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PBL2 > CR3: Paul Odemah > Flashcards

CR3: Paul Odemah Flashcards

1
Q
  1. Define ejection fraction and what levels would you consider normal? (2 mark)
A

Ejection fraction is the % of blood that leaves the LV [1]
Above 50% is normal [1]

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2
Q
  1. Why do patients with heart failure have elevated levels of brain natriuretic peptide (BNP)? (2 marks)
A

BNP is released when there is increased pressure in the ventricles (which occurs during heart failure) as helps to stimulate natriuresis and causes vessel relaxation.

Release of BNP indirectly proportional to ventricular volume

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3
Q
  1. Describe two X-ray findings you may expect to see in patients with heart failure? (2 marks)
A

Kerley B lines
Batwing opacities
Pleural effusion
Cardiomegaly

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4
Q
  1. How would you treat Paul’s pulmonary oedema as seen on chest X-ray? (2 marks)
A

In all heart failure patients, regardless of classification, they should be symptomatically fluid “offloaded” (1 mark0 with the use of loop diuretics (1 mark) such as furosemide.

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5
Q

Heart Failure

Explain why the patient is breathless [1]

A

This is because the pulmonary venous pressure exceeds the oncotic pressures maintaining fluid within the pulmonary capillaries (cf Starling Principle). Breathlessness may then be due to inadequate transfer of oxygen from the alveoli to the blood.

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6
Q

Heart failure

Explain why the patient’s breathlessness is raised at night [3]

A
  1. This becomes exaggerated at night as the pulmonary venous pressure increases when someone is lying down and also because the respiratory drive is reduced during sleep.
  2. there is less sympathetic bronchodilation during sleep and this decreases oxygen diffusion into the alveoli.
  3. nerve endings in the lungs are activated and trigger an alarm reaction that wakes him up.
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7
Q

Heart failure

Explain the different lung sounds heard in the during heart failure [2

A

Crackles: bubbling or popping sounds that represent the presence of fluid or secretions, or the sudden opening of closed airways.
* Crackles that result from fluid (pulmonary edema) or secretions (pneumonia) are described as “wet” or “coarse,”
* Crackles that occur from the sudden opening of closed airways (atelectasis) are referred to as “dry” or “fine.”

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8
Q

Heart failure

What suggests he has congestive heart failure (both left and right heart failure)? [1]

A

Oedema: raised central venous pressure disrupting the Starling mechanism in the systemic capillaries causes his oedema

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9
Q

State the three causes of aortic stenosis [3]

A

i. Calcification and fibrosis of normal trileaflet valves
ii. Congenital bicuspid valves
iii. Rheumatic heart disease

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10
Q

Explain the pathophysiology of:

i. Calcification and fibrosis of normal trileaflet valves [1]
ii. Congenital bicuspid valves [1]
iii. Rheumatic heart disease [1]

A

Calcification:
* Ongoing process: endocardial injury initiates an inflammatory process similar to atherosclerosis, leading to leaflet fibrosis and deposition of calcium on valve

Congenital bicuspid valves:
* The valve may not open fully. Blood flow from the heart to the body is reduced or blocked

Rheumatic disease:
* Autoimmune inflammatory reaction is triggered by prior Streptococcus infection that targets the valvular endothelium, leading to inflammation and eventually calcification.

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11
Q

Explain 5 symptoms of aortic stenosis [5]

A

i. Dyspnoea - increase in diastolic pressure in stiff non-compliant LV. LV is thicker because has to use more energy to expel blood (hypertrophy)
ii. Angina - increase O2 demand of hypertrophied LV
iii. Syncope - either paroxysmal ventricular arrhythmias or exertional cerebral hypoperfusion (less blood is leaving)
iv. LVF - contractile failure as ventricle dilates – causes heart failure
v. Sudden death - ventricular arrhythmias

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12
Q

Describe the murmur found in aortic stenosis patients [6]

A
  • Alternating strong and weak pulse (crescendo / decrescendo)
  • S4 ejection click
  • Late diastole
  • Prominent S4 ejection click
  • soft/absent S2
  • Narrow pulse pressure
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13
Q

What is the preferred imaging for aortic stenosis? [1]

A

Echocardiogram

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14
Q

What method of imaging would be used to assess a patient’s aortic valve calcium score? [1]

A

cardiac CT-Scan

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15
Q

What ECG change commonly seen in aortic stenosis? [1]

A

Commonly shows LV hypertrophy: elevated T waves

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16
Q

What is managment for aortic stenosis if:

Asymptomatic? [1]
Symptomatic? [1]
Asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction? [1]

A

Asymptomatic then observe the patient is a general rule

Symptomatic then valve replacement

Asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery

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17
Q

What are options for aortic valve replacement (AVR)? [5]

A

TAVI

Valve replacement
* Mechanical valve
* Bioprosthetic valve

Valvotomy - procedure in which the stenotic valve leaflets are forced apart, it may be
* Percutaneous balloon valvotomy
* Open valvotomy:

18
Q

Explain the three types of heart failure [3]

A
19
Q

What is the most common cause of HF? [1]

A

Coronary artery disease

20
Q

What are the 4 main causes of heart failure [4]

A

i. Coronary artery disease (most common)
ii. Hypertension
iii. Valvular disease
iv. Myocarditis.

21
Q

Which diagnostic molecule is raised in HF? [1]

A

BNP

22
Q

Describe diagnostic pathway for HF

A
23
Q

A patient presents with heart failure and upon assessment has an ejection fraction of 48%. What is his diagnosis?

Heart failure with reduced ejection fraction (HFrEF): LVEF
Heart failure with minimally reduced ejection fraction (HFmrEF): LVEF
Heart failure with preserved ejection fraction (HFpEF)

A

Heart failure with reduced ejection fraction (HFrEF): LVEF : < 40%
Heart failure with minimally reduced ejection fraction (HFmrEF): LVEF: 40-40%
Heart failure with preserved ejection fraction (HFpEF) LVEF: >≥50%

24
Q

How do you treat heart failure if it arises from systolic and diagnostic failure? [2]

A

Systolic and diastolic failure
1. Treat aetiological and aggravating factors (e.g. MI / anaemia etc / CAD)
2. Treat fluid retention with diuretics (want net loss of fluid)

25
Q

What are the treatments for systolic heart failure? [9]

A
  1. ACE-Is (all grades of heart failure). Can cause dry cough.
  2. ARBs (if ACE-Is cannot be tolerated)
  3. beta-blockers (all grades of heart failure)
  4. spironolactone (NYHA grade III and IV only)
  5. Devices:
    * cardiac resynchronization therapy (CRT) (pacemaker: causes two sides of heart to pump together – increases EF)
    * ± ICD implanted cardiac defib: monitors heart rhythm – if goes into VF or VT, will give a shock into normal rhythm)
  6. ARB/neprilysin inhibitor (neprilysin inhibits breakdown of BNP) (It includes the neprilysin inhibitor sacubitril (AHU377) and the ARB valsartan)
  7. SGLT-2 inhibitors (ESC guidelines 2021).
  8. Heart transplant
26
Q

Describe the prognosis of HF [1]

A

In a patient like this who has not had any treatment I would
expect his 5-year survival to be less than 50%.

27
Q

Patients with worsening HF often die due to which complication? [1]

A

ventricular arrhythmias

28
Q

Which type of diuretics are the mainstay of diuretic treatment in HF? [1]

A

b. In general, due to their greater effectiveness, loop diuretics, such as furosemide, are the mainstay of diuretic therapy in HF. Indeed loop diuretics produce more intense and shorter diuresis than thiazides, which results in more gentle and prolonged diuresis.

29
Q

How does dilated cardiomyopathy lead to HF?

A

i. Causes nonsynchronous myocytes: impaired ventricular filling
ii. Decreases stroke volume
iii. Decreases cardiac output
iv. Increases preload

30
Q
  1. Define ejection fraction and what levels would you consider normal? (2 mark)
A

Ejection fraction is the % of blood that leaves the LV [1]
Above 50% is normal [1]

31
Q

An absent a wave on a JVP waveform would indicate

Pulmonary hypertension
Complete heart block / ventricular arrhythmias
Tricuspid regurgitation
Atrial fibrillation

A

Atrial fibrillation

32
Q

right atrial contraction is represented on a JVP waveform by

a wave
x descent
c wave
x’ descent
v wave
y descent

A

a wave

33
Q

tricuspid valve opens and blood from right atrium flows into ventricles is represented on a JVP waveform by

a wave
x descent
c wave
x’ descent
v wave
y descent

A

y descent

34
Q

tricuspid valve closes and right ventricle contracts is is represented on a JVP waveform by

a wave
x descent
c wave
x’ descent
v wave
y descent

A

c wave

35
Q

filling of right atrium agaisnt a closed tricuspid valve is represented on a JVP waveform by

a wave
x descent
c wave
x’ descent
v wave
y descent

A

v wave

36
Q

Canon a waves on a JVP waveform would indicate

Pulmonary hypertension
Complete heart block / ventricular arrhythmias
Tricuspid regurgitation
Atrial fibrillation

A

Complete heart block / ventricular arrhythmias

37
Q

Large a waves on a JVP waveform would indicate

Pulmonary hypertension
Complete heart block / ventricular arrhythmias
Tricuspid regurgitation
Atrial fibrillation

A

Pulmonary hypertension

38
Q

This JVP waveform would indicate

Pulmonary hypertension
Complete heart block / ventricular arrhythmias
Tricuspid regurgitation
Atrial fibrillation

A

**Tricuspid regurgitation
**: large V waves

39
Q

Acute LVF causes what type of lung failure? [1]

A

Type 1 resp. failure

40
Q

Testing for BNP is sensitive but not specific. This means that when negative it is useful in ruling out heart failure, but when positive result
can have other causes. Other causes of a raised BNP include:? [5]

A
  • Tachycardia
  • Sepsis
  • Pulmonary embolism
  • Renal impairment
  • COPD
41
Q

Acute managment for LVF? [4]

A
42
Q

Chronic HF management? [4]

A

ABAL

  • ACE inhibitor (e.g. ramipril titrated as tolerated up to 10mg once daily)
  • Beta Blocker (e.g. bisoprolol titrated as tolerated up to 10mg once daily)
  • Aldosterone antagonist when symptoms not controlled with A and B (spironolactone or eplerenone)(spiro causes man boobs)
  • Loop diuretics improves symptoms (e.g. furosemide 40mg once daily)

PBL2 (20 decks)

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