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Lecture week III COPY > Heart failure and BNP > Flashcards

Heart failure and BNP Flashcards

1
Q

BNP physiological mechanism

A
  1. REDUCE SYSTEMIC VASCULAR RESISTANCE THEREBY REDUCE AFTERLOAD
    - ACT VIA ANP RECEPTORS SO EFFECTS ARE THE SAME AS ANP
  2. Renal : dilates the afferent glomerular arterioles and constricts efferent glomerular arterioles increasing GFR
    - inhibits renin secretion by RAAS
  3. Adrenal - reduces aldosterone secretion by zona glomerulosa of adrenal cortex
  4. relaxes vascular smooth muscles - systemic vasodilation
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2
Q

BNP DEFINITION

A

1, Brain natriuretic peptide is a hormone secreted by cardio myocytes in the heart ventricles in response to stretching caused by increased ventricular volume

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3
Q

ANP

A
  1. synthesized and secreted by atria in response to increased blood volume
  2. both ANP and BNP act via ANP receptors so same effect on the body
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4
Q

BNP vs NT-proBNP

A

proBNP is cleaved to form:

  1. BNP
    - biologically active
    - 20 min half life
    - labile
    - higher in healthy females
  2. NT-proBNP
    - 60 - 120 min half life
    - stable
    - increases with age
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5
Q

Factors that increase BNP/NT-proBNP

A
  1. tachycardia / ischameia / acute coronar syndrome
  2. liver cirrhosis
  3. renal impairment
  4. Sepsis
  5. COPD
  6. Exercise
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6
Q

Factors that decrease BNP/NT-proBNP

A
  1. Obesity
  2. Ace inhibitors
  3. Angiotensin receptor blockers
  4. Aldosterone antagonists
  5. Diuretics
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7
Q

BNP values normal and raised

A

normal < 100 ng/L

raised > 100 ng/L

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8
Q

NT-proBNP values normal and raised

A

normal < 300 ng/L

raised > 300 ng/L

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9
Q

definition of heart failure

A
  1. Heart failure is when the heart is unable to supply blood to meet the body’s demand
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10
Q

two major types of heart failure are;

A
  1. Systolic heart failure - the heart can’t pump hard enough to meet the body’s demands
  2. Diastolic heart failure - not enough blood fills into the heart
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11
Q

definition of cardiac output

A

the volume of blood ejected per minute

2. CO = beats per minute x volume of blood per beat

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12
Q

definition of ejection fraction

A

Stroke volume / Total volume

  1. 50-70% - normal ejection fraction
  2. 40% - 50% - borderline
  3. < 40 % - systolic heart failure
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13
Q

properties of diastolic heart failure

A

the heart is not filling enough

  1. stroke volume is low
  2. total volume filled up in the ventricles is also low
  3. therefore ; ejection fraction is normal !
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14
Q

Laplace’s law

A
  1. the pressure within the radius of the heart is = tension around the wall of the heart
  2. increase in preload = increase in radius
  3. ventricles dilate and remodelled so it stays dilated and easy to dilate further
  4. same pressure over a greater radius -> increased tension around the wall of the heart ->the more it is stretched -> easier it is to dilate further
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15
Q

How are the stages of heart failure determined?

A
  1. New York heart association classification

2. 4 main stages of heart failure

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16
Q

NYHA Class 1

A
  1. no limitations of physical activity
  2. physical activity doesn’t cause ;
    - breathlessness
    - fatigue
    - palpitations
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17
Q

NYHA Class II

A
  1. slight limitation of physical acitivity
  2. comfortable at reast but ordinary physical activity can cause;
    - breathlessness/fatigue/palpiations
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18
Q

NYHA Class III

A
  1. Marked limitation of physical activity
  2. Comfortable at rest but less than ordinary physical activity can cause;
    - breathlessness/fatigue/palp
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19
Q

NYHA Class IV

A
  1. unable to carry on any physical activity without discomfort
  2. Symptoms present at rest
  3. Any physical activity can result in discomfort and fatigue
20
Q

Symptoms of right sided heart failure

A
  1. awakening at night with shortness of breath
  2. shortness of breath during exercise
  3. shortness of breath lying flat (orthopnea)
  4. coughing/ wheezing
  5. fluid retention - swelling of ankles, legs and feet
  6. increased urge to urinate especially at night due to congestion of renal arteries and renal veins
21
Q

Symptoms of left sided heart failure

A
  1. shortness of breath
  2. chronic lack of energy - due to disturbed ability to respire as a result of pulmonary oedema
  3. Difficulty sleeping at night due to breathing problems
  4. Cough with frothy sputum
  5. Confusion + impaired memory
  6. Pulmonary oedema -> hypoxia
22
Q

Management of heart failure

A
  1. Signs + Symptoms suggestive of HF
  2. Clinical examination ( fbc, fasting blood glucose, serum urea)
  3. BNP levels tested ( or ECG if no BNP)
    - (BNP levels > 100) —> Heart failure is possible
  4. Refer to ECHO if BNP raised
    ECHO : LVEF < 40
  5. Do ECG if not already done to determine the cause of heart failure
23
Q

Chest X ray in heart failure

A
  1. Kerley B lines
  2. Prominent vasculature
  3. Cardiomegaly
  4. Upper lobe division - blood vessels are congested so can see upper lobes clearly
24
Q

First line in heart failure

A
  1. Beta blockers AND Ace inhibitors
    ( if intolerant to ACE inhibitors give ARBS)
  • Ace inhibitors inhibit angiotensin converting enzyme which is responsible for breaking down bradykinin,
  • more bradykinin -> vasodilation + gives a dry cough
25
Q

Side effects of ace inhibitors

A
  1. low bp
  2. low potassium -
  3. renal failure - acts to distrupt RAAS
  4. dry cough
  5. hypoglycaemia
26
Q

contraindic to ace inhibitors

A
  1. angio oedema
  2. bilateral renal artery stenosis
  3. pregnancy
27
Q

Ace inhibitors

A

improves symptoms and prolongs life

28
Q

Second line in Heart Failure

A
  1. Mineralcorticoid receptor antagonist
  2. ACE/ARB
  3. Beta blocker
29
Q

Third line in Heart failure

A
  1. Sacubritil/Valsartan ( ERNESTO )
  2. Mineralcorticoid receptor antagonist
  3. Beta blocker
    ( DISCONTINUE ARB/ACEI )
30
Q

Fourth line in Heart Failure

A
  1. ICD - implantable cardiac defibrillator ( pacemaker w defib function )
    OR
    - Cardiac resychronisation therapy generator - inputs voltage into sinoatrial node
    - used only if cardiac conduction shows LBBB or prolonged QRS complex, to ensure ventricles are well coordinated
  2. Ivabradine
31
Q

Fifth line in Heart Failure

A
  1. Digoxin

2. Hydralazine/Isosorbide dinitrate if intolerant to ace inhibitors/ARBs/SacubritilVasartan)

32
Q

6th line in Heart failure

A

CARDIAC TRANSPLANT

33
Q

Ivabradine - mechanism of action

A
  1. used if heart rate is > 75 on beta blockers and still have symptoms
  2. Inhibits ‘f’ funny channels in the heart and reduces the amount of potassium entering the cell
    - slows down repolarisation
    - heart rate reduction
  3. reduces symptoms but does not reduce mortality
  4. Side effects - slow heart rate/ low bp/ AF
34
Q

Adjuncts to reduce risk in HF

A
  1. Opiods - peripheral vasodilation and pain relief
  2. Statin - reduces cholesterol
  3. Asprin - inhibits thromboxane and reduces tendency to clot
  4. Warfarin - patients who have AF
  5. Amlodapine - calcium channel blocker to reduce blood pressure if still high
  6. Iron (if anemic)
35
Q

Hydralazine/Isosorbides dinitrate

A
  1. used in patients intolerant to ace inhibitors/arbs/sacubritil+valsartan
  2. increases circulating NO in the blood which is responsible for vasodilation
  3. increases capacity of blood around the body
  4. decreases preload
36
Q

Entresto - Sacubritil/Valsartan

A
  1. used in the place of ace inhibitors + angiotensin receptor blockers
  2. sacubritil blocks Neprilysin enzyme which is responsible for breaking down acute phase proteins and naturetic peptides
  3. increase in ANP/BNP/Bradykinin etc
  4. RESULTS -
    - decreases sympathetic tone
    - vasodilation
    - lowers blood pressure
37
Q

Beta blockers

A
  1. blocks beta receptors
  2. Bisoprolol + Carvedilol + Metoprolol
    Reduces mortality in heart failure
38
Q

Mineral receptor corticoids

A
  1. also known as aldosterone antagonists / Potassium sparing diuretics
  2. Reduces production of Na/K ATPASE pumps and thus reduces water retention
  3. leads to reduced preload
  4. Spirnolactone / Epleronone
39
Q

Cardiac surgery options

A
  1. cardiac transplant

2. Left ventricular assist device - helps pump blood out of the left ventricle into the aorta

40
Q

Symptomatic treatment only w/o increase in mortality

A
  1. Diuretics
  2. Digoxin
  3. Ivabradine
41
Q

Treatment to reduce CVS risk factors

A
  1. Statins
  2. Antithrombolytics
  3. Antihypertensives
  4. Iron if anaemic
42
Q

Digoxin

A
  1. cardiac myocytes increase uptake of calcium to increase power and contractility of the muscle
  2. eliminate K+ from cardiac myocytes to increase time for repolarisation thus slow down the heart rate
    - inc stroke vol + reduces work of heart
    3, Toxicity of digoxin - can cause disturbance of colour vision/tachycardia or decrease of heart rate / abdo pain
    - Antidote - Digibind to counteract these effects
43
Q

Digoxin toxicity?

A

Toxicity of digoxin

  • can cause disturbance of colour vision
  • toxic if hypokaelemic -> arrythmias
44
Q

Side effects of MRA

A 
Gynaecomastia
Hyperkalaemia
Renal impairment
Hepatotoxicity
Changes in libido
45
Q

Side effects of ACE i

A 
Hyperkalaemia
Hypoglycaemia
Dry cough
Renal impairment
Hypotension
46
Q

3 x initial Ix of HF

A

1) NT- ProBNP: massively elevated
2) ABG: shows type 1 respiratory failure
3) Awaiting bedside ECHO

47
Q

Name 2 drugs contraindic in Tx of HF

A
  1. Veramapil - negative inotrope

2. Nsaid - fluid retention

Lecture week III COPY (11 decks)

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