Heart Failure Flashcards
What is heart failure?
- inability of heart to pump blood around the body
- cardiac output is low
What is the most common cause heart failure?
- cardiomyopathy (heart muscle disease)
- specifically ischemic heart disease
How may people are diagnosed with heart failure per year in the UK?
- incidence = 200,000
- prevelence = 900,000
What is the life expectancy of a patient with heart failure in the UK?
- 5 years
- admitted with advanced heart failure <1 year despite treatment
Heart failure can be subdivided into 3 clinical syndromes. What are these 3 syndromes?
1 - chronic heart failure = peripheral oedema
2 - acute heart failure = pulmonary oedema
3 - cardiogenic shock = low BP (<90mmHg)
Left systolic heart failure is the most common cause of heart failure. What can happen to the left ventricle as a result of this?
- left ventricular weakness / dilation
- means any subsequent contractions are weaker
There are a lot of conditions that cause left systolic heart failure, but what is the main cause?
- ischaemic heart disease (MI/ischaemia)
What is the volume in the left ventricle dependent on?
- preload = blood returning to heart
- afterload = systemic vascular resistance
How are we able to measure left ventricle function?
- measure left ventricle ejection fraction
- LV ejection fraction = SV / end diastolic volume
How can you calculate end diastolic volume?
- stroke volume - end systolic volume
In systolic left sided heart failure, what is the first common sign of left sided heart failure?
- reduced stroke volume
- due to decreased left ventricle contractility (WEAK)
In systolic left sided heart failure, stroke volume is decreased due to a weakened left ventricle. This means that more blood is left in the left side of the heart at the end of systole. What does this do to the diastolic pressure in the left side of the heart?
- increased blood left in heart
- causes increased left sided diastolic pressure
If the increased blood left in the heart causes an increase in left sided diastolic pressure, what does this do to left ventricle end diastolic volume?
- LV becomes dilated due to volume overload
- this results in a reduced LV ejection fraction
In a normal heart the left ventricle ejection fraction is normally between 55-70%. What is the LV ejection fraction in systolic heart failure heart failure?
- <40%
In heart failure there is a forwards and backwards heart failure. In patients with heart failure there is an increase in the pressure in the left ventricle, causing a reduction in LV contractility. What does this do to cardiac output?
- reduces cardiac output
- this is a forward theory
In heart failure there is a forwards and backwards heart failure. In patients with heart failure there is an increase in the pressure in the left ventricle, causing a reduction in LV contractility. What does this do to pressure in the left atrium and pulmonry veins?
- increases pressure in LA and PV
- pressure moves backwards
- backwards theory
What are the common sysmptoms that patient present with in heart failure?
- breathlessness on exertion
- Orthopnoea (breathlessness lieing down)
- Paroxysmal nocturnal dyspnea (PND) (breathlessness sleeping)
- Fatigue due to low cardiac output
- Leg swelling (oedema) due to change in pressures
What method is used to stratify the severity of heart failure?
- New York Heart Association (NYHA)
- class 1-4
In patients with heart failure, what are 3 simple non invasive assessments can clinicians perform?
- increased jugular vein pressure (JVP)
- pitting shows oedema (pulmonary and peripheral)
- lung ascultation gives lung crackles (air moving through fluid)
What are the first 2 investigation clinicians perform in patients with suspected heart failure?
- ECG
- Brain Natriuretic Peptide (BNP)
What is Brain Natriuretic Peptide (BNP) that is used in patients with suspected heart failure?
- peptide released by the right atrium
- released when stretched too much
In hospitals, in addition to ECG and BNP, what are the 3 main investigations used?
- echocardiogram
- MRI scan
- cardiac catheterisation
In a patient with an acute myocardial infarction (a cause of left heart failure) there is an increase in pressure in the LV caused by LV damage. This can increase pressure and send this backwards into the LA, pulmomary vein and into pulmonary capillaries. If the pressure in the capillaries is too high, what can this cause?
- acute pulmonary oedema
- pressue is higher than osmotic pressure
In a patient with acute myocardial infarction there is an increase in pressure in LV which is transmitted backward into pulmonary capillaries. What pressure must the pulmonary capillaries be above to cause oedema in the lungs?
- >25mmHg (normal is 10mmHg or less)
- 25mmHg has to be above serum albumin which is 25g/L
In a patient with acute myocardial infarction there is an increase in pressure in LV which is transmitted backward into pulmonary capillaries causing oedema in the lungs. What happens to patients pulse, BP and temperature?
- pulse = thready and weak (heart not contracting properly)
- BP = <90mmHg
- cold and clammy (blood doesnt reach skin properly)
- all due to reduced cardiac output
In a patient who has had a myocardial infarction but survived does not experience sufficient pressure in the left ventricle to cause backward theory, causing pulmonary oedema. However, the increased pressure instead can be transmitted where?
- pulmonary artery
- right ventricle
- right atrium
- this causes right sided heart failure
In a patient who has had a myocardial infarction but survived does not experience sufficient pressure in the left ventricle to cause backward theory, causing pulmonary oedema. However, the increased pressure instead can be transmitted back to the right side of the heart causing right sided heart failure. What can this then cause?
- RA exceeds osmotic pressure
- fluid leaks out of capillaries generally following gravity
- chronic peripheral oedema follows
What is the most common cause of right sided heart failure?
- left sided heart failure
In right sided heart failure in addition to oedema in the peripheries, where else can fluid collect?
- ascites (fluid in abdomen)
- pleural effusion
- elevated JVP
What is cor pulmonael?
- right sided heart failure due to lung disease
- COPD, pulmonary hypertension, lung fibrosis
The body retain fluid in an attempt to maintain cardiac output through the starling law. Increased fluid increased venous return and preload and ultimately cardiac output. However, this can commonly cause what?
- pulmonary and peripheral oedema
In a patient with heart failure there will be low cardiac output. This causes low perfusion of the kidneys. What do the kidneys do in response to this?
- releases renin
- renin leads to angiotensin II and aldosterone
- leads to Na+ and H20 retention and increased BP
- this is good short term to maintain cardiac output
What is the neuroendocrine activation in heart failure?
- activation in both neural and endocrine systems
How is the neuroendocrine system activated in heart failure?
- sympathetic activity
- low BP renal baroreceptors
- low NaCl in kidenys
In a patient with heart failure is angiotensin II a good or bad thing?
- bad thing
- increases afterload in an already weak heart
- causes oedema
What is the role of the sympathetic system in heart failure?
- if cardiac output is low the sympathetic system is activated
- catecholamines (adrenalin and noradrenalin) are increased
- increases cardiac output
Although sympathetic activity in heart failure is a good thing to increase cardiac output, why can it be a bad thing as well?
- activate RAAS causing vasoconstriction
- causes oedame
- increases afterload which makes heart work harder
What is catecholamine cardiotoxicity that is caused by sympathetic activity?
- high levels of catecholamines are bad
- causes cardiac structural changes
- LV dilation and remodelling
- increase LV dysfunction
What is diastolic heart failure?
- increased stiffness in left ventricle and decreased compliance
- maintained ejection fraction
- increases pressure but maintain systolic function
- heart failure with preserved ejection fraction
What is the diagnosis of heart failure with preserved ejection fraction?
- LV ejection fraction >40% but heart failure symptoms
- normal LV volume
In diastolic heart failure with preserved ejection fraction are the effects the same?
- yes
- causes all the same effects as systolic heart failure
What patients commonly present with LV diastolic heart failure?
- elderly patients
- T2DM
- atrial fibrillation
Is LV diastolic heart failure calssified as a restrictive or obstructive cardiac disease?
- restrictive
- heart is stiff so blood cannot fill
What are some other common diseases that can cause LV diastolic heart failure?
- left ventricular hypertrophy
- hypertension
- sarcoidosis
- amyloid heart disease
In heart failure why are loop diuretics useful?
- used to remove oedema
- furosemide
- blocks Na+/K+/Cl- co-transporter
In heart failure why are ACE inhibitors useful?
- inhibit RAAS
- reduce vasoconstriction
- Ramipril
In heart failure in patients who cannot take ACE inhibitors, why are angiotensin receptor antagonists useful?
- inhibit effects of angiotensin II
- losartan
In heart failure why are aldosterone inhibitors useful?
- inhibit Na+ and H2O retention
- spirolactone
In heart failure why are Beta Blockers useful?
- good for arrythmias
When managing a patient with heart failure, what does PODMAN refer to?
- P = Position sit up right (gravity takes fluid away from lungs)
- O = Oxygen (provide oxygen)
- D = Diuretics (removed fluid and lowers BP)
- M = Morphine (reduces stress, pain and BP)
- A = Anti emetic (sickness drug)
- N = Nitrate (GTN)
In heart failure, would you avoid giving a patient with acute or chronic heart failure a beta blocker?
- acute heart failure
