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Congestive Heart Failure Flashcards

(48 cards)

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1
Q

Define Atherosclerosis

A

The process of progressive thickening and hardening of the walls of medium and large-sized arteries as a result of cholesterol deposition

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2
Q

Non- Modifiable CVD risk factors (5)

A

Age
Male sex
Family History
Low Birth weight
Premature Birth

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3
Q

Modifiable CVD risk factors (6)

A

Hypertension
Smoking
Diabetes mellitus
Hypercholesterolemia
Obesity
Physical inactivity

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4
Q

CVD continuum (8)

A

Risk factors/ diabetes/ Hypertension

Ather + LVH

MI

Remodelling

Ventriuclar Dilation

Congestive Haert Failure

End-stage Heart disease

Death

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5
Q

Definition of Heart Failure (3)

A

“A complex of symptoms—shortness of breath, fatigue, and congestion

Due to an impairment of the heart’s ability to empty* or fill* properly, (systolic or diastolic)

= leading to inadequate perfusion of tissues during exertion, and retention of fluid”

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6
Q

Heart Failure facts (4)

A

 Affects 1-2% of population

 10% among persons ≥ 70 years

 Prognosis 25-40% mortality ~ 5 years(similar to cancer)

 Prognosis worse if (1yr ~ worse than cancer)
– severe symptoms
– high dose of diuretics
– low BP
– low sodium

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7
Q

Causes of Heart Failure (3)

A

Decreased contractility:
- Coronary heart dis.
- Cardiomyopathies
Viral myocarditis (Covid)
Infiltrations

  • Drugs
    ß-adrenergic blockers
    Verapamil
    Doxorubicin
  • Arrhythmias

Increased Afterload:
- Hypertension
- Valvular disease
- HOCM

Increased Output:
- Anaemia
- Hyperthyroidism
- AV shunts

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8
Q

Acute Decompensation (6)

A

One or more events
1. Discontinuation of treatment
2. ACS (new event)
3. Arrhythmias (AF)
4. Infection
5. Anaemia
6. Pulmonary Embolism

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9
Q

New York Heart
Association (NYHA) - 4 classes (4)

A

Class I:
– No limitation of physical activity
– Ordinary physical activity does not cause SOB (dyspnoea) or fatigue

Class II:
– Slight limitation of physical activity
– Ordinary physical activity result in dyspnoea or fatigue

Class III:
– Marked limitation of physical activity
– Less than ordinary physical activity result in
dyspnoea or fatigue

Class IV:
– Inability to carry out any physical activity
without discomfort
– Symptoms are present at rest

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10
Q

Diagnosis of HF - 5 steps (5)

A
  1. (BNP) or NT-proBNP:
    if <400 ng/L HF is unlikely if <400 ng/L HF is unlikely
  2. ECHO: HF, rEF or HF, pEF
  3. Cardiac MRI (CMR)
  4. Other tests: ECG, CXR, U&Es, ABGs, D-dimer
  5. Look for cause(s) of decompensation: Troponin for ACS, ECG for Arrhythmias, etc.
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11
Q

Ejection Fraction (3)

A

Is a percentage of how much blood the left
ventricle pumps out with each contraction

EF of 60% means that 60% of the total amount of blood in the left
ventricle is pushed out with each heartbeat.

EF also called Fractional shortening

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12
Q

Types of HF (2)

A

Failure of filling of blood:
– Diastolic HF
– HF (Heart failure with preserved ejection fraction >50%)
- HFpEF patients are older, female, hypertension, obesity, anaemia, and AF

Failure of ejection of blood:
–– Systolic HF
–– HFHF
(Heart failure with reduced ejection fraction ≤40%)

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13
Q

Aims of Treatment (4)

A
  1. Removal of the underlying or
    precipitating causes
  2. Improving survival & reducing mortality
  3. Relief of symptoms (& Improvement in quality of life)(& Improvement in quality of life)
  4. Prevention of re-admissions to hospital, recurrent ischaemic
    events, and further deterioration in left ventricular function
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14
Q

Removal of precipitating causes (5)

A

 Treatment of hypertension

 Correction of valvular lesions

 Anaemia, thyrotoxicosis, fluid
overload, increased dietary salt intake

 Poor compliance with treatment

 Drugs: beta-blockers, salt- retaining drugs (NSAIDs, steroids)

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15
Q

Standard Drug Therapy
(1st , 2nd + 3rd line) (9)

A

1st:
- ACE inhibitors / ARNI
- Beta Blockers

2nd:
- Angiotensin receptor antagonists (ARBs)
- Aldosterone antagonists
- Hydralazine/nitrate

3rd:
- Diuretics
- Digoxin
- Sacubitril-Valsartan (ARNI)
- SGLT2 inhibitors

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16
Q

RAAS + which drug is used where (4)

A

1) Angiotensin (+ renin)
- beta blockers + renin inhib

2) = angiotensin I (+ACE Chymase)
- ACE inhib

3) = Angiotensin II
- ARBs

4) Aldosterone + Vasoconstriction

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17
Q

ACE Inhibitors (4)

A
  • Indicated in all patients with heart failure (EF<40)
    (unless contraindicated)

e.g.’s
–– Captopril
–– Enalapril
–– Lisinopril
–– Perindopril
–– Ramipril
–– Trandolapril

  • Documented survival benefit
  • Several large controlled trials
    –– CONSENSUS
    –– SOLVD
    –– SAVE
    –– AIRE
    –– TRACE
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18
Q

How do ACE inhib work? (8)

A

Reduce angiotensin II levels

 Arteriolar vasodilatation

 Reduce systemic vascular resistance

 Reduce norepinephrine release

 Decrease sympathetic activity

 Decrease aldosterone secretion

 Suppress
vasopressin release

 Increase bradykinin levels

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19
Q

Acute Infarction Ramipril
Efficacy (AIRE) (5)

A

 Effect of Ramipril on mortality and
morbidity of survivors of acute MI with HF

 2006 patients, EF ≤ 35% post-MI

Follow-up average 15 months

Overall mortality significantly reduced 27%

Development of severe heart failure reduced by 23%

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20
Q

ACEi: other uses (6)

Study These Flashcards
A

 Heart failure
 Hypertension
 Post-Myocardial Infarction (LVD)
 Diabetic nephropathy
 Diabetic retinopathy

21
Q

ACEi: side effects (6)

Study These Flashcards
A

First dose hypotension
Cough
Angioedema
Rash
Deterioration of renal function (in RAS)

22
Q

ACEi: Contraindications (3)

Study These Flashcards
A
  • Pregnancy(or risk of pregnancy)
  • Renal artery stenosis (bilateral, single k)R

Caution: Peripheral vascular disease
–– Low BP
–– High dose diuretic, hypovolaemia
–– Age >70 ys
–– Creatinine >150μmol/L
–– +NSAIDs

23
Q

What if ACEi are
contraindicated or untolerated? (3)

Study These Flashcards
A

Other vasodilators
–– Angiotensin Receptor Blockers e.g. Candesartan, Losartan

–– Hydrallazine & Nitrates

– Angiotensin receptor-neprilysin inhibitor
(ARNI )

24
Q

Angiotensin Receptor
Blockers (ARBs) (4)

Study These Flashcards
A
  • Block angiotensin II type 1 receptors

Examples:
–– Losartan
–– Candesartan
–– Irbesartan
–– Valsartan
–– Eprosartan

25
ELITE study - ARBs (4)
 Evaluation of Losartan In The Elderly  722 patients with CHF  Designed to study effects of losartan on renal function (vs captopril)  All cause mortality was 46% lowe
26
Sacubitril-Valsartan (Entresto)- ARNI (6)
 Angiotensin receptor-neprilysin inhibitor (ARNI)  Moderate to severe heart failure [NYHA class II–IV]  LV ejection fraction of ≤35%  Already on a stable dose of ACEi or ARBs  PARADIGM-HF Trial 43% reduction in mortality
27
PARADIGM-HF (8)
P-rospective comparison of A-ngiotensin II R-eceptor blocker neprilysin inhibitor with A-ngiotensin-converting enzyme inhibitor to D-etermine I-mpact on Global M-ortality and morbidity in heart failure
28
Beta-Blockers (7)
 Reduce sympatho-adrenergic activity  Reduce afterload  Decrease myocardial oxygen demand  Reduce ventricular remodelling  Reduce renin release  Coronary and peripheral vasodilatation  Negative inotropic effect
29
Evidence Based Medicine Beta-Blockers (4)
only 3 used for HF Beta-blockers reduce mortality in mild -to-moderate CHF, reduce hospitalization, improve symptoms Benefit not clear in class I or class IV Reduction in mortality may not be a class effect (metoprolol vs atenolol)
30
MERIT-HF - BB (6)
 39991 patients in USA & Europe  NYHA II- III  Metoprolol-XL 12.5mg up to 200mg od  Total mortality: Decreased by 34%  CV mortality: Decreased by 38%  Sudden death: Decreased by 41%
31
Beta-Blockers: Side effects (8)
 Fatigue  Sleep disturbances  Bradycardia  Hypotension  Heart failure (start low, go slow)  Conduction disorders  Bronchospasm  GI disturbances
32
BB: Cautions & Contraindications (7)
 Asthma, COAD  Uncontrolled heart failure  Severe bradycardia  Hypotension or shock  AV block (2AV block (2nd& 3rddegrees), SSS  Pheochromocytoma (unless with alphablocker)  Peripheral vascular disease
33
Spironolactone- including side effects (3)
 Blocks aldosterone receptors on the distal convoluted tubule  RALES study  Side effects: – Gynaecomastia (painful) – Testicular atrophy – Menstrual irregularities – Hyperkalaemia (esp. renal impairment)
34
RALES Randomised Aldactone Evaluation Study (6)
 1663 patients, severe heart failure (NYHA1663 patients, severe heart failure (NYHA IV) (LVEF<35%)  Rx ACEi + Loop diuretic ± Digoxin  Spironolactone 25mg - 50mg od  Total mortality :Total mortality : 30% p<0.001reduction  Cardiac mortality 31% reduction  Hospitalization:35% reductionr
35
Epleronone - including study ( 4)
 Eplerenone produces less painful gynaecomastia than spironolactone EPHESUS study:  13% reduction in mortality from cardiovascular causes or hospitalization  21% reduction in sudden death  Can cause hyperkalaemia and renal dysfunction  Eplerenone produces less painful gynaecomastia than spironolactone EPHESUS study:  13% reduction in mortality from cardiovascular causes or hospitalization  21% reduction in sudden death  Can cause hyperkalaemia and renal dysfunction
36
Digoxin (3)
Inhibits Na+-K+ ATPase pump, inactivating Na+- Ca2+ exchanger, increasing Ca2+  Increases force of contraction  Other effects –– dec. AV conduction –– inc. vagal activity –– dec. heart rate
37
Digoxin: uses + side effects (4)
 Slowing ventricular rate in rapid AF  Treatment of heart failure in patients who remain symptomatic despite optimal doses of diuretics and ACEi Side effects: –– Nausea, vomiting, arrhythmias, confusion –– Toxicity enhanced by hypokalaemia#
38
Evidence Based Medicine Digoxin (4)
- Digoxin has no effect on mortality(DIG trial) - Clinical effects are not dramatic - Withdrawal of digoxin may cause clinical deterioration in 1/4 of patients stable on digoxin and diuretic ±ACEi (digoxin and diuretic ±ACEi (RADIANCERADIANCE and PROVED trials) - Reduces hospitalization rates
39
Diuretics (7)
 Relieve symptoms  Relieve circulatory congestion and pulmonary and peripheral oedema  Reduce atrial and ventricular diastolic pressure  Do not improve LV dysfunction  Little impact on mortality** Frusemide  Other loop diuretics e.g. bumetanide  Metolazone
40
Diuretics: side effects (2)
 Metabolic effects: –– Hypokalaemia (low K) = (arrhythmias) –– Hyperglycaemia (high glucose)= (diabetes) –– Hyperuricaemia (high uric acid)= (gout)  Social disruption –– Frequency, urgency, incontinence
41
Hydralazine & Nitrate (4)
 Hydralazine in combination with nitrate (especially if the patient is of African or Caribbean origin and  moderate to severe heart failure [NYHA class III–IV]  V-HeFT (Vasodilator-Heart Failure Trial) 43% reduction in mortality  A-HeFT (African American-Heart Failure Trial)
42
Sodium-GLucose co- Transporter-2 inhibitors (4)
 SGLT2 inhibitors or gliflozins  Indicated in Type 2 Diabetes mellitus  Inhibit reabsorption of glucose in the kidney and lower blood sugar Examples: Dapagliflozin, Empagliflozin, Canagliflozin, Ertugliflozin, Sotugliflozin
42
Non-Drug Therapy of Heart Failure (2)
Cardiac-Resynchronization Therapy (RCT) surgery
43
Cardiac-Resynchronization Therapy (RCT) (4)
 Using atrial-synchronized bi-ventricular pacing  Indicated for patients with severe symptoms and intra-ventricular conduction delays i.e. QRS ≥120 msec  Leads to dys-synchronous LV contraction, contraction, impaired emptying, MR  Can reduce symptoms, improve functional capacity, reduce hospitalizations and increase survival
44
Surgery (3)
 Ventricular Assist Devices  Cardiac Transplantation  Xeno Cardiac transplantation (genetically modified pig heart) 7th January 2022
45
SUMMARY 1 (Diuretics, ACEi, Digoxin) (3)
 Diuretics alone alleviate symptoms but do not but do not improve heart function or mortality  ACEiA improve LV dysfunction, CV mortality and total mortality but do not appear to protect against sudden death  Digoxinimprove symptoms, reduces hospitalization rates but no positive effect on survival
46
SUMMARY 2 (BB, Spironolactone) (2)
 Beta-blockers reduce mortality in mild-to-reduce mortality in CHF, reduce hospitalization, improve symptoms –– Benefit not clear in class I or class IV –– Reduction in mortality may not be a class effect (metoprolol vs atenolol)  Spironolactone reduce CV and total mortality and hospitalization
47
SUMMARY 3 (ARNI, Gliflozins) (2)
 ARNI reduce mortality in HFrEF, reduce hospitalization, improve symptoms Gliflozins (Dapagliflozin and Empagliflozin) reduce CV mortality and hospitalization in HFrEF and HFpEF

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