levels for BNP?

A

Normal <100pg/ml
Raised 100-400 pg/ml
High >400pg/ml

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6
Q

Auscultation of the chest in a patient with heart failure, you can often hear what?

A

A third heart sound

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7
Q

What are the main symptoms of heart failure?

A

Breathlessness
Reduced exercise tolerance
Oedema
Fatigue

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8
Q

What are the main signs seen in heart failure?

A 
Cyanosis 
Tachycardia 
Elevated JVP
Displaced apex beat 
Pulmonary oedema 
Pitting oedema
S3 heart sound (S3 gallop)
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9
Q

What are the signs and symptoms associated with left sided heart failure?

A

Pulmonary oedema - fluid backs up into lungs
Dyspnoea - extra fluid causes difficulty breathing
Orthopnoea (difficultly breathing when lying flat)
Crackles - bibasel crepitations due to extra fluid in lungs

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10
Q

What are the signs and symptoms of right sided heart failure?

A

Raised JVP - blood that cannot pump backs up to right side of body
Ascites - fluid backs up to abdominal organs
Pitting oedema - fluid backs up to the legs

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11
Q

What is the CHADS2 score?

A 
Score for stroke risk assessment in AF
C - Cardiac heart failure 
H - hypertension 
A - Age >75
D - diabetes 
S - stroke or TIA
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12
Q

What are the management options in acute heart failure?

A 
Oxygen 
Diuretics
Opiates
Vasodilators 
CPAP (continuous positive airway pressure)
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13
Q

What is the Duke’s criteria used to help diagnose?

A

Infective endocarditis

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14
Q

What are the major criteria regarding dukes criteria?

A

Two positive blood cultures showing typical organisms consistent with infective endocarditis
Persistent bacteraemia from two blood cultures taken >12 hour apart or three or more positive blood cultures where the pathogen is less specific such as staph.aureus

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15
Q

What are the minor criteria in dukes criteria?

A

Predisposing heart failure
IV drug use
Fever >38
Vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, janeway lesions, petechiae or purpura
Immunological phenomena: glomerulonephritis, oslers nodes, Roth spots

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16
Q

What is the most common cause of infective endocarditis?

A

Staphylococcus aureus

17
Q

What are the risk factors for developing infective endocarditis?

A 
Previous episode of infective endocarditis 
Previously normal valves
Rheumatic valve disease 
Prosthetic valves
Congenital heart defects
IVDU
18
Q

What is orthopnoea?

What commonly causes it?

A

Breathlessness when lying flat

Symptom of left ventricular failure and/or pulmonary oedema

19
Q

How can the JVP and carotid pulse be differentiated?

A

JVP beats twice - is multiphase
JVP is non palpable
JVP can be occluded by lightly pressing against the neck

20
Q

How do you grade heart murmurs?

A

Grade 1 - murmur is heard on listening for some time
Grade 2 - faint murmur heard immediately on auscultation
Grade 3 - loud murmur with no palpable thrill
Grade 4 - loud murmur with a palpable thrill

21
Q

What are the common causes for heart failure?

A 
Ischaemic heart disease 
Structural causes
Congenital heart disease 
Rate related causes - e.g, AF, heart block 
Pulmonary causes - e.g, COPD, pulmonary fibrosis 
Alcohol and drugs
Autoimmune disease 
Pericardial disease
22
Q

What are the causes of mitral regurgitation?

A

Rheumatic heart disease
Ischaemic heart disease - associated with papillary muscle rupture
Valvular vegetations - as in patients with endocarditis
Physiological mitral valve regurgitation due to dilated left atrium

23
Q

Define ejection fraction?

What is a normal ejection fraction?

A

Ejection fraction is a measurement of how much blood is being pumped out of the heart with each contraction (stroke volume/end diastolic volume)

Normal EF: 50-70%

24
Q

Why would you not cardiovert someone who has been in AF for longer than 48 hours (unless it was going to be life saving)?

A

In AF blood flow is turbulent and can cause clots to form, which is significantly more risky if you have been in AF > 48 hours

If normal sinus rhythm is restored this could dislodge clots and cause an embolic stroke

25
Q

How do you treat AF (cardiovert a patient)

A

> 65 and IHD: Control rate with beta blocker or verapamil
2nd line: digoxin or amiodarone

<65 1st presentation: Flecanide used for pre excited AF (caution with structural heart disease, use amiodarone instead)

Electrical cardioversion - Shock the heart back to normal rhythm (only use if in AF for less than 48 hours)

26
Q

What are peripheral signs of infective endocarditis?

A

Petechiae
Splinter haemorrhages - dark red linear lesions on nail beds
Osler nodes - red raised lesions on hands and feet
Janeway lesions - non tender erythematous lesions on palms
Roth spots - retinal haemorrhages with small clear centres

27
Q

What are the signs on a chest X ray which indicate heart failure?

A 
Cardiomegaly 
Bats wings - signals alveolar oedema 
Kerley B lines - signals interstitial oedema 
Pleural effusion 
Dilated prominent upper Lobe vessels
28
Q

What are the main signs and symptoms of infective endocarditis?

A

Fever

New murmur

29
Q

When should patients with AF be considered for electrical cardioversion?

A

If they present feeling very unwell with low blood pressure

30
Q

What investigations would you do in a patient presenting with heart failure?

A

Bloods - FBC, U&E, TFTs, glucose, BNP, glucose
ECG
Chest X ray
ECHO

31
Q

What is pulses Alternans?

A

Where the upstroke of the pulse alternatives between strong and weak

It is commonly seen in patients with heart failure as is indicates systolic dysfunction

Year 3 (24 decks)

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