Card Set Information
what is the definition of heart failure?
inability of the heart to function as a pump and maintain sufficient cardiac output to meet the demands of the body
what % of over 65s have HF?
what is congestive cardiac failure?
both RVF and LVF together. i.e. biventricular. most common form
what are the causes of left ventricular systolic dysfunction?
ischaemic heart disease
: dilated so cant contract properly
mitral and aortic valve disease
what are the causes of diastolic dysfunction?
: restrictive or hypertrophic (eg LVH)
can be due to myocardial infiltration e.g. amyloidosis
what is high output heart failure and what are the causes?
high output in the face of much increased needs and failure occurs when CO fails to meet these needs
wet beri beri (thiamine=B1 deficiency
what are the causes of right heart failure?
secondary to left heart failure usually
or cor pulmonale
what are the SYMPTOMS of left heart failure? and what are they due to?
fatigue, reduced exercise capacity
pink frothy sputum
what are the SIGNS of LHF?
: normal/high if hypertensive disease/low
: low volume, rhythm normal/irregular due to ectopics/AF
displaced apex beat laterally as LVH
: fine inspiratory crackles, bibasal
third heart sound (gallop) due to rapid filling of ventricles
: due to dilatation of mitral annulus
what are the SYMPTOMS of RHF?
dyspnoea (but no orthop or PND)
reduced exercise capacity
chest pain as RV pressure rises or RV becomes dilated
what are the SIGNS of RHF?
peripheral oedema up to thighs, sacrum, abode wall
pulsation in neck and face, tender pulsatile liver
: tricuspid regurgitation (due to dilatation of RV)
left parasternal heave due to RV hypertrophy/dilatation
what are the signs of RHF?
what are the signs of heart failure on examination?
: ill, exhausted
: cool peripheries
: tachycardia, pulsus alternans
: low SBP, wide pulse pressure
: RV heave due to pulmonary hypertension
: S3 gallop, murmur (mitral or aortic)
: tachypnoea, bibasal end insp crackles, wheeze, pleural effusions
: hepatomegaly (pulsatile in TR), ascites
: ankle and sacral
what are the investigations needed to diagnose heart failure?
: cardiothoracic ratio > 50%, ABCDE
: indicate cause eg ischaemia, MI, ventricular hypertrophy
BNP/NT porBNP raised (normal excludes HF!) do in all dyspnoea
: confirms if there is LV systolic or diastolic dysfunction. may show cause e.g. valve/regional wall motion abnormal in IHD, CM, pericardial disease/wall thickness
: anaemia, renal function, thyroid function need to be done
what is a stress echo and what does it assess?
dobutamine (beta1 agonist) to increase contractility and heart rate
asses if ischaemia/viability of myocardium
what is BNP and when is it released?
brain natriuretic peptide
released from ventricles in response to dilatation and STRETCH
what ejection fraction defines systolic dysfunction?
what are the CXR signs of heart failure?
: alveolar oedema = bat's wings shadowing
: kerley B lines - attributed to interstitial oedema as pulmonary venous pressure rises and engorged peripheral lymphatics
: cardiomegaly (cardiothoracic ratio > 50%)
: dilated prominent upper lobe vessels (upper lobe diversion as lower lobes congested)
: pleural effusions
why is exercise testing done in HF?
max O2 consumption (VO2 max) = oxygen consumption does not rise any further despite increasing levels of exertion
: cardiac transplant
why is ambulatory ECG done in HF?
what does radionuclide imaging do?
myocardial perfusion scanning
why should cardiac catheterisation be done?
determine if CAD - need for aspirin/statins/revascularisation
: RAP, pulm artery pressure, PACWP
what is the NYHA classification of heart failure?
: asymptomatic on ordinary activity
: comfortable at rest, dyspnoea on ordinary activities
: less ordinary activity causes dyspnoea which is limiting
: dyspnoea at rest. all activity causes discomfort
what is the mechanism of disease process in HF?
1. poor ventricular function or myocardial damage e.g. post MI or dilated CM
2. heart failure
3. reduced stroke volume and reduced cardiac output
4. kicks of neurohumoral response
5. RAAS and activation of sympathetic NS
6. vasoconstriction, inc sympathetic tone, AT II release, ET release, reduce NO release,
7. Na and water retention due to increased ADH and ado
8. further stress on ventricle wall and dilatation due to remodelling
9. leads to worsening of ventricular function
which types of arrhythmias can lead to heart failure?
: atrial contraction is lost
: atrial contraction is dissociated from ventricular contractions
: reduce ventricular filling time, increase myocardial workload and O2 demand --> ischaemia & ventricular dilatation
how are the kidneys involved in pathogenesis of heart failure?
in heart failure get vascular redistribution of blood to areas vital for IMMEDIATE survival.
so vasoconstriction to skin, skeletal muscle, gut and kidneys
reduced renal perfusion - stimulate RAAS
ATII is powerful vasoconstrictor of renal efferent and systemic arterioles where is stimulates release of NA from sympathetic nerve endings, promotes adrenal release of aldosterone
which part of the nervous system is chronically activated in heart failure and how does this affect function?
SYMPATHETIC nervous system
RAAS, salt and water retention, vasoconstriction…
also chronic sympathetic stimulation results in DOWN REGULATION of cardiac B-receptors --> attenuating hearts usual response to EXERCISE
where are ANP and BNP released from and what are their actions?
: physiological ANTAGONISTS to ATII effects - so cause vasodilation, salt and excretion
what are the effects on the heart of peripheral vasoconstriction?
increased systemic vascular resistance so increased cardiac work and myocardial oxygen consumption
what is cardiomegaly on CXR due to?
L or R V dilation
What is nutmeg liver? and cause?
chronic passive venous congestion of liver
secondary to right heart failure
or congestive heart failure
normally pleural effusions in HF are bilateral, when would they be unilateral and which side normally?
why? high filling pressures so pts find uncomfortable sleeping on left so sleep on right and get a dependent oedema collecting on R
what is the conservative management of chronic heart failure?
avoid exacerbating factors
: NSAIDs cause fluid retention and verapamil (negative inotrope)
eat less salt
maintain optimal weight and nutrition
minimise alcohol consumption
which drugs are used for symptom relief in heart failure?
: fruseminde and bumetanide
relieve dyspnoea and signs of salt and water retention
give with spironolactone if low K or predisposed to arrhythmia or concurrent digoxin therapy (as low K increases risk of digoxin toxicity)
when are thiazide diuretics used as well?
refractory oedema to loop diuretics
which drug should be started on in all patients with left ventricular systolic dysfunction?
start with low dose and titrate up to max tolerated dose
name 2 side effects of ACEi
dry cough then change to ATII inhibit
hypotension with first dose
when are ACEi contraindicated?
bilateral RAS as ACEi can cause anuria
what are the benefits of beta blockers in HF? and who should use them? give e.g.
e.g. carvedilol (extra alpha antagonist so reduce BP, good if HTN)
if STABLE i.e. euvolaemic NOT OVERLOADED. small dose titrate up
give with ACEi
they improve symptoms, LV function, reduce sympathetic activation
so reduce HR --> inc time for diastole and less cardiac energy spending
what are the 3 main first lines drugs for HF?
: spironolactone, frusemide
if first line drugs dont work, which drug should be tried for HF?
if patient is intolerant to both ACEi and ARB which drug should be used?
hydralazine and isosorbine dinitrate (vasodilators)
what is the management for intractable heart failure?
taking DRUGS? compliance?
at max dose?
strict bed rest so need DVT prophylaxis (heparin and teds)
metolazone and iv frusemide (not well absorbed via gut)
daily weight and U&E (beware low K)
may need iv inotropes
what is the management of acute heart failure?
: anxiolytic and venodilator and reduce breathlessness
frusemide iv slowly
GTN spray 2 puffs. NOT IF SBP < 90
ventilation if worsening
venesect if worsening
if sys BP < 100 treat as cardiogenic shock
ventricular assist device
: mechanical pumps that replace work of ventricles, bridge to transplant or to recovery!
what investigations need to be done in acute heart failure suspicion/pulmonary oedema?
: signs of MI
if the patient has AF and heart failure which drugs should they be on?
: Na-K ATPase inhibitor, increase Na-Ca exchange so rise in intracellular calcium
what are the device therapies used in HF and when for each one?
implantable cardioverter defibrillator (ICD)
: reduce SCD from arrhythmia
cardiac resynchronisation therapy (CRT)
: use eg LBBB dyssynchrony, EF<35%, NYHA III/IV, QRS > 15, already on optimal medical therapy
what are the surgical options for HF?
: angina, ischaemic problems
what are the causes of acute heart failure?
1. post MI
: LVSD or papillary muscle rupture
3. acute valve regurgitation (mitral or aortic)
5. decompensated chronic heart failure
7. thyroid probs
what are the complications of heart failure?
: stroke, peripheral embolism, DVT, PE
: hepatic congestion and dysfunction, malab
: muscle wasting
: pulmonary congestion, respiratory muscle weakness, pulmonary hypertension