Chronic heart failure Flashcards
1
Q
What is Class I according to the NYHA classification?
A
No limitation to physical activity
2
Q
What is Class II according to the NYHA classification?
A
Slight limitation of ordinary activity
3
Q
What is Class III according to the NYHA classification?
A
Marked limitation, even during less-than-ordinary activity
4
Q
What is Class IV according to the NYHA classification?
A
Severe limitation with symptoms at rest
5
Q
What are some clinical sign of cardiac failure?
A
-cool, pale, cyanotic extremities
- tachycardia
- elevated JVP
third heart sound S3
- displaced apex: LV enlargement
- crackles or decreased breath sounds
- peripheral oedema
- Ascites
- Hepatomegaly
6
Q
Give 5 clinical tests are used to diagnose heart failure
A
- CXR
- ECG
Blood investigations - Echo/Cardiac MRI or CT
- Coronary angiography/ CTCA
7
Q
What are some medical treatments for LVSD?
LVSD: Left Ventricular Systolic Dysfunction
A
- Using Loop Diuretics
- Mineralocorticoid Receptor Antagonists ( Aldosterone antagonist, potassium-sparing)
- ACE inhibitors
- Beta-Blockers
- SA Node Blockade
- Digoxin
- ARNI
- surgical interventions
8
Q
Give example of loop diuretics and their action
A
- Frusemide - Bumetanide
given iv or orally - Inhibit Na+ reabsorption from the proximal tubule
- K+ loss from distal tubule
9
Q
What are some side effects of loop diuretics?
A
- electrolyte abnormalities
- hypovolaemia and diminished renal function
- hypokalaemia
10
Q
Give example of mineralocorticoid receptor antagonists. What is their action?
A
- Eplerenone, Spironolactone
- acts on distal tubule as an aldosterone agonist, and is potassium-sparing
- promotes Na+ secretion and K+ re-absorption
- reduces hypertrophy and fibrosis
11
Q
What are some side effects of mineralocorticoid receptor antagonists ?
A
- Gynecomastia (enlargement of men’s breast): especially spironolactone
- Hyperkalaemia, renal function abnormalities
12
Q
Give an example of ACE inhibitors and their action
A
- Ramipril, Perindopril, Enalapril, Captopril, Lisinopril
- act on the activated RAAS, given in small slowly titrated doses
- block production of angiotensin:–> vasodilation, lower BP, reduced cardiac output
13
Q
What are some side effects of ACE inhibitors?
A
- cough
- hypotension
- renal impairment
14
Q
How does heart rate contribute to chronic heart failure?
A
- excessively high heart rate –> decreased time for ventricular filling – decreased SV and CO
- ventricles contract harder, due to reduced volume
- increased atrial preload is too much
- atrial/ ventricular hypertrophy
15
Q
What is Frank-Starling’s Law?
A
- this describes the relationship between Preload and Cardiac output
- an increase in volume of blood filling the hear stretches the fibres causing greater contractile force, increasing the stroke volume
- only to a point after which the fibres are overstretched, and contrile force is decreased
16
Q
Give two examples of low output heart failure
A
- systolic heart failure
- diastolic heart failure
17
Q
What is High output heart failure?
A
- when other medical conditions cause an increased demand on cardiac output
- the heart itself is functioning normally but cannot keep up with unusually high demand for blood to one or more organs
18
Q
What are causes of high output heart failure?
A
- thyrotoxicosis
- profound anaemia
- pregnancy
- pagets disease:abnormal
- acromegaly
- sepsis
19
Q
What is pagets disease?
A
formation of new bone when - replacing old bone is abnormal
- gradually bone becomes weak and brittle
20
Q
What is systolic heart failure?
A
- the progressive deterioration of myocardial contractile function
21
Q
What causes systolic heart failure?
A
- Ischaemic injury
- Volume overload
- Pressure overload
22
Q
What is diastolic Heart Failure?
A
- inability of the heart chamber to relax, expand and fill sufficiently during diastole to accommodate an adequate blood volume
23
Q
What causes diastolic heart failure?
A
- significant left ventricular hypertrophy
- infiltrative disorders
- constrictive pericarditis
- restrictive cardiomyopathy
24
Q
Define Cardiomyopathies
A
Disease of the heart muscle leading to functional impairment
25
What is dilated cardiomyopathy and its causes?
- the hearts ability to pump blood is decreased due to lower function of the left ventricle
- 50% familial aetiology
- ETOH, pregnancy, systemic disease, muscular dystrophies
- Myocarditis
26
What is hypertrophic cardiomyopathy?
- hereditary disease
| - where the myocardium becomes abnormally thick
27
What is restrictive cardiomyopathy?
- least common
- where the myocardium is rigid, but not thickened, therefore heart is unable to pump blood
- main cause in the uk in the amyloid, protein produced in the bone marrow
28
Describe the neurohormonal compensatory mechanism for heart failure
- release of noradrenaline, increases heart rate and myocardial contractility
- release of ANP/ BNP
- activation of renin-angiotensin - aldosterone system
29
What is ANP/BNP?
- (B-type) Atrial natriuretic peptide
- secreted by the cardiac atria
- promotes excretion of water and sodium
- lowering blood pressure
30
Describe the Renin- Angiotensin-Aldosterone System
- Renin, ACE
- Angiotensinogen --> Angiotensin I --> Angiotensin II
- vasoconstriction, ADH secreted, Aldosterone secretion
- more water and sodium moves out of the collecting duct, retained in the blood
31
Describe the NP (naturistic peptide) System
- proBNP released
| - BNP(active), NT-proBNP (non-active)
32
What is the action of active BNP?
- stimulates diuresis
- vasodilation
- inhibits RAAS
- inhibits the SNS
33
What does RAAS stand for
the Renin-Angiotensin-Aldosterone System
34
What are the 7 clinical types of heart failure?
- Left-sided HF
- Right-sided HF
- Biventricular HF: left HF causing right HF due to overload of pulmonary circulation
- Chronic HF
- Acute HF
- Compensated HF
- Decompensated HF
35
What is Left-sided Heart failure and what are the causes?
- when there is insufficient afterload on the left heart, resulting in overload in the left atrium - leading to increased pressure in the pulmonary circulation (oedema and congestion)
Causes
- Ischaemic heart disease
- Hypertension
- Valvular heart disease
- Myocardial disease
36
What is the effect of left ventricular failure on the kidneys?
- Decreased renal failure due to reduced cardiac output
- activation of RAAS
- retention of salt and water with consequent expansion of interstitial fluid and blood volume
37
What is the effect of left ventricular failure on the Brain?
- causes Hypoxic encephalopathy ( lack of oxygen brain disorder)
- Irritability
- Loss of attention
- Restlessness
- Stupor and coma
38
What is right-sided heart failure and what is its cause?
- the inability of the heart to properly expel the contents of the right ventricle
Causes
- Cor-pulmonale: Right-sided HF due to significant pulmonary hypertension, due to increased resistance in the pulmonary circulation
- usually the result of a respiratory disease: COPD,
pulmonary emboli
- Valvular heart disease
- Congenital heart disease
39
What are the systemic effects of Right Heart failure?
- Liver and portal system
- Spleen
- Abdomen
- Subcutaneous tissue
- Liver and portal system: congestive hepatomegaly, centrilobular necrosis if severe, cardiac cirrhosis
- Spleen: congestive splenomegaly
- Abdomen: Ascites- accumulation of transudate in the peritoneal cavity
- Subcutaneous tissue: peripheral oedema (ankles), sacral oedema if bedridden
- pleural and pericardial effusion
40
Give examples of Beta-blockers and explain their action.
| - What apart from CHF can it be used to treat?
- Bisoprolol, Carvedilol, Metoprolol
- block the action of adrenaline and noradrenaline on adrenergic beta receptors
- slows HR + reduces BP
- given orally in small doses in slow titrations
- Can be used to treat arrhythmias
41
What are the side effects of Beta-blockers?
- Bronchospasm
| - Claudication: pain caused by too little blood flow to the arms and legs
42
Give an example of a SA Node Blockade and explain their action.
- Ivabradine
- blocks the If channel (funny current) within the SA node
- Slow HR, no effect on BP
- Given orally with dose titration
43
What are the side effects of SA Node Blockades?
- Visual aura (hallucinations)
| - Bradycardia ( too slow heart rate)
44
What is the action of Digoxin and when is it indicated?
- Increase myocardial contractility
- Slows conduction at the AV node (used in AF)
- Excreted by kidney
Indication
- Acute HF especially in AF
- Chronic HF in selected cases
45
Give an example of Angiotensin Receptor Neprilysin Inhibitor (ARNI). What is its action?
- Sacubitril, Valsartan
- acts on the activate RAAS
- blocks the break down of natriuretic peptides (A and B)
- blocks production of angiotensin: vasodilation, BP lowered, reduced cardiac work
- promote natriuresis: increased Na extraction, vasodilation, reduce hypertrophy and fibrosis
46
What are the side-effects of Angiotensin Receptor Neprilysin Inhibitor (ARNI)
- Hypotension
| - renal impairment
47
What are other non-pharmcological treatments for LVSD?
- Cardiac Resynchronisation therapy
- Implantable Cardioverter Defibrillator (ICD)
- Dialysis and Ultrafiltration
- Ventricular Assist Device (LVAD/RVAD)
- Intra-aortic balloon pump
- Cardiac transplantation
- Stem cell therapy**
