Clinical Presentation and Management of Heart Failure

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  • Created by: LBCW0502
  • Created on: 30-01-19 11:10
What are the indications for the following medicines for cardiovascular treatment: aspirin, apixaban, atorvastatin, omeprazole, ramipril, bisprolol and GTN spray?
Secondary prevention of ischaemia, prophylaxis/reduce risk of stroke due to CHADVASC score, lower cholesterol levels (atherosclerotic plaque), reduce chances of GI bleed, hypertension, AF and relieve symptoms of angina
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What is pitting oedema?
Swollen ankles/legs/feet, build-up of fluid between cells and interstitial fluid. Doesn't spring back up when pressure is applied/removed
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What does crackles at the base of the lungs indicate?
Build up of fluid in the base of the lungs (angioedema - SOB, fluid in chest/lungs)
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What is NT-proBNP?
Naturietic peptides - released from the heart when under pressure. Measured to give an indication on the extent of pressure on the heart (>125 pg/mL indicates the heart being under strain)
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What is an ECHO?
Echocardiogram - a graphic outline of the heart's movement. Produced using an ultrasound (high frequency sound waves on the chest). Produce image of the heart (valves and chambers) - evaluate the pumping action of the heart
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What is heart failure?
The inability of the heart to meet the circulatory demands of the body caused by structural or functional abnormalities
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What is HFrEF?
Heart failure due to left ventricular systolic dysfunction - reduced left ventricular ejection fraction. Left chamber not able to pump hard enough (usually ~ 70%, but for heart failure patients usually <40%) - most common type of heart failure
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What is HFpEF?
Heart failure with a preserved ejection fraction. Left ventricle chamber size is reduced but still ejects ~70% of blood. Walls of the heart become thick, internal chambers are reduced
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What is acute (decompensated) heart failure?
Known to have HRrEF. Worsening symptoms of heart failure e.g. SOB, legs become swollen, fatigue etc.
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How do you calculate CO?
HR x SV
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Describe features of baroreceptors
Located in the aortic arch. Pressure sensitive, measure drop in pressure (stimulation of sympathetic response)
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Outline the neurohormonal model for the sympathetic response
Decrease CO, decrease aortic blood flow, SNS activated, release NA, arterio-constriction, increase in after-load, remodelling (to decrease CO or), increase cardiac workload
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What happens to the neurohormonal model for the sympathetic response in patients with heart failure?
During a heart attack, adrenaline still released due to baroreceptors detecting fall in pressure. Heart told to beat harder and faster (despite muscle damage) - worsening damage of the heart
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Which organs are sensitive to CO?
The kidneys (each one takes 1/4 of the CO)
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What will happen in the kidneys if the CO is decreased? (1)
Decrease renal blood flow. RAS activated. Angiotensin produced (causes constriction of arterioles and veins). Increases preload and increases cardiac workload
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What will happen in the kidneys if the CO is decreased? (2)
Decrease in CO decreases renal blood flow/RAS activated. Aldosterone produced (increases sodium and water retention). Increase in preload and increases cardiac workload (Starling's law). Kidneys regulate volume in system based on CO
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What will happen in the kidneys if the CO is decreased? (3)
Kidneys only detect renal blood flow. Indication of needing more volume in the system by making the heart work harder
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What is Starling's Law?
SV increases in response to an increase in volume of blood in ventricles before contraction (heart muscle stretches - works harder)
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Which peptides are released when there is an increase in cardiac workload?
Naturetic peptides (NT-proBNP - diagnostic tool) - causes dilation of blood vessels (remodelling, decrease BP, Na/H2O excretion) which leads to decrease in cardiac workload
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How do you calculate BP?
TPR x CO
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What is the effect of the RAS and SNS on the naturetic peptides?
Angiotensin system and SNS overwhelm naturetic peptides - heart is damaged further and continues to beat harder and faster
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Which medicines are used in the treatment of heart failure? (1)
ACE-I (reduce mortality), beta blockers (attenuate SNS, stop drive of heart rate, chance of muscle healing/stop further damage). Diuretics (loop, aldosterone antagonists). Nitrates (veno-constriction), hydralazine (constrict arterioles)
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Which medicines are used in the treatment of heart failure? (2)
NEP-I (increase potency of naturetic peptides by inhibiting the enzyme responsible for the breakdown of peptides). Digoxin (increases force of contraction without increasing rate). Spironolactone (aldosterone antagonist) - ESC guidelines
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How should the dosage for medicines to treat heart failure be managed?
Titrate to maximum dose the patient can tolerate (if symptoms persist and cannot tolerate medicines, alternatives are considered in the guidelines - patients >55 yrs unlikely to get heart transplant)
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The heart should take up how much of the chest cavity?
No more than a third of the chest cavity
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What is cardiomegaly and pulmonary congestion?
Abnormal enlargement of the heart and fluid in the lungs
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Why is it important to remove the fluid from the lungs gradually?
If the fluid is removed quickly, the patient will experience dehydration
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What are the treatment options for HFrEF? (1)
Beta blockers (e.g. bisoprolol, carvedilol). ACE-I, ARBs
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What are the treatment options for HFrEF? (2)
Loop diuretics (e.g. furosemide, bumetanide). Act on loop of Henle. Potent, cause diuresis. Inhibits sodium reabsorption at distal loop of Henle. Side effects - electrolyte imbalance (hypokalaemia, hyperuricaemia), metabolic alkalosis
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What are the treatment options for HFrEF? (3)
Auditory disorders (IV) and AKI. Mineralocorticoid receptor antagonists (e.g. spironolactone, eplerenone) - block effect of aldosterone, decrease preload. Side effects - electrolyte imbalance (hyperkalaemia), headache, insomnia, muscle spasms
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What are the treatment options for HFrEF? (4)
Renal impairment, skin reactions, gynocomastia (S>>E, spironolactone has a similar structure to hormones, eplerenone is preferred)
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What are the treatment options for HFrEF? - ARNI (1)
ARNI (e.g. sacutibil/valsartan) - sacubitil's active metabolite inhibits neprilysin (neutral endopeptidase which cleaves natiuretic peptides/BNP), valsartan is an ARB, they decrease preload and after load. Side effects - anaemia, cough, diarrhoea
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What are the treatment options for HFrEF? - ARNI (2)
Electrolyte imbalance, gastritis, hypoglycaemia, hypotension, renal impairment, angioedema
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What are the treatment options for HFrEF? - Nitrates
Isosorbide mononitrate. Stimulation of soluble guanylate cyclase by NO derived from organic nitrate ester molecule. Causes venodilation (decreases preload/myocardial oxygen demand). Side effects include flushing and hypotension. (With hydralazine)
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What are the treatment options for HFrEF? - Hydralazine
Relaxes smooth muscle cell layer in arterial vessels (potentially involves an altered Ca 2+ balance in cells). Decrease peripheral resistance, lowers BP and decreases afterload. Side effects - flushing, hypotension, tachycardia, lupus-like syndrome
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Describe features of cardiac devices
Cardiac resynchronisation therapy. Re-wire heart (electrical circuit damage, place ventricle leads around damage). Cardiac resynchronisation therapy defibrillator, cardiac resynchronisation therapy pacemaker, expensive but can improve quality of life
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What are the key features of monitoring in primary care?
Patient symptoms and side effects from medicines. Check BP (aim to have slow strong pulses), U&E (especially when doses are changed), renal function. Measure eGFR/creatinine/K+/HR (modifications in dosage)
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Card 2

Front

What is pitting oedema?

Back

Swollen ankles/legs/feet, build-up of fluid between cells and interstitial fluid. Doesn't spring back up when pressure is applied/removed

Card 3

Front

What does crackles at the base of the lungs indicate?

Back

Preview of the front of card 3

Card 4

Front

What is NT-proBNP?

Back

Preview of the front of card 4

Card 5

Front

What is an ECHO?

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