HF Flashcards
(90 cards)
1
Q
What is HF
What does the syndrome consist of
A
Inability of heart to increase CO to meet demand
Clinical syndrome of Dyspnoea Fatique Fluid retention Neurohormonal disturbance Progressive cardiac dysfunction
2
Q
What are the two types of HF
Acute
Chronic
Acute on Chronic
L most common cause of R (congestive)
Can have high or low output
Low = common
High = rare e.g. due to decreased resistance, severe anaemia and thyrotoxicosis storm
A
Systolic - reduced EF <40%
- Decreased pumping / CO and fluid back up
- Heart will work with larger EDV and HR to meet demand if CO not increased even if this reduces EF
Diastolic - preserved EF
- Hypertrophy so doesn’t fill or relax
- Fluid back up
- Require other diagnostic evidence as preserved EF e.g. raised BNP or structural HD
3
Q
What are main causes HF
A
CAD MI HTN DM FH cardiomyopathy
4
Q
What causes LVSD
Cardiac vs non-cardiac causes
A
Cardiac MI IHD Chronic pressure overload - Hypertension - Obstructing valve causing chronic Chronic volume - Valvular regurgitation e.g. after IE can cause acute - Shunt Arrhythmia - tachy or Brady - Common precipitate acute through decompensation HCM or dilated Myocarditis Pericardial effusion / disease
Non-cardiac Pulmonary vascular / Cor-pulmonale = RHF Muscular dystrophy Haemochrmotosis Alcohol HIV Lyme's Sarcoidosis Phaeochromocytoma High output state - anaemia / thiamine Thyroid Drugs -ve inotrope
5
Q
What causes diastolic dysfunction
A
Ventricular hypertrophy
Constrictive pericarditis
Cardiac tamponade
Restrictive cardiomyopathy
6
Q
What are the symptoms of HF
A
SOB Orthopnoea - pillows PND - attack of cough / SOB waking up Cough - frothy, worse at night Wheeze Fatigue Peripheral oedema Reduced exercise activity Fluid overload - JVP / oedema Cyanosis Weight loss - may not notice due to oedema as overall catatonic state Sarcopenia Nocturia Cold periphery
7
Q
What are signs of HF
A
Tachycardia Tachypnoea Bilateral crackles (pulmonary oedema) 3rd HS Displaced apex Hypotension - suggest shock Narrow pulse pressure Pulse aternans - strong and weak beats RV heave Cardiomegaly
8
Q
What is ejection fraction
A
Continuous variable measured with ECHO
The amount of blood ejected with each contraction
9
Q
What is normal, mild, severe
A
Normal = 50-80% Mild = 40-50% Severe = <30%
Can get HFrEF if <40%
HF mr EF (mildly reduced) if 40-49% + other criteria
HRpEF = normal so >50%
10
Q
How do you screen for HF
A
Hx and exam
12 lead ECG
BNP - N type
ECHO if either abnormal within 2-6 weeks for definite Dx
- In clinical practice just get ECHO
Urgent ECHO + specialist review if BNP >2000 within 2 weeks
Previous MI doesn’t require screen- ECHO
HF unlikely if BNP low and ECG normal
11
Q
What does ECG show
A
Previous MI or current MI causing acute
Hypertrophy
12
Q
What are other tests in HF to help confirm
A
Urine dip Bloods - FBC, U+E, LFT - Renal / cirrhosis can cause overload HbA1c, Lipids, TFT CXR - Look for oedema or other cause for SOB Coronary angiography Stress testing Cardiac MRI - Determine ischaemia vs non-ischaemic cause
13
Q
What do you need to Dx HF
A
S+S
Evidence of cardiac dysfunction
Response to therapy
14
Q
Increased BNP (released to counteract RAAS in response to stretch)
A
Age LVH Ischaemia Valve Tachycardia Overload Hyperaemia inc PE Low GFR CKD Sepsis DM Liver cirrhosis
15
Q
What causes decreased BNP
A
Obesity
ACEI
BB
Diuretic / aldosterone antagonist
16
Q
What are the CXR findings in HF
A
Alveolar oedema
B-lines as fluid in interlope fissures
Cardiomegaly >0.5 of largest heart border
Dilated upper lobe veins (increased prominence and diameter)
Effusion - pleural
17
Q
How do you treat HF
A
Treat cause - arrythmia/ valve disease Treat exacerbating factors - anaemia. /thyroid / BP / infection Lifestyle Heart failure specialist nurse Rx for reducing mortality Pulmonary oedema Rx Refractory RX
18
Q
What lifestyle
A
Stop smoking Reduce alcohol Eat less salt Optimise weight + nutrition Exercise Annual flu vaccine One of pneumococcal vaccine Statin Aspirin 75mg Offer cardiac rehab
19
Q
What Rx reduces mortality / increases prognosis
A
ACEI + BB = 1st line
- Don’t give BB in acute
- Bisoprolol or carvediol only one
Hydralazine and nitrate = 2nd line if don’t tolerate or still Sx
Aldosterone antagonist (spironolactone) + nitrate if reduced EF and still symptoms
Can add ANRI to replace ACEI if still symptomatic
20
Q
How do you treat pulmonary oedema / symptoms
A
Furosemide oral or IV if acute
GTN (nitrate)
Morphine (vasodilator)
Hydralazine + nitrate = vasodilator + diuretic
Add thiazide if refractory
K sparing if low or concurrent digoxin use
21
Q
What do you do if refractory / specialist care
When do you consider pacemaker / cardiac resynchronisation
A
Reasses cause and compliance Digoxin - small inotrope Ivabradine Dobutamine Consider transplant Consider pacemaker / cardiac resynchronisation / PCI
Pacemaker if
- LVEF <35% and >40 days post MI
- Despite OMT still symptoms
- Hx of VT / VF
Cardiac resynchronisation
- If ECHO shows ventricle not contracting properly
- e.g. want bottom part of ventricle to contract to squeeze blood up rather than top
- Consider if EF <35% and prolonged QRS
- if LBBB different parts will contract
22
Q
When is digoxin used
A
AF
23
Q
When would you start on Ivabradine
A
Max therapy
HR >75
Sinus rhythm
EF <35%
24
Q
What should you avoid in angina and HF
A
Rate limiting CCB
25
What is the New York classification of HF
Class 1 = no symptoms or limitation
Class 2 = mild limitation to exercise - SOB / angina, none at rest
Class 3 = moderate limitation in activity, not at rest
Class 4 = severe limitation at rest, often bed bound
26
What is BNP
Hormone produced by left myocardium in response to strain to counteract RAAS
27
What does BNP do
```
Increase GFR
Reduce Na reabsorption and
Vasodilator
Diuretic
Suppress sympathetic and RAAS
```
28
What do you want to monitor in HF
Monitor U+E as renal function can be affected
Drugs e.g. diuretic can be nephrotoxic
Get baseline
Re-check within week if change dose
29
What do you do if K low
If no retention reduce diuretic dose or add in spironolactone
30
What is also useful in HF
Monitor weight
| If increasing increase diuretic
31
What is your dry weight
No pulmonary oedema
| Normal JVP
32
How do you follow up HF
```
Every 6-12 months
BP
HR
Symptom - Oedema
U+E, FBC, glucose
Flu immunisation
```
33
What is acute HF and what happens
Sudden onset or worsening of chronic HF that is life threatening
Left ventricle unable to pump blood so backs up in atrium and then lungs
Leak fluid = pulmonary oedema
Interfres with gas exchange causing SOB / desaturations
34
What causes acute HF without previous Hx
```
Increased filling pressure or myocardial dysfunction
MI / ACS
Fluid overload
Sepsis
Arrhythmia
Valve dysfunction
Myocarditis
Toxins
Cardioversion / surgery can cause
```
35
What leads to decompensate (worsening of chronic HF)
```
ACS
- look for this
Hypertensive crisis
Arrhythmia - AF
Valve disease
Mechanical cause
PE
```
Worsening
- Age
- Stroke / SAH
- Renal or liver dysfunction
- Cirrhosis with ascites
- COPD
- Severe infection or burns
- Anaemia
- Metabolic
36
What are the symptoms of acute HF
Often present syncope /SOB
Underlying cause - chest pain / viral infection
SOB
- Worse lying flat and better sitting up
Syncope
Sudden onset desaturation
Reduced exercise
Fatigue
Cough + frothy
Cyanosis
Tachycardia
Tachypnoea
Displaced apex
Bibasal crackles due to pulmonary oedema
Wheeze
S3
If severe can get hypotension due to cariogenic shock
R failure can develop - increased JVP + peripheral oedema
37
What investigations do you do if suspect acute HF (treat first even before Dx confirmed)
ECG - look for arrhythmia / MI
Blood - FBC (anaemia), U+E, CRP, troponin?, glucose, D-dimer
CXR - fluid / cardiomegaly
ABG - type 1 resp failure
Treat before these tests
ECHO - effusion / tamponade
Do immediate if unstable or within 48 hours
BNP
Look for cause
38
How do you treat acute HF
How do you treat if severe / cardiogneic shock
What is important to do
IV access
Stop fluids
Sit patient up
Oxygen if sats <96 but careful in COPD
Loop diuretic - Often IV
Vasodilator e.g. nitrate only if BP >90
IV opiates - act as vasodilator and reduce anxiety
Monitor fluid balance - UO / intake, U+E
Put catheter in
DVT propphylaxis - TED + LMWH
Do daily weight + Na and fluid restrict when stable
If resp failure but no shock
- Oxygen
- NIV - CPAP or BiPAP
- Intubation
```
If cardiogenic shock / not-responding
Transfer ICU
Inotropes - NA / dobutamine (often need CCU / ITU)
Vasopressors
NIV - CPAP
Ultra filtration if resistant
Mechanical circulatory assistance
```
Treat and look for underlying cause
- AF = digoxin not BB
- ACS = revascularise
- Arrhythmia = cardiovert
- HTN crisis = aggressive BP reudction
- PE = anti-coag
If patient dry and perfusing
- Oral therapy adequate
if patient dry but not perfusing
- Try fluid challenge
- Consider inotrope if hypo-perfused
39
What should you think of discontinuing short tern
BB as -ve inotropic
| Sometimes used in chronic setting
40
What causes peripheral oedema
```
Heart failure = most common
Cellulitis
DVT
Lack of mobility
Chronic venous insuffinecy
Lymphoedema
```
41
What investigations do you do for oedema
FBC, U+E, LFT, albumin
CXR - look for pulmonary
ECHO
USS if ascites
42
How do you treat
Elevate leg
Compression
Furosemide if severe or cardiac cause
43
What causes severe pulmonary oedema
```
Left ventricular failure
LVF post ACS or IHD
Acute valve regurgitation
- IE/ dissection
Arrhythmia
Myocarditis
HTN crisis
PE
ARDS any cause
Fluid overload
High altitude
Neurogenic - seizure / stroke / head injury
Re-exapnsion
Infections
```
44
What are the symptoms of pulmonary oedema
What suggests cardiac cause
```
Dyspnoea
Orthopnea
Cough
Distressed
Pale, clammy and sweaty
Tachycardia
Tachypnoea
JVP increased
Wheeze
Fine crackles - bilateral
Type 1 and type 2 failure
High cardio-pulmonary wedge pressure suggest cardiac cause
```
45
What should you consider
Changes to drugs / fluid
Acute illness
Prior MI
46
How do you investigate
```
CXR
ECG
U+E, troponin, ABG
Consider ECHO
BNP
```
47
What does CXR look like for oedema
```
Bilateral shadowing
Upper lobe venous diversion
Small effusion at costophrenic angle
Fluid in fissures
Fluid in septal lines
Same as HF
```
48
How do you monitor oedema
```
ABG
ECG
BP
Pulse
Cyanosis
RR
JVP
Urine output
```
49
How do you treat pulmonary oedema
```
Sit patient up
High flow O2 if sats low
IV access
Treat arrythmia
Diamorphine 5mg IV
Furosemide IV
GTN spray - don't give if low systolic
IV nitrate - if BP >100 (last resort) -
AVOID OPAITE
```
50
What do you do if patient worsening
Further furosemide
Consider CPAP
Increase nitrate
Consider Doputamine to increase CO if HF
Intropes
Consider other causes - dissection / PE / pneumonia
51
What do you do if BP <100
Treat as cariogenic shock
52
What is DDX
Asthma
COPD
Pneumonia - usually unilateral
53
What do you do once stable
```
Daily weight
Repeat CXR
Oral furosemide / bumetanide
Addition of thiaizde
ACEI if LVEF <40%
BB or spirnolactone
Pacing
Optimise AF
```
54
What are nitrates and when are they CI
Vasodilator + diuretic
| If low systolic
55
What causes congestive HF
```
Ischaemia
Valve
LVF
PS
Lung disease - cor pulmonale
```
56
What are symptoms of congestive
```
SOB
PND
Orthopnoea
Pulmonary oedema
Tachycardia
Crepitation’s due to fluid
Increased JVP
Hepatomegaly
Peripheral oedema / ascites
Nausea
Anorexia
Epistaxis
```
57
What drugs do you stop if pulmonary oedema / acute HF as worsen
ACEI = retention
BB = -ve inotrope
Rate limting CCB
Lithium
58
What should you give if acute HF due to AF
Digoxin
| BB CI in HF as -ve inotropic
59
What should you monitor with digoxin
K
| Renal
60
When is morphine useful / when do you have caution
If distressed
Vasodilator so reduces preload
Prescribe anti-emetic as well
Caution if liver / COPD
61
What dose of GTN
2x 500mg one of
| Regular 250mg
62
What anti-emetic
Metaclopramide
63
What do you want to know when on diuretic
Urine Output
64
When do you get urgent assessment
if BNP >2000
65
What do you monitor
U+E as treatment of HF affects
66
When are ACEI CI
Valvular heart disease
67
What should everyone with HF get
HF specialist nurse
68
What do you think if patient suddenly desaturations
Have they had fluid and can they process it - CKD / AS
69
If heart failure is severe what can occur
Cardiogenic shock - hypotension
70
What type of resp failure in HF
Type 1
| do ABG
71
What is most important thing to look at on ECHO
EF - % of blood pumped out with each contraction
| Should be >50%
72
What do you look at for future CVS risk
```
Cholesterol
BP
Weight
SMoknig
DM
```
73
What are RF of chronic heart failure
```
Hypertension
CAD
Previous MI
Valve issues
DM
Age
Alcohol
Smoking
Obesity
Infection
High or low haematocrit
```
74
What is pathophysiological behind HF
```
CO decreased so compensatory mechanism kick in
Systolic dysfunction
Neurohormonal
Sympathetic
RAAS / BNP
```
75
What is neurohormonal changes
Vasoconstriction
Renal sodium retention by RAAS to increase preload
Activation of sympathetic system
76
What does sympathetic system do
Peripheral vasconstriction to increase resistance and after load
Renin stimulation
Myocyte hypertension
All increases after load and worsens HF
77
What does RAAS do
Activate by increased sympathetic
Peripheral vasoconstriction - ANG II
Aldosterone = increased Na and H20 retention
Leads to more overload and CO drops further
78
What is systolic dysfunction
If heart healthy if stretched it will contract harder
In HF the heart dilates and contraction weakens
Overincrease in preload and increase in after load leads to cardiac strain
CO drops further
Reduces GFR
Activation of sympa and RAAS = further damage
79
Role of BNP
Vasodilator + diuretic but much weaker than RAAS
80
What is Cor Pulmonale
R sided heart failure
81
What causes
```
COPD = most common
Interstitial lung disease
PE
CF
Pulmonary hypertension
```
82
What are symptoms
```
Asymptomatic
SOB - also caused by disease
Peripheral oedema
Cyanosis
Syncope
Chest pain
```
83
What are signs
```
Hypoxia
Cyanosis
Raised JVP
3rd HS
RV heave
Tricuspid regurgitation = pan systolic
Pulsatile hepatomegaly
```
84
How do you Rx
Treat cause
Long term O2
Poor prognosis
85
What do you think if young patient present with Sx of HF
Have they had flu like Sx/ myocarditis in the past
86
What is DDX of breathlessness / HF SX
```
Heart failure
Pulmonary HTN
COPD
Asthma
Pulmonary fibrosis
```
All cause SOB
Don't all cause peripheral oedema
87
What does ECHO look at - trans thoracic
Ejection fraction
| Contraction and pumping function of ventricle
88
What should you do before management of HF
Work out haemo-dynamic profile
Are they congested
Are they perfusing
89
How do you treat HFpEF
Diuretics and manage co-morbid
| No benefit with other drugs
90
What are risks of HF
```
Arrythmia
Sudden cardiac death
CKD and liver
Depression
Cachexia
```
