Heart Failure, Oedema and Infective Endocarditis Flashcards by Giulia Uitenbosch

What is heart failure?

A condition caused by cardiac dysfunction and resulting in dyspnoea, fatigue and the inability to do exercise

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How can heart failure diagnosis be made with confidence?

Clinical history/exam
+ evidence of cardiac dysfunction
(+ response to diuretics)

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What examinations should be carried out to assess cardiac dysfunction in heart failure?

Echocardiogram
Ventriculogram
Cardiac MRI
Radionuclide imaging

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What are some potential causes of heart failure?

Many severe structural diseases:
LV systolic/diastolic dysfunction
RV failure  
Valve disease
Myocarditis
Pericardial restriction 
Restrictive cardiomyopathy
Arrhythmias

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What tests should be done to screen for heart failure?

12 lead ECG

Blood test for BNP levels

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With that investigations can LV dysfunction be diagnosed?

Thorough history 
ECG
CXR
Echo
CT/coronary angiogram
Blood tests (FBC, U&amp;E, glucose, BNP)

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What can cause LV systolic dysfunction?

Dilated cardiomyopathy
Infarction (MI)
Severe valve disease

bacterial/viral infections
Toxins
IVDA
Systemic diseases 
Hypertension

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What is the prognosis for heart failure?

Poor, only 58% are alive within 5 years.

30-40% mortality at 1 year

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How is heart failure classified?

Depending on severity of symptoms. Worse prognosis for worse stage

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What is the common treatment for heart failure?

Diuretics
ACE inhibitors (or ARB’s)
Beta blockers
Aldosterone receptor blockers

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What are some common symptoms of heart failure?

Shortness of breath (rest/exertion)
Fatigue
Inability to do exercise
Leg swelling 
Orthopnea/PND

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What are some signs of heart failure?

Tachycardia 
Raised JVP
Crackles on auscultation
Displaced apex beat
Third heart sound

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What is the prevalence of heart failure?

Affects 1-2% of the population in the UK

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Are heart failure patients likely to be readmitted after an emergency admission?

Yes, most likely in the first 3 months

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What is Sympson’s biplane rule?

A measure for calculating LV ejection fraction from an echocardiogram

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How can LVEF be measured in heart failure patients?

Echocardiogram
MUGA (ventriculogram)
Cardiac MRI

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What are the main risk factors for heart failure?

Hypertension
IHD (coronary disease)
Alcohol
Diabetes
Valve disease
Congenital defects
Viral infections

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What is the main system involved in heart failure, and what are its implications?

RAAS system
It’s activated by the reduction in LV ejection fraction causing lower cardiac output
This causes water/salt retention to increase BP and blood volume, which in turn puts more strain on the heart

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What is the number one risk factor for heart failure?

Hypertension

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What are the aims of heart failure treatment?

Improve survival

Reduce symptoms

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What are the main therapeutic options in heart failure to reduce detrimental neurohormonal effects (RAAS activation)?

ACEi (ramipril)
ARB (valsartan)
Beta blockers (bisoprolol)

What are the main therapeutic options in heart failure to improve beneficial neurohormonal effects (ANP/BNP)?

ARNI’s (valsartan+sacubitril)

Neprolysin (sacubitril)

Why should ANP/BNP be stimulated in heart failure?

Because it promotes water and salt excretion and vasodilation
Opposite effect of RAAS

Why should the RAAS be inhibited in heart failure?

Because it causes a reaction to the reduced cardiac output which causes higher blood volume (higher preload) and puts even more strain on the heart

What are the main therapeutic options in heart failure to reduce symptoms?

Diuretics (furosemide +/- thiazides)

What are the main therapeutic options in heart failure to improve the contractility of the heart?

Positive inotropes: Digoxin Isorbate mononitrate or dinitrate Ivabradine: slows heart rate (only give if BPM>70)

When should beta blockers be given to a patient with heart failure?

Once/if they are stable. Don’t give in acute circumstances as their sympathetic drive is the only thing keeping them alive

What are some disadvantages of using diuretics in heart failure?

``` Can cause: hypotension Low K+ and Na+ Dehydration Gout Increased levels of other drugs in the body (toxicity) ```

What types drugs should be closely monitored when putting a patient with heart failure on diuretics? Give some examples

``` Narrow therapeutic index drugs: Gentamicin/vancomycin Lithium NSAIDs Digoxin ```

What are some disadvantages of ACEi in heart failure?

Doesn’t block alternative angiotensin pathways ``` Can cause: First dose hypotension Angioedema (afrocaribbeans) Cough Hypotension Kidney damage ```

What drug-drug interaction is important when giving elderly patients ACEi?

NSAIDs

What other way can angiotensin I be converted into angiotensin II?

Chymase pathway

Which receptor is blocked by angiotensin receptor blockers?

AT1

What are the main three physiological aims of heart failure treatment?

Decrease RAAS activation Increase ANP/BNP action Improve cardiac function

What is the combined action of ARNIs in heart failure?

Valsartan - stops angiotensin II conversion | Sacubitril - prevents ANP/BNP breakdown

Why would warfarin be given to heart failure patients?

To prevent clots forming in dilated LV from the ineffective pumping of blood out of the heart

What are risk factors for native valve Infective endocarditis (IE)?

``` Rheumatic heart disease Mitral valve disease (prolapse) Degenerative heart disease Congenital heart disease Indwelling medical devices Alcoholism Diabetes IVDA Immunocompromised ```

What are the mechanisms of infection in IE?

Through mechanical damage -> exposure of extra cellular proteins -> inflammation (NBTE) Inflammation -> integrins which bind to fibronectin on organism -> organism adheres to inflamed area

How would bacteria enter the bloodstream to adhere to the inflamed endocardium in IE?

Medical procedures Dental procedures Extra cardiac infections Poor dental hygiene

What are some common symptoms of IE?

Fever Weight loss, malaise, fatigue Headache, arthalgia, weakness

What are some common signs of IE?

Skin lesions: Janeway lesions, Olsen nodes, cutaneous infarcts, petechial rash, septic emboli Eyes: Roth spots Nails: splinter haemorrhages Neurological/meningeal signs

What investigations should be done to diagnose IE?

``` Blood cultures (3x, 30 mins apart) Blood test: FBC, CRP, ESR, U&E CXR Urinalysis echocardiogram PET or SPECT Cardiac MRI ```

What criteria are used for diagnosing IE?

Modified Duke criteria

What are the major criteria for IE diagnosis?

1. Positive blood cultures (>2, 12 hours apart, causative organisms) 2. Abnormal imaging tests

What are some of the causative agents for IE?

``` Strep viridans Strep bovis Enterococci Staph aureus Coxiella Burnetii Fungi HACEK gram -ve group ```

What is the treatment of IE?

IV antibiotics Ampicillin/flucloxacillin Gentamicin/vancomycin Rifampicin

What complications could arise from IE and may call for surgery?

Heart failure Uncontrolled infection Risk of systemic embolisation (PE, CVA)

What are possible prevention methods for IE?

- Prophylactic antibiotics for high risk patients during high risk procedures - Effective dental hygiene/check ups - infection control - aseptic techniques

What are the minor Duke criteria for IE diagnosis?

- Predisposing factors - Fever - Vascular signs - Immunological signs - Microbiological evidence

What is the prevalence of IE?

3-10 in 100,000 people Men > women Women worse prognosis