Heart failure assessment & treatment Flashcards

1
Q

Describe the 4 stages of the new york heart association

A

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

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2
Q

Describe the 4 evolution stages of HF according to AHA guidelines

A

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

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3
Q

Why assess HF?

A

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

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4
Q

Describe the signs and symptoms of HF?

A

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

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5
Q

Describe the differential diagnosis instead of a HF diagnosis

A

Chest pain could be respiratory, muscoskeletal

Fluid retention could be drug induced e.g., NSAIDS

Depression/anxiety disorders could cause arrythmias

Obesity

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6
Q

What diagnostic tool are used to assess HF?

A
  1. Echo
  2. Blood tests (looks for ANP, BNP & CNP, as indicates decreased plasma volume and BP)
  3. ECG
  4. X-ray
  5. Nuclear medicine
  6. Stress test
  7. Myocardial biopsy
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7
Q

Describe the lifestyle modifications as a treatment of HF

A
  1. Weight loss
  2. Quit smoking
  3. avoid alcohol/drugs
  4. increase exercise
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8
Q

Describe the medical considerations of HF

A

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

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9
Q

Name examples of pharmacological medicine used for HF

A
  1. Digoxin
  2. Diuretics
  3. ARBS
  4. ACEs
  5. Beta blockers
  6. Adolsterone antagonists
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10
Q

Describe the use of digoxin in HF treatment

A

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

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11
Q

Describe the use of diuretics in HF treatment

A

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.

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12
Q

Describe the use of ACE inhibitors in HF treatment

A

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.

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13
Q

Describe the use of Beta blockers in HF treatment

A

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

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14
Q

Describe the use of aldosterone antagonists in HF treatment

A

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

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15
Q

Describe the use of ARBS in HF treatment

A

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

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16
Q

Define cardiac resynchronsation therapy

A

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.

17
Q

Describe a CRT device

A

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%

18
Q

Describes the benefits of CRT

A
  1. Improves symptoms, reduction of SOB, fatigue and fluid retention.
  2. increased exercise capacity allowing them to carry out everyday tasks as they have increased stamina
  3. Improved EF as heart ability to pump blood is improved
19
Q

Describe the risks of CRTS

A

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

20
Q

Describe the use of ICD

A

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

21
Q

Describe the benefits of an ICD

A
  1. Prevents sudden cardiac death by detecting life-threatening arrythmias
  2. Shown improvement of HF survival rates by reducing deaths from arrhythmias
  3. ICD’s improve quality of life by reducing fear of sudden cardiac death. allows patients to live in confidence
22
Q

Describe the risks & limitations of ICD

A
  1. Inappropriate shocks may be given, ICD may misinterpret a rhythm, this can be painful/distressing for a patient
  2. Surgical risks such as bleeding, infection or device misplacements
  3. Device may malfunction (rare), device may fail to shock to restore rhythm, correct therapy cannot be given when needed most
23
Q

Describe an LVAD

A

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

24
Q

Describe the benefits of LVAD

A
  1. It improves HF symptoms such as SOB & fatigue
  2. It improves quality of life for patients as it relieves their symptoms & improves their daily functioning
  3. It increases survival rate in HF patients, it prolongs life expectancy especially for those awaiting transplant
25
Describe the risks & limitations of LVAD
1. LVAD is connected to a power battery that could be a source of infection 2. Device may malfunction, LV struggles to contract without device, immediate intervention is needed, can result in death 3. Risk of blood clots forming in and around device which can break off and cause an MI, stroke or P.E
26
Describe the use of a heart transplant
A surgical procedure to remove a diseased heart and replace it with a donor healthy heart. It is the last resort for end-stage HF. HT is for patients who meet HT criteria The heart must be compatible with the patient's blood type, heart size and other factors. Donor heart is connected to major BV's and the heart will take over the pumping function After transplant, immunosuppressants are given to prevent autoimmune response. The immune system is monitored closely.
27
Describe the benefits of a heart transplant
1. It restores normal heart function & improves symptoms, prolongs patient life expectancy 2. It improves patients quality of life, have improved energy levels, patients can have a active lifestyle. 3. Heart transplant patients can live up too many years as long as they manage their condition effectively e.g., follow up care & immunosuppressants. who gets a transplant: 1. Patients that have an indication to have a long-life expectancy 2. Patients with severe heart failure (usually with a low EF) who have exhausted all medical treatments. 3. Irreversible CAD, dilated/ restrictive cardiomyopathy patients
28
Describe the risks and limitations of a heart transplant
1. Rejection: heart could be rejected by the body, an autoimmune response as donor heart is recognized as foreign 2. Immunosuppressants: used to prevent autoimmune response, however makes person more vulnerable to secondary infection, cancer/kidney damage 3. Organ shortage: limited supply of hearts which limits access to patients who may need them
29
Describe the stages of HF according to new england med journal
Stage A: patients are at high risk, but show no symptoms, Treat possible diabetes, hypertension, provide education to patient and family, decrease smoking/ drinking, encourage exercise Treatment of ACE inhibitors Stage B: Patients indicate structural HD, have no symptoms, Treatment of ACE & ARB's, sometimes beta-blockers when appropriate Stage C: Structural disease indicated showing symptoms Treatment using diuretics, ACEs, ARBs, Beta-blockers, low salt diet, digoxin, valve surgery & cardiac resynchronisation Stage D: very symptomatic needs intervention, Treatment: transplant, hospice care & inotropes