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TCD 9 Heart Failure Zainab Ajaj ChronicHeartfailure CorPulmonale What we AcuteLVFandPulmonaryOedema will cover InfectiveEndocarditis today PracticeQuestions OSCEsChronic Heart FailureAetiology ● Heartfailure(alsoCCF–congestivecardiacfailure)isaclinical syndromeinvolvingreducedcardiacoutput. ● “Theinabilityofthehearttopumpadequateamountsofbloodto meetthebody’smetabolicdemands” ● Cardiacoutput(CO)=Heartrate(HR)xStrokevolume(SV) ● SVrequiresadequatepreload,optimalmyocardialcontractility, decreasedafterload ● Therefore,COcanbereducedbyanyofthefollowing(causing HF): - ↓HR - ↓preload - ↓ contractility - ↑afterloadCauses ThemostcommoncausesofHFarecoronaryheartdisease(MI),hypertension, valvularheartdiseaseandAF.TheacronymHIGH-VISusefultoremembercauses: ● Hypertension ● Infection/immune:viral(e.g.HIV),autoimmune(e.g.SLE,RA) ● Genetic:Hypertrophicobstructivecardiomyopathy(HOCM) ● Heartattack:ischaemicheartdisease ● Volumeoverload:renalorhepaticfailure ● Infiltration:sarcoidosis,haemochromatosis ● Structural:valvulardisease,septaldefects High-outputcardiacfailure-stateswheredemand>normalcardiacoutpute.g. anaemia,pregnancyandsepsis.Presentation ● Breathlessnessonexertion(quantifyhowlongtheywalkbeforefeelingSOB) ● Orthopnoea-SOBwhenlyingflatrelievedbysitting/standing(askhowmany pillowstheyuseatnight) ● ParoxysmalNocturnalDyspnoea(PND)-suddenlywakingatnightwith severeSOBandcough ● Cough-usuallynocturnal,withorwithout“pinkfrothysputum” ● Fatiguelimitingexercisetolerance(reducedappetite,weightloss) ● Ankleswelling ● Presyncope/syncope Differentials? COPD, lung fibrosis, lung cancerOther parts of the history ● PMH:hypertension,Coronaryarterydiseaseandvalvularheartdisease ● MH:medicationscause/worsenHFe.g.calciumantagonists, antiarrhythmics,beta-blockers(acutephase) ● FH:closerelativeswithcardiacissuese.g.cardiomyopathyorcoronary arterydisease ● SH:riskfactors-smoking,alcohol&recreationaldruguseClinical Examination CardiovascularExamination: RespiratoryExamination ● Tachypnoea ● Tachycardia ● Hypotension ● RaisedJVP ● Stonydullnessonpercussion- ● Pulsusalternans pleuraleffusion ● Displacedapexbeat ● Bibasalend-inspiratorycrackles +/- ● RVheave wheeze ● Galloprhythm(S3) ● Murmurs(valvularheartdisease) Abdominalexamination ● Peripheraloedema-ankles+/- ● Ascites sacrum ● HepatomegalyRaised JVP Pitting oedemaInvestigations ● FBC:anaemia ● U&Es:renalfunction,electrolyteabnormalities,importantformedicationchoices ● LFTs:hepaticcongestion ● Lipids/HbA1c:ischaemicriskprofile ● TFTs:hyperthyroidism/hypothyroidism ● Troponin:ifconsideringrecentmyocardialinfarction ● Cardiomyopathyscreen-serumiron,copper,ACE,RF,ANCA/ANA ● ECG-shouldbeperformedonpatientswithsuspectedHF.Mayindicateunderlying causeofHFsuchas: - MI - BundleBranchBlock - Arrhythmias - VentricularhypertrophyNT-pro BNP N-terminalpro-B-typenatriureticpeptide(NT-proBNP)-smallproteinsproduced bythebodyreleasedbyheartinlargequantitieswhenitsensesitneedstowork harder. Usedwhenthere’saclinicalsuspicionofHFtoinformurgencyofother investigations(echocardiography): ● NT-proBNPlevel<400ng/L–heartfailureunlikely ● NT-proBNPlevel400-2000ng/L–referroutinelyforspecialistassessmentand transthoracicechocardiographywithin6weeks ● NT-proBNPlevel>2000ng/L–referurgentlyforspecialistassessmentand transthoracicechocardiographywithin2weeksEchocardiogram AllpatientswithsuspectedHFshouldundergo CardiacMRI transthoracicechocardiography.Itcanconfirm Goldstandardinvestigationfor thediagnosis assessingventricularmass,volume andwallmotion.Usedtypicallywhen echoprovidesinadequateviews. ● Cancalculatetheejectionfraction, ventricularwallthicknessetc. ● Anejectionfraction(EF)of<40% stronglyindicatedheartfailure ● Canconfirmanyunderlyingstructural abnormalities–suchasvalvedisease ● Fillingpressurescanbeestimatedby dopplerechocardiographyChest X-ray ● Alveolaroedema(bat-wing opacification) ● KerleyBlines(interstitialoedema) ● Cardiomegaly(cardiothoracicratio >50%PAfilm) ● Dilatedupperlobevessels ● Effusions(pleuraleffusions- bluntedcostophrenicangles)Classification of HF TheNewYorkHeartAssociation’s(NYHA)classificationsystem isusedtoclassifythe severityofpatientssymptomsandleveloffunctioning ● ClassI: nosymptomsduringordinaryphysicalactivity ● ClassII:slightlimitationofphysicalactivitybysymptoms ● ClassIII:lessthanordinaryactivityleadstosymptoms ● ClassIV:inabilitytocarryoutanyactivitywithoutsymptomsGeneral Management Lifestylemanagement: ● Regularexercise(astolerated) ● Diet-fluid&saltrestriction ● Smokingcessation ● Reducingalcoholconsumption Othergeneralmeasures: ● Yearlyflu&pneumococcalvaccination ● Optimizingtreatmentofco-morbidities ● Medicationreview ● Depression(upto20%)MedicalTreatment ● ACEinhibitors(e.g.Ramipril)-commencedforallpatientswithCHF&reduced ejectionfraction(≤40%).Improveventricularfunctionandreducemortality.If theycan’ttolerateuseanARB.MonitorU&Es. ● Beta-blockers(e.g.Bisoprolol)-commencedforallpatientswithCHF& reducedejectionfraction(≤40%).DecreaseHRandoxygendemand. Improve symptoms not prognosis ● Diuretics(e.g.Furosemide)-torelievesymptomsoffluidoverload(SOB, peripheraloedema). Increasesodiumexcretionviadiuresissoreducecardiac afterload.MonitorU&Es. ● Aldosteroneantagonists(e.g.Spironolactone)-ifpatientssymptomspersist despiteACEinhibitors,beta-blockersanddiuretics.Monitorpotassium.CorPulmonale ● Rightsidedheartfailureduetorespiratorydisease-COPD(mostcommon cause),PE,interstitiallungfibrosis,CF,primarypulmonaryhypertension. ● Increasespressure&resistanceinpulmonaryarteriesmeansRVunableto effectivelypumpbloodoutoftheventriclesandintothepulmonaryarteries. Resultinginbackpressureofbloodintothesystemicvenoussystem. ● Presentation:SOB(worseonexertion),peripheraloedema,syncopeorchest pain ● Signs:hypoxia,cyanosis,raisedJVP,ankle/sacraloedema,S3,murmurs (tricuspidregurgitation),hepatomegaly(backpressureinhepaticvein)Acute Left Ventricular failure VF)Causes LVunabletomovebloodthroughheartresultinginbackpressureofbloodintotheleft atrium,pulmonaryveinsandintothelungs. Vesselsengorgedwithblood(increasedvolume&pressure)sofluidleakscausing pulmonaryoedema.Thisiswherelungtissue&alveoliarefullofinterstitialfluidwhich willinterferewithgasexchange. Triggers: ● AcuteMI ● Arrhythmia ● Sepsis ● Acutevalvedysfunction ● Iatrogenic(e.g.aggressiveIVfluidsinelderlypatientwithimpairedLVfunction)Presentation and investigations Symptoms: ● AcuteSOB ● Unwell/fatigue ● Cough(frothywhite/pinksputum) Onexamination-sameasdiscussedforCHFbutimportanttothinkaboutunderlyingcause (chestpain-MI,palpitations-arrhythmias,fever-sepsis,murmurs) Investigations: ● ECG ● ABG ● Bloods(FBC&CRP-infection,U&Es,BNP-heartfailure,troponin-MI) ● CXR(bilateralpleuraleffusions,kerleyblines,fluidininterlobarfissures) ● BloodsManagement STOPIVfluids!! ● Position(situp) ● Oxygen ● Diuretics(e.g.IVfurosemide40mgstat) Makesuretomonitorfluidbalance,U&Esanddailybodyweight. Ifsevereacutepulmonaryoedemaconsider: ● Morphine(vasodilators) ● Antiemetics(e.g.IVmetoclopramide10mg) ● Nitrates (GTNinfusion/spray) Non-invasiveVentilation(NIV)-ContinuousPositiveAirwayPressure(CPAP)-tight fittingmaskthatforcefullyblowsairintolungstoopenairways.You’reonthewardround,apatienthasafever&anewmurmur. Whatarewethinking? Infective EndocarditisCauses ● Infective Endocarditis (IE) is caused byinfection of the endocardium by bacteria, or very rarely, fungus. ● It most commonly affects theheart valves (natural or prosthetic) ● Most commonly occur at sites of previous damage but, particularly virulent organisms (e.g. staphylococcus aureus and streptococcus pneumoniae) can infect previously normal areas of tissue ● For example, Staph. Aureus will commonly infect the tricuspid valve inIV drug users. ● Strep. Viridans is the commonest cause (usually subacute) followed by Staph. aureus ● It can present acutely or, more commonly, subacutely, where the symptoms may be more non-specific. ● Risk factors include aortic or mitral valve disease, tricuspid valves in IV drug users, Rheumatic fever, prosthetic valvesPresentation Symptoms: Signs: ● Fever+newmurmur ● Petechiae-smallred/purplespots ● Petechiae ● Splinterhaemorrhages ● Cardiac/renalfailure ● Janewaylesions(sub-acutepresentation)- non-tendererythematous,hemorrhagicor ● Rigors pustularspotsonpalmsorsole ● Nightsweats ● Oslernodes(rare)-painfulredlesionsonthe palmsandsole Splinter haemorrhages Janeway lesions Osler nodesDiagnosis Investigations: ● Bloodcultures:3setsatdifferenttimesatdifferentsitesatpeakoffever ● Bloods:normocytic,normochromicanaemia,lowplatelet,neutrophilia,high ESR/CRP ● U&Es ● Urinalysis:microscopichaematuria ● ECG:MI,newAVblock ● Echo:mayshowvegetations What criteria do we use to diagnose IE? ModifiedDuke’sCriteriaTreatment ● Involvemicrobiologists&cardiologists ● ANTIBIOTICS:flucloxacillin,vancomycin,gentamicin,rifampicinetc. ● Surgery:Ifthere’sHF,fungalIE,persistentbacteraemia,repeatedemboliPractise Questions1. A 68 year old man has had increasing shortness of breath over the past three months. He says this has worsened to the point where he is unable to walk more than 10 metres without having to stop for rest. He sleeps with three pillows. On examination he is comfortable at rest, but becomes short of breath while undressing and transferring to the couch for examination. Examination reveals pedal oedema bilaterally to the mid shins and bilateral basal lung crepitations. Which of the following is the best description of his shortness of breath? A. NYHA Class II B. NYHA Class III C. NYHA Class IV D. NYHA Class I E. NYHA Classification not appropriate1.A 68 year old man has had increasing shortness of breath over the past three months. He says this has worsened to the point where he is unable to walk more than 10 metres without having to stop for rest. He sleeps with three pillows. On examination he is comfortable at rest, but becomes short of breath while undressing and transferring to the couch for examination. Examination reveals pedal oedema bilaterally to the mid shins and bilateral basal lung crepitations. Which of the following is the best description of his shortness of breath? A. NYHA Class II Why? B. NYHA Class III Class III defined as marked C. NYHA Class IV limitation in physical activity but D. NYHA Class I comfortable at rest E. NYHA Classification not appropriate2.A 65 year old man is reviewed in the cardiology clinic after a recent echocardiogram which showed an ejection fraction of 55% and no significant valve disease. On examination, he has bilateral pitting oedema in the ankles. His past medical history includes type 2 diabetes, glaucoma and smokes 20 cigarettes a day. His blood pressure is 120/70. What is the next best step in management? A. Ramipril B. Losartan C. Furosemide D. Lifestyle advice E. Bisoprolol2.A 65 year old man is reviewed in the cardiology clinic after a recent echocardiogram which showed an ejection fraction of 55% and no significant valve disease. On examination, he has bilateral pitting oedema in the ankles. His past medical history includes type 2 diabetes, glaucoma and smokes 20 cigarettes a day. His blood pressure is 120/70. What is the next best step in management? Why? A. Ramipril B. Losartan He has HF with preserved ejection C. Furosemide fraction but has ankle oedema so needs diuretics to manage fluid D. Lifestyle advice E. Bisoprolol overload.3.A78yearoldgentlemanisreviewedinthecardiologyclinic.Hehasrecentlybeendiagnosedwith congestivecardiacfailureandhasbeenstartedonfurosemide,ramipril,bisoprololandspironolactone.He iscomplainingofadrycoughforthepast6weeksandallrespiratorycauseshavebeenexcluded. Hehasapastmedicalhistoryofhypertensionandischaemicheartdisease. Itisdecidedthathisramiprilshouldbestoppedduetohisdrycough. Whichofthefollowingisthenextbeststepinthemanagementofhischronicheartfailure? A. Metoprolol B. Calciumchannelblocker C. AngiotensinIIreceptorblocker D. Eplerenone E. Bumetanide3.A78yearoldgentlemanisreviewedinthecardiologyclinic.Hehasrecentlybeendiagnosedwith congestivecardiacfailureandhasbeenstartedonfurosemide,ramipril,bisoprololandspironolactone.He iscomplainingofadrycoughforthepast6weeksandallrespiratorycauseshavebeenexcluded. Hehasapastmedicalhistoryofhypertensionandischaemicheartdisease. Itisdecidedthathisramiprilshouldbestoppedduetohisdrycough. Whichofthefollowingisthenextbeststepinthemanagementofhischronicheartfailure? A. Metoprolol Why? B. Calciumchannelblocker C. AngiotensinIIreceptorblocker If ACE is not tolerated, we use ARB for D. Eplerenone patients with HF with left systolic dysfunction. ARBs are less likely to E. Bumetanide cause dry cough as a SE.4.A69yearoldAfricanladyisseeninthecardiologyclinic.Shecomplainsofshortnessofbreathon minimalexertionandreducedexercisetolerance.Herechocardiogramshowsanejectionfractionof 35%andmoderateaorticstenosis.Onexamination,sheisdyspneicandhasbilateralpittingoedema tothemidcalf. Hercurrentmedicationincludesramipril,bisoprololandaspirin.Spironolactonewasrecently stoppedduetohyperkalaemia. Whatisthenextbeststepinmanagement? A. Ivabradine B. Hydralazine/nitrate C. Eplerenone D. ImplantableCardioverterDefibrillator(ICD) E. Cardiacresynchronisationtherapy4.A69yearoldAfricanladyisseeninthecardiologyclinic.Shecomplainsofshortnessofbreathon minimalexertionandreducedexercisetolerance.Herechocardiogramshowsanejectionfractionof 35%andmoderateaorticstenosis.Onexamination,sheisdyspneicandhasbilateralpittingoedema tothemidcalf. Hercurrentmedicationincludesramipril,bisoprololandaspirin.Spironolactonewasrecently stoppedduetohyperkalaemia. Whatisthenextbeststepinmanagement? Why? A. Ivabradine Patient is still symptomatic (unable to B. Hydralazine/nitrate tolerate spironolactone) so next step is Hydralazine/nitrate. Especially C. Eplerenone indicated in afro-caribbean patients D. ImplantableCardioverterDefibrillator(ICD) with moderate-severe HF E. Cardiacresynchronisationtherapy5.A49yearoldmaleIVdruguserpresentstothecardiologyrapidaccesscliniccomplainingofchestpainandfatigue.He mentionsthathehasalsobeensufferingfromfeelingshakyandsweatingbutfeelscoldallthetime.Helastinjectedheroin5 daysagoandtakesnoregularmedications. Hisobservationsareasfollows:respiratoryrate22breaths/minute,saturations96%roomair,bloodpressure101/56mmHg, heartrate107bpm,temperature38.1degreescelsius Hehasanejectionsystolicmurmuronauscultationofhischest,hislungfieldshavecrepitationsinthemidzonesbilaterallyand heisGCS14/15asheisconfused. Bloodculturesreturnaspositive Whatisthemostcommoncausativeagentofinfectiveendocarditisinthispatientpopulation? A. Enterococcus B. Staphylococcussaprophyticus C. Staphylococcusepidermidis D. Escherichiacoli E. Staphylococcusaureus5.A49yearoldmaleIVdruguserpresentstothecardiologyrapidaccesscliniccomplainingofchestpainandfatigue.He mentionsthathehasalsobeensufferingfromfeelingshakyandsweatingbutfeelscoldallthetime.Helastinjectedheroin5 daysagoandtakesnoregularmedications. Hisobservationsareasfollows:respiratoryrate22breaths/minute,saturations96%roomair,bloodpressure101/56mmHg, heartrate107bpm,temperature38.1degreescelsius Hehasanejectionsystolicmurmuronauscultationofhischest,hislungfieldshavecrepitationsinthemidzonesbilaterallyand heisGCS14/15asheisconfused. Bloodculturesreturnaspositive Whatisthemostcommoncausativeagentofinfectiveendocarditisinthispatientpopulation? A. Enterococcus Why? B. Staphylococcussaprophyticus Main cause of IE in IV drug users C. Staphylococcusepidermidis (found on skin so advances into D. Escherichiacoli circulation with non aseptic use of E. Staphylococcusaureus IV needles) Poor prognosis.6.A65-year-oldfemaleisdiagnosedwithinfectiveendocarditisusingthemodifiedDuke'scriteria. Whichoftheseisamajorcriterion? A. Typicalorganismin1bloodcultureset B. Typicalorganismin2separatebloodculturesets C. Feverof37.5degreesCelsius D. Immunologicalphenomenae.g.Osler'snodes E. Anewmurmur6.A65-year-oldfemaleisdiagnosedwithinfectiveendocarditisusingthemodifiedDuke'scriteria. Whichoftheseisamajorcriterion? A. Typicalorganismin1bloodcultureset B. Typicalorganismin2separatebloodculturesets C. Feverof37.5degreesCelsius D. Immunologicalphenomenae.g.Osler'snodes E. AnewmurmurOSCEsHistory ● Breathlessnessonexertion-howlongdoyouwalkbeforefeelingSOB? ● Orthopnoea-howmanypillowsdoyouuseatnight? ● PND-doyouwakeupsuddenlyatnightfeelingSOB? ● Cough-atnight?Productive? ● Fatigue-tired?Appetite?Weightloss? ● Peripheraloedema-ankleswelling? ● PMH-MI?HTN?Valvedisease?Irregularheartbeat? ● FH:suddendeath?(HOCM) ● SH:doyousmoke?alcohol?recreationaldrugs? DDxforSOBandtiredness:COPD,lungfibrosis(job?),anaemia,acuteSOB causese.g.pneumonia,pneumothorax,MIExplanation stations ● Diagnosis-briefhistory?Whatdoyouknowaboutheartfailure?Whatwould youliketoknow?(ICE)Laymanterms.“Heartnotabletopumpbloodaround thebodyaseffectivelydueto__”-relatetoPMH.Explainhowthiscauses symptomstheyareexperiencing-lessbloodtolungssoSOB&tired.Chunk& check.Management-lifestyle&medical. ● Medications(ACEinhibitors-rememberSEofdrycough) ● Datainterpretation-CXR(ABCDE)Resources ● https://zerotofinals.com/medicine/cardiology/heartfailure/ ● https://zerotofinals.com/medicine/cardiology/corpulmonale/ ● https://zerotofinals.com/medicine/cardiology/acutelvf/ ● https://geekymedics.com/chronic-heart-failure-chf/ ● https://geekymedics.com/acute-heart-failure/ ● Oxfordhandbookofclinicalmedicine ● https://quesmed.comThank you. Any questions?