Heart Failure Flashcards by Aliya Hussain

What is heart failure (AKA CCF)?

A collection of diseases in which there is a low CO - any pathological process damaging pump action can cause this

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Classifications of heart failure?

Left heart failure
Right heart failure
Mixed

a) Acute esp. acute LVF
b) Chronic

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Main cause of signs and symptoms in heart failure?

Fluid retention

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Main causes of left-sided heart failure?

IHD causing past MIs

Cardiomyopathy (primary heart muscle disease of unknown cause)

Valvular disease preventing blood flow, e.g: aortic stenosis, or an incompetent valve, e.g: aortic regurgitation

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Main causes of right-sided heart failure?

Secondary to left-sided HF

Cor pulmonale - lungs are hypoxic due to disease and so pulmonary vessels vasoconstrict; right side of heart must work harder against resistance and will eventually fail

Congenital heart disease more often cause right-sided HF than left-sided

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Symptoms of left-sided heart failure?

Dyspnoea on exertion and, if progression occurs, at rest

Orthopnoea - when lying flat, effect of gravity causes fluid in lungs; many people prop themselves up with pillows

Paroxysmal Nocturnal Dyspnoea

Pulmonary oedema causes sudden dyspnoea and pink, frothy sputum (not deep red of haemoptysis)

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Clinical signs of left ventricular failure?

Tachycardia to compensate for decreased CO

Fine crepitations (AKA crackles) on auscultation of lung bases

Pleural effusion where fluid fills the pleural space

(S3 + tachycardia in a patient = gallop rhythm)

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Changes on CXR with left ventricular failure?

Cardiomegaly (heart shadow should be around 50% the width between the ribs)

Bats wing shadow, esp. in lower zones

Interstitial fluid (black lungs will appear whiter, part. in hilar regions due to oedema)

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Symptoms of right-sided heart failure?

Peripheral oedema (ankles/sacrum)

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Clinical signs of right-sided heart failure?

Oedema (ankle/sacral)

Elevated JVP (>4cm above sternal angle)

Hepatomegaly (enlarged liver)

Ascites (oedema in abdomen)

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CXR findings in right-sided heart failure?

Majority are normal as right ventricle is not very visible

May see lung disease that is the causes of the right-sided HF

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Treatments of CCF, depending on cause?

If cause is previous MIs or cardiomyopathies:
Standard medical therapy of CCF

For cor pulmonale:
Diuretics - to excrete fluid
Oxygen - to treat lung disease
These are the only therapies used

For valvular disease:
Ideally, surgery to replace valve

For fast AF:
Digoxin
DC shock

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Problem in fast AF?

Heart rate is so high that ventricles do not fully empty before filling occurs; so, AF must be slowed down

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What is the standard medical treatment for CCF?

Diuretics - to excrete retained fluid
ACEI
β-blockers (caution required)
Spironolactone (severe cases only) - aldosterone antagonist

Digoxin (not good for heart failure + sinus rhythm; only good for heart failure + AF)
Other vasodilators (e.g: nitrates, hydralazine)

Implantable cardiac defibrillators
Cardiac resynchronisation therapy
Transplantation

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Diuretics used in heart failure?

Thiazide diuretics for mild CCF only

Loop diuretics are more commonly used, e.g: furosemide

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Side effects of loop diuretics?

Loss of K+ (dangerous as both hypo/hyperkalaemia are arrhythmogenic)

Conincidental drugs, e.g: ACEI, spironolactone) help retain and normalise K+

Examples of ACEIs?

Captopril
Enalapril
Lisinopril

All end with -PRIL

Side effects of ACEIs?

Angioneurotic oedema is life-threatening, due to potential swelling in larynx, but rare; it is more common in black people

First dose hypotension, esp: if serum Na+ is low

Renal impairment - after ACEIs are begun, monitor UE; ACEIs can be good for diabetics and bad for those with renal artery stenosis

Dry cough - if this occurs, switch patient to an ARB

Examples of Angiotensin II Receptor Blockers (ARBs)?

Losartan
Valsartan

All end in - ARTAN

Use of β-blockers in heart failure?

Good in medium-long term BUT worsen CCF in short-term/acutely

START LOW, GO SLOW

Initial risks with β-blockers in heart failure?

Hypotension

Worsening dyspnoea

Main β-blockers used in heart failure?

Due to clinical trails usage:
Bisoprolol (β1-selective)
Carvedilol (non-selective + α blockade)

Use of spironolactone in heart failure?

Used in SEVERE CCF

Side effects of spironolactone?

Hyperkalaemia
Renal dysfunction
Hynaecomastia (also an anti-androgen and so males can grow breasts; this can be painful)

Why is Ivabridine used in heart failure and when?

Slows HR ONLY in sinus rhythm Only used if HR is fast despite use of β-blockers

What is Sacubitril-Valsartan?

Combo ARB and Neprilysin inhibitor: | Neprilysin inhibitor blocks natriuretic peptide breakdown and boost levels of it

When is Sacubitril-Valsartan used in heart failure?

Will replace ACEIs in moderate-severe heart failure in the future

Why are Implantable Cardiac Defibrillators used in patients with heart failure?

Heart failure patients tend to die in 2 ways: 1. Can worsen over a few months 2. Appear fine and there is sudden cardiac death due to arrhythmia The ICD detects sinus rhythm and defibrillates the patient when an arrhythmia occurs

When is Cardiac Resynchronisation Therapy (CRT) used?

Only for patients with prolonged QRS (bundle branch block); in this, ventricles do not contract simultaneously but milliseconds apart and so blood flow is less smooth Only 20-30% of patients fit these requirements

What does CRT involve?

3 pacemakers are inserted to force the left and right ventricle to contract simultaneously; blood flow is smoother and there is increased CO

Safety issues with digoxin?

Has a narrow therapeutic window and so levels must be measured It is slowly excreted by the kidneys and, e.g: in elderly renal impairment, a reduced dose is required

Side effects of digoxin?

Nausea and vomiting Bradycardia and heart block Any arrhythmia, e.g: ventricular tachycardia or PAT (Paroxysmal Atrial Tachycardia) with AV block - common arrhythmia in those with digoxin toxicity

When are 2 of the different effects of digoxin good or bad?

AV block: Good in fast AF, to slow it down Bad/toxin in those with bradycardia or heart block; until digoxin level is known, it should not be given to those with a slow HR Ventricular irritability: ALWAYS BAD/toxic as it can lead to ventricular arrhythmias

Therapy for ACUTE left ventricular failure?

1. Sit up 2. Oxygen, however care must be taken in COPD 3. IV furosemide 4. IV diamorphine - NOT in those with COPD as it can cause respiratory depression; this is an issue as many with heart failure are smokers and also have COPD