Heart failure assessment & treatment Flashcards
Describe the 4 stages of the new york heart association
Class I: no symptoms
Class II: slight limitation to physical activity resulting in fatigue, SOB, but fine at rest
Class III: comfortable at rest, noticable limitations on exercise, fatigue & palpitations
Class IV: unable to carry out exercise, uncomfortable at rest
Describe the 4 evolution stages of HF according to AHA guidelines
Stage A: patients are high risk e.g., obese, but show no symptoms or structural abnormalities
Stage B: Patient has a structural disorder, but is asymptomatic
Stage C: Patient has current or past HF symptoms associated with structural HD
Stage D: patients in end-stages that need specialized intervention
Why assess HF?
Assessing HF involves patient history, physical examination & laboratory & diagnostic tests
It allows us to:
1. Determine type of cardiac dysfunction
2. Determine aeitology
3. Define prognosis
4. Guide therapy
Describe the signs and symptoms of HF?
Symptoms:
1. Exertion & SOB
2. PND
3. Tachycardia
4. cough
5. Hemoptysis
6. fatigue
Signs:
1. pulmonary oedema
2. S3 gallop
3. pleural effusion
4. cheyne-stokes Rs
5. Basilar rates
Describe the differential diagnosis instead of a HF diagnosis
Chest pain could be respiratory, muscoskeletal
Fluid retention could be drug induced e.g., NSAIDS
Depression/anxiety disorders could cause arrythmias
Obesity
What diagnostic tool are used to assess HF?
- Echo
- Blood tests (looks for ANP, BNP & CNP, as indicates decreased plasma volume and BP)
- ECG
- X-ray
- Nuclear medicine
- Stress test
- Myocardial biopsy
Describe the lifestyle modifications as a treatment of HF
- Weight loss
- Quit smoking
- avoid alcohol/drugs
- increase exercise
Describe the medical considerations of HF
To treat underlying hypertension, hyperlipidemia, diabetes and arrythmias
To consider surgery, coronary revascularisation e.g., bypass
Anticoagulants to prevent blood clots
to take daily weights
to take on a low salt diet
outpatient monitoring
Name examples of pharmacological medicine used for HF
- Digoxin
- Diuretics
- ARBS
- ACEs
- Beta blockers
- Adolsterone antagonists
Describe the use of digoxin in HF treatment
Digoxin: enhances inotropy (force of contraction) of cardiac muscle & reduces activation of SNS and RAAS
Found naturally in foxgloves
Digoxin has been shown to reduce symptoms, increase exercise tolerance, improve haemodynamic, decrease risk of HF progression, reduce hospitalization for HF
However, it fails to improve survival and can be toxic in high doses
Describe the use of diuretics in HF treatment
Used to remove fluid retention. Used alongside other drugs. Improves exercise tolerance. Can be adjusted as patients weight changes.
examples: furosemide
However, it may cause electrolyte depletion, it should not be used as a solo treatment for HF & higher doses of diuretics are associated with increased mortality.
Describe the use of ACE inhibitors in HF treatment
They block conversion of angiotensin 1 to angiotensin 2, prevents deterioration, reduces Na+ retention,
examples: lisinopril
They are recommended for all HF patients as they relieve symptoms and improve exercise tolerance. They also reduce risk of death and progression of disease.
However, benefits may not be shown immediately, take longer than 2 months to see benefits.
Describe the use of Beta blockers in HF treatment
Protect as they inhibit the SNS, blocking effects of adrenaline/noradrenaline. It decreases HR, CO and BP,
Examples: bisoprolol & propranolol
It decreases the contractility of the heart & increases in EF. When used with other meds see to reduce mortality/ morbidity
Side effects: bradycardia, fatigue, dizziness, cold hand & feet, sexual dysfuntion
Describe the use of aldosterone antagonists in HF treatment
They block the action of aldosterone to promote Na+ & water excretion. It decreases fluid retention. Decreased blood pressure in vessels and kidneys. It reduces fibrosis and remodelling
examples: eplerenone & spironolactone
AA are generally well tolerated & have been shown to reduce mortality/morbidity of patients
Used for stage 3 NYHA patients
Risk: It inhibits the excretion of potassium leading to hyperkalemia.
Side effects: arrhythmias due to hyperkalemia, breast tissue enlargement, impairment of renal function
Describe the use of ARBS in HF treatment
Known as angiotensin receptor blockers, they block angiotensin type 2 receptors. This enables vasodialtion and BP to decrease, results in less fluid retention as Na+ and H2O can be excreted.
Examples: Losartan
They reduce the workload on the heart, also used to treat hypertension.
It prevents harmful remodelling and fibrosis. ARB’s can protect kidneys by reducing blood pressure
ARB’s should be used for patients who are intolerant to ACE inhibitors.
Side effects: swelling or tongue or throat, angioedema, fatigue, dizziness, hyperkalemia as potassium is retained
Define cardiac resynchronsation therapy
It is used for HF patients that have out of sync heartbeats due to a LBBB. CRT used to help the heart chambers contract in synchrony to improve efficiency.
It is seen to improve heart function, symptoms and quality of life.
Describe a CRT device
CRT device is implanted via surgery, with leads placed in the heart through the veins, device is implanted under the skin near the collarbone.
CRT device: a specialized pacemaker that has a biventricular pacemaker consisting of 3 leads: RA lead to synchronise & monitor atrial activity, RV lead to regulate RV contraction & LV lead to stimulate LV to contract in synchrony with RV
This device is give to patients with moderate to severe HF (NYHA class III/IV patients). HF is symptomatic despite optimal medical therapy, QRS complex is greater than 130ms & LVEF is less than 35%
Describes the benefits of CRT
- Improves symptoms, reduction of SOB, fatigue and fluid retention.
- increased exercise capacity allowing them to carry out everyday tasks as they have increased stamina
- Improved EF as heart ability to pump blood is improved
Describe the risks of CRTS
Infection: As with any surgery, there is a risk of infection at the site of the device implantation.
Lead Displacement: The leads may become displaced or malfunction, requiring additional procedures.
Device Malfunction: Although rare, the CRT device may malfunction and need to be repaired or replaced.
CRT devices need to be followed up by a cardiac physiologist who is specialized in implantable devices
Describe the use of ICD
refers to an implantable cardioverter-defibrillator which is used to treat HF & arrythmias. It delivers shock to restore normal rhythm if detects a life-threatening arrythmia.
It will also give out pacing impulses in less severe arrythmias occur e.g., fast and organized VT, it will give a series of pacing impulses to slow down & restore normal rhythm.
Used for patients that: Have HF with reduced EF of 35% or less
Patients with a history of ventricular arrythmias e.g., V tachy or Vfib
Describe the benefits of an ICD
- Prevents sudden cardiac death by detecting life-threatening arrythmias
- Shown improvement of HF survival rates by reducing deaths from arrhythmias
- ICD’s improve quality of life by reducing fear of sudden cardiac death. allows patients to live in confidence
Describe the risks & limitations of ICD
- Inappropriate shocks may be given, ICD may misinterpret a rhythm, this can be painful/distressing for a patient
- Surgical risks such as bleeding, infection or device misplacements
- Device may malfunction (rare), device may fail to shock to restore rhythm, correct therapy cannot be given when needed most
Describe an LVAD
LVAD is a device used as a mechanical pump to help the LV pump blood into systemic circulation. It is used in severe cases such as people awaiting transplant or are not eligible.
It is surgically implanted, device is powered by an external battery connected to the patient via leads. It can provide long-term support
Describe the benefits of LVAD
- It improves HF symptoms such as SOB & fatigue
- It improves quality of life for patients as it relieves their symptoms & improves their daily functioning
- It increases survival rate in HF patients, it prolongs life expectancy especially for those awaiting transplant
