Heart Failure Flashcards

Question

Investigations done in heart failure.

Answer 1

* *Renal** function (baseline and for diuretic effect), 2. **FBC** (anaemia should be treated as consequence of bone marrow issue) 3. **LFT’s** hepatic congestion 4. **TFT’s** Thyroid disease 5. **Ferritin and transferrin** (Younger patients with possible haemochromatosis) 6. Brain natriuretic peptide **(NT-proBNP**) ## Footnote **Furthermore you should do a CXR an ECHO and possibly a cardiac MRI if ECHO is inconclusive.**

Answer 2

FBC Serum crea (to find eGFR for baseline and diuretic effect) Electrolytes LFTs Cardiac enzymes BNP NT-proBNP Thyroid function Ferritin and transferrin (rule out haemochromatosis)

Answer 3

Cardiomegaly Pulmonary congestion with upper lobe diversion Fluid in fissures Kerley B lines (**shown in picture**) Pulmonary oedema Perihilar shadowing/consolidations Alveolar oedea Air bronchograms Increased width of vascular pedicle

Answer 4

Levels less than 100 ng/L essential rule out acute heart failure. NT-proBNP should be measured only where there is doubt about the diagnosis. A level above the normal range does not equate to a diagnosis of heart failure as any stimulus which causes cardiac chamber stress elevate these peptides.

Answer 5

Atrial fibrillation RV strain etc....

Answer 6

Can identify ischaemia, ventricular hypertrophy or arrhythmia.

Answer 7

Cardiac chambers dimensions Systolic and diastolic function Regional wall motion abnormalities Valvular disease Cardiomyopathies

Answer 8

Assess viability in dysfunctional myocardium. Dobutamine identifies contractile reserve in stunned or hibernating myocardium.

Answer 9

Radionucletoide angiography (RNA) can quantify ventricular ejection fraction. SPECT or PET can demostrate myocardial ischaemia and viability in dysfuncitonal myocardium.

Answer 10

Assess cardiac structure, function and viability in dysfunctional myocardium. This is done by dobutamine (mimics exercise) for contractile reserve or gadolinium for delayed enhancement.

Answer 11

For diagnosis of ischaemic heart failure and for measurement of pulmonary artery pressure, left atrial pressure and left ventricular end-diastolic pressure.

Answer 12

Echocardiography is the key investigation. It will confirm whether the diagnosis is correct. Possible findings inclue dilated poorly contracting left ventricle i.e. systolic function. Stiff, poorly relaxing, often small diameter left ventricle i.e. diastolic dysfunction. Valvular disease Atrial myxoma Pericardial disease.

Answer 13

It may elaborate the cause of heart failure as an echo may miss right ventricle.

Answer 14

Heart failure suspected because of symptoms and signs... Assess presence of cardiac disease by ECG, CXR, natriuretic peptides. **If these are normal heart failure is unlikely.** If abnormal do imaging by echocardiography. **If this is normal heart failure is unlikely.** If abnormal assess the aetiology, degree, precipitating factors and type of cardiac dysfunction. Do additional diagnostic tests where appropriate. Choose treatment.

Answer 15

For diagnosis of cardiomyopathies such as amyloid and for follow-up of transplanted patients to assess rejection.

Answer 16

Used in patients with suspected arrhythmia and may be employed in those with severe heart failure or inherited cardiomyopathy to determine whether a defibrillator is appropriate.

Answer 17

Relief of symptoms Prevention Control of disease Slowing down disease progression Improvement of quality of life and length of life.

Answer 18

Smoking cessation Restriction of alcohol consumption Salt restriction Fluid restriction Effective control of hypertension, diabetes and hyperlipidaemia.

Answer 19

Education Salt restriction and important for patients to weigh themselves to see if they collect fluids. Stop smoking Low-level endurance physical activity. Strenuous should be avoided. Vaccination against pneumococcal and influenza. Patients on nitrate should not also take sildenafil for sex. Driving is okay unless you want to drive large lorries or buses and have HFREF.

Answer 20

Funcitonal capacity by NYHA class, exercise tolerance test and echocardiography. Fluid status (body weight, clinical assessment and serum crea + electrolytes) Cardiac rhythm with ECG and Holter.

Answer 21

Diuretics ACEi/ARBs Betablockers Aldosterone antagonists Angiotensin receptor neprilysin inhibitors Cardiac glycosides Vasodilators and nitrates Inotropic and vasopressor agents Anticoagulants Ivabradine

Answer 22

Dyspnoea Poor exercise tolerance Fatigue Orthopnoea PND Nocturnal cough (+/- pink frothy sputum) Wheeze Nocturia Cold peripheries Weight loss

Answer 23

Causes usch as LVF, pulmonary stenosis, lung disease. Symptoms: Peripheral odeema up to thighs, sacrum and abdominal wall. Ascites Nausea Anorexia Facial engorgement Epistaxis Raised JVP

Answer 24

New-onset acute or decompensation of chronic herat failure characterised by pulmonary and/or peripheral oedema with or without signs of peripheral hypoperfusion.

Answer 25

A slowly insidious disease progressing slowly. Venous congestion is common but arterial pressure is well maintained until very late.

Answer 26

Excessive preload like mitral regurg or fluid overload. Pump failure such as systolic or diastolic HF, bradycardia Chronic excessive afterload like aortic stenosis or hypertension.

Answer 27

Requires symptoms of failure and objective evidence of cardiac dysfunction at rest. For CCF use Framingham criteria.

Answer 28

**Major Criteria** **2+ required for positive diagnosis (or 1, plus 2 minor)** Acute pulmonary edema Cardiomegaly Hepatojugular reflux Neck vein distention Paroxysmal nocturnal dyspnea or orthopnea Pulmonary rales Third heart sound (S3 gallop rhythm) Weight loss \>4.5 kg in 5 days in response to treatment **Minor Criteria** **2+ required for positive diagnosis (or 2 major)** Ankle edema Dyspnea on exertion Hepatomegaly Nocturnal cough Pleural effusion Tachycardia (HR \>120)

Answer 29

FBC, U&Es, BNP, CXR, ECG Echocardiography **(key investigation)** Stress ECHO Cardiac MRI Biopsy

Answer 30

Dilated prominent upper lobe vessels Alveolar oedema (Bat's wings) Kerley B lines (interstitial oedema) Cardiomegaly Pleural effusion

Answer 31

Clinically Do a NT-ProBNP as well but do not wait for results because of the risk of deterioration in the time between. Do ECHO as well once treated.

Answer 32

Pour SOD Pour away (stop) their IV fluids Sit up Oxygen Diuretics

Answer 33

1 - Sit patient upright 2 - High-flow oxygen if SpO2 3 - IV access and monitor ECG, treat any arrhythmias like AF 4 - Investigations whilst continuing treatment 5 - Diamorphine 1.25-5mg IV slowly **(not routinely used according to NICE)** 6 - Furosemide 40-80 mg IV slowly (more might be needed in renal failure) 7 - GTN spray 2 puffs SL or 2 x 0.3 mg tablets SL (do not give if SBP \< 90 mmHg) **(Not routinely used according to NICE)** 8 - Necessary investigations, examinations and history 9 - If SBP \> 100 mmHg start nitrate infusion like isosorbide dinitrate 2-10 mg/h IVI. Keep the SBP \> 90 mmHg. **(Not routinely used according to NICE)** If still worsening; Further dose of furosemide Considered CPAP Increase nitrate infusion Consider differentials **If SBP \< 100 mHg treat as cardiogenic shock**

Answer 34

Daily weights and aim to reduce weight 0.5kg/day Check obs Repeat CXR Change to oral furosemide or bumetanide If on large doses of loop diuretic considered the addition of a thiazide like bendroflumathiazide or metolazone. ACEi if LVEF \<40%, if ACEis is CI consider hydralazine and nitrate Considered b-blockers and spironlactone if LVEF \<35% Consider biventricular pacing or cardiac transplant

Answer 35

It is not likely.

Answer 36

Stop smoking Stop drinking alcohol Less salt Optimise weight and nutrition Treat underlying cause such as arrhythmias and valve disease Treat exacerbating factors like anaemia, thyroid disease, infection and HTN Avoid exacerbating factors like NSAIDs, and verapamil Annual flu and one-off pneumococcal vaccine.

Answer 37

Diuretics like furosemide or bumetanide ACEi (LVEF) B-blocker like carvedilol titrated up. Spironolactone Digoxin Vasodilators

Answer 38

Consider differentials Assess adherence Switch furosemide to bumetanide Minimal extertion and fluid/salt restriction Metolazone and IV furosemide Opiates and IV nitrates for symptom control Weight daily Frequent U&Es DVT prophylaxis

Answer 39

Ischaemic heart dsiease Valvular heart disease HTN Acute and chronic kindey disease A-fib

Answer 40

Diuretics **first line** ACEi ARBs ARNI Beta-blockers Vasodilators Ivabradine Nitrates

Answer 41

**Furosemide** 40-500 mg daily in divided doses - titrate up if renally impaired. IV only when very fluid overloaded. **Bumetanide** (2.5 mg OD) better oral bioavailability - can be better when very oedematous. **Metolazone** can be used for dramatic diuresis. **Bendroflumethiazide** is sometimes used in adjunct to a loop. If there is hypokaelamia (usually countered by ACEi but...) consider **spironolactone.** **Spironlactone** is also used when there is liver failure as well.

Answer 42

Useful when the patient is also hypertensive. Improves symptoms, signs, exercise tolerance, survival and slows disease progression. It is considered in all with LVEF.

Answer 43

Valsartan and candesartan is used if ACEi is CId or not tolerated. It's titrated up.

Answer 44

Angiotensin Receptor Neprilysin inhibitor. Sacubitril/valsartan. It's an option for treating symptomatic chronic heart failure with **reduced ejection fraction**. **Only in NYHA II-IV** with a left ventricular ejection fraction **of 35% or less and who are already taking a stable dose of ACEi or ARBs.**

Answer 45

**START LOW AND GO SLOW.** Start B-blocker if patient's systolic \> 100 mmHg with a resting heart rate \> 60 bpm. CIs such as AV block and postural hypotension or bronchospasms/asthma. **Carvedilol** is titrated up from 3.125 mg BD orally with food for 2 weeks and then increase to 25 mg BD there after. If using **bisoprolol** start with 1.25 mg OD orally for 1 week and increase to 2.5 mg OD for 1 week. Incrase to 3.75 mg OD for 1 week, then 5 mg OD for 4 weeks. 7.5 OD for 4 weeks and then finally to 10 mg OD.

Answer 46

Hydralazine and isosorbide mononitrate in combination have a beneficial effect on survival. Especially in african or carribean origin. **ACEi or ARBs should not be used as well.**

Answer 47

If cannot tolerate B-blockers. Or if resting heart rate is higher than 75 bpm despite b-blockers. Patient must be sinus rhythm to benefit. **Avoid with diltiazem or verapamil**. Useful when BP is low and has now impact on BP.

Answer 48

Reduces preload Reduces pulm oedema and reduce ventricular size. Can be used in chronic especially for relief of orthopnoea and exertional dyspnoea.

Answer 49

Special pacemaker devices if there is evidence of LBBB. This means QRS complex is broad and there is early depolarisation. Pacemaker can help the QRS complex to narrow again and heart can pump normally. **It is called CRT or cardiac resynchronisation pacemaker**.

Answer 50

**ICDs** (implantable cardiac defibrillators) They do not improve symptoms but prevent sudden cardiac death by cardioverting VT/VF by detection. Are used as secondary prevention in survivers of sudden cardiac arrest or for primary prevention.

Heart Failure Flashcards

(77 cards)