Heart failure Flashcards by Tolu Daramola

What is heart failure?

Occurs when the heart can not maintain an adequate cardiac output to meet the demands of the body

This results from any structural or functional abnormality that impairs the heart’s function

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Name the 2 types of heart failure

Low output

High output

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Name examples of low output heart failure

Systolic heart failure

Diastolic heart failure

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What is high output heart failure?

Heart functions normally but demands of body is increased beyond what the heart can supply

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Name causes of high output heart failure

Thyrotoxicosis
Profound anaemia
Pregnancy
Pagets’ disease
Acromegaly
Sepsis

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Define systolic heart failure

Progressive deterioration of myocardial contractile function

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Name causes of systolic heart failure

Ischaemic injury

Volume overload

Pressure overload

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Define diastolic heart failure

Inability of heart chamber to relax, expand and fill sufficiently during diastole to accommodate an adequate blood volume

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Name causes of diastolic heart failure

Significant left ventricular hypertrophy (i.e., lumen severely narrowed)

Infiltrative disorders

Constrictive pericarditis

Restrictive cardiomyopathy

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Name cause of heart failure (overall)

Coronary heart disease

Hypertensive heart disease

Valvular heart disease

Myocardial disease/cardiomyopathies

Congenital heart disease

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Define cardiomyopathy

Diffuse disease of heart muscle leading to functional impairment

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What are the different types of cardiomyopathy?

Dilated
-various causes (50% familial)
-ETOH, pregnancy, systemic diseases (e.g., SLE), drug toxicity, myocarditis

Hypertrophic cardiomyopathy
-hereditary

Restrictive cardiomyopathy
-Rare
-amyloid is main cause in the UK

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What is the pathophysiology of heart failure?

Pump failure = ↑SV and ↓CO

This starts compensatory mechanisms

Frank Starling mechanism = vasoconstriction, ↑venous return to heart, increased preload, heart muscle fibres stretch, enhanced contractility

Myocardial structural change = augment muscle mass +/- cardiac chamber dilation

Activation of hormonal system
-noradrenaline relase = ↑HR + ↑myocardial contractility (causes vasoconstriction)
-BNP/ANP release
-Activation of RAAS

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How can compensatory mechanism worsen heart failure?

Vasoconstriction
-↑ resistance against which heart has to pump = ↓CO

Na + H2O retention
↑fluid = ↑ preload - if stretch too much ↓ contractile strength and CO

Excessive tachycardia
↓diastolic filling time = ↓ventricular filling = ↓SV and ↓CO

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True or False

Chamber dilation happens in both pressure and volume overload

FALSE

Chamber dilation happens in volume overload - the muscle mass and thickness are increased in proportion to chamber diameter

Augmentation of muscle happens in pressure overload (e.g., left ventricular hypertrophy)

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What are the clinical types of HF?

Left vs right sided

Acute vs chronic

Compensated vs decompensated

What is left-sided HF?

Failure of left side of heart

Blood backs up from heart to pulmonary circulation

What are the causes of left-sided HF?

Ischaemic heart disease

HTN

Valvular heart disease

Myocardial disease

What are the complications of left-sided HF?

Lungs - pulmonary oedema. Presents with:
-breathlessness
-orthopnoea
-paroxysmal nocturnal dyspnoea

Kidney
↓renal perfusion = RAAS activation = retention of salt + water

Brain - hypoxic encephalopathy. Presents with
-irritability
-loss of attention
-restlessness
-stupor or coma

What is right-sided HF?

Usually a consequence of left-sided HF (together they are called congestive heart failure)

NOTE: CCF can also be due to the same pathological process happening on each side of the heart

What is cor pulmonale?

Right-sided HF due to pulmonary HTN/increased resistance in pulmonary circulation

Usually due to respiratory disease e.g., COPD or pulmonary emboli

Name other causes of right-sided HF

Valvular heart disease

Congenital heart disease

What are the systemic effects of right-sided HF?

Liver and portal system
-congestive hepatomegaly
-centrilobular necrosis (when severe)
-cardiac cirrhosis

Spleen
-congestive splenomegaly

Abdomen
-ascites (accumulation of transudate in peritoneal cavity)

Subcutaneous tissue
-peripheral oedema (esp. ankle and preitibial)
-sacral oedema is bed-ridden

Pleural and pericardial space
-effusions

What are the clinical presentations of HF?

Orthopnoea

Paroxysmal nocturnal dyspnoea

Oedema

Hepatic congestion

Ascites

Fatigue

Weakness

What are the New York Heart Association (NYHA) classifications of HF?

Class I = no limitations of physical activity Class II = slight limitation of ordinary activity Class III = marked limitation, even during less than ordinary activity Class IV = severe limitations with symptoms at rest

What are the clinical signs of HF?

Tachypnoea Crackles/reduced breath sounds on auscultation Cool peripheries Cyanosis Elevated JVP Third heart sound (S3) - gallop rhythm Displaced apex - LV enlargement Peripheral oedema Ascites Hepatomegaly

True or false Acute pulmonary oedema is a medical emergency

TRUE The signs are: Acute breathlessness Pallor Cyanosis Sweating Rapid pulse Hypoxia Crackles in lungs

Name clinical investigations for HF

Bedside -ECG Bloods - baseline + BNP Imaging -CXR (check for cardiomegaly) -Echocardiogram/ -Cardiac MRI/CT/CT.PET -CTCA/coronary angiography

What are the current drug treatments for AF

ACEis/ARBs ARNI Aldosterone antagonists - e.g., spironolactone, eplerenone Beta-blockers SA node blockade - e.g., Ivabridine Diuretics -loops e.g., furosemide -thiazides e.g., bendroflumethiazide -quinazolines e.g., metolazone Digoxin -↑ cardiac motility -slows conduction at AV node -excreted by kidney

What is the immediate treatment of acute pulmonary oedema?

High flow O2 IV morphine IV nitrates IV furosemide

What is the definitive treatment of acute pulmonary oedema?

Identify causes Oral diuretics Medical therapy Revascularisation (if appropriate)

Which drugs should not be used in heart failure? Why?

CCBs depress heart function further and exacerbate symptoms

Which CCB can be used in HF? Why?

Amlodipine Does not affect the myocardial contractility

Sources

https://bnf.nice.org.uk/treatment-summaries/calcium-channel-blockers/#:~:text=Amlodipine%20and%20felodipine%20also%20resemble,clinical%20deterioration%20in%20heart%20failure.