heart failure (treatment (vasoselective calcium channel blockers: di…
tachycardiac at rest
ivabridine, SA node blocker
Diuretics, vasodilators,positive ionoprophic drugs.
vasoselective calcium channel blockers: di hydro piridine
leads to positive ionopropic effect. and non- dihydro piridines (non- vasoselective) negative ionopropic. verapimil and diltiazam might not make better.
statins: stops the atherosclerotic process. worsen dementia. also myalgia side effects.
digoxin: doesnt reduce mortality, controls symptoms, positive ionotrope, controls symptoms, reduced hospitalisation, used as rate control in AF, if they have low BP thenits a good option.
hydralazine and nitrates: increase vasodilation decrease pre adn afterload. optimum starling forces on the heart.
ARBs: useful for those with ACEi cough. end with SARTAN
decrease the stimulation of the SNS on the heart. catecholamine are toxic to the heart. the old school ones were not as good. beta blockers secletion is important. carbenelol, mesoprolol, lebetolol, metoprolol (slow release) are the cardioselective ones. survival benefit is increased when used wih ACEi. contraindicated in asthma, bradycardia an hypotension and AV block, resting limb ischaemia.
decrease fluid , then ACEi or ARB, then B blocker, then when optimised can use the other stuff. reduces hospitalisation.
refractory treatment: LVAD
treat the underlying cause
ischaemic heart disease
: MI = dyskenetic wall, and or ischaemic dysfunction hybernating myocardium. can revascularise with stents or CABG. pacemakers.
reno vascular stenosis
: need revascularisation
: increased haemodynalic load, aim to decrease the pre and afterload in heart failure. B blockers, ARBS, ACE inhibitrs,. and diuretics.
sodium and water retention, negative ionotrppy and direct cardiac toxicity.
NSAIDS, anti arrythmics because neg ionotropes, calcium channel blockers because of neg ionotropic (amlodipine), chemotherapic agents.
lifestyle factors: exercise
Smoking cessation, alcohol restriction, salt restriction, weight loss, daily weights and fluid balance
correct systemic facotrs: diabetes, thyrid, anaemia and arrythmias
morbidity and mortality
digoxin has no survival benefit only symptomatic, diuretics, B blockers dont start when acute decomp, ace and arbs block RAAS for fluid overload, hydralisine and nitrates (vasodilators), spironolactone.
diuretics loop is best but thiazides can be used, positive ionoprope (digoxin) beta blockers, ACEi and ARBs.
Valvular heart disease
Coronary heart disease
right heart fialure
causes: RCA disease inferior MI, amyloidosis, increased afterload: pulmonary hypertension, primary or secondary due to LV failure, pulmonary valve stenosis, PE.
acute heart failure
Pulmonary oedema, peripheral oedema, type one respiratory failure
causes: AMI, acute valvular regurgiation, myocarditis, arrythmia.
high output heart failure
normal pumping heart cannot meet the damands of the tissues
anaemia, thyrotoxicosis, pregnancy
Acute decompensation heart failure
Infections, like pneumonia
AF can worsen it
non-compliance with fluid balance, dont take diuretics and eat salt
heart failure with reduced ejection fraction EF <50%
Ischaemic cardiomyopathy, dilated, valvulopathy, hypertension.
idiopathic, myocarditis, ischaemic heart disease, infultrative disease
Heart failure with preserved ejection fraction
Ischaemic cardiomyopathy, Htn, valvulopathy, (not dilated), anything that stops the heart relaxing, like HOCM, infultrative diseases like amyloidosis and sarcoidosis, restrictive pericarditis.
ultrasound of the vena cava, cardiopulmonary exercise testing, cardiac biopsy, cardiac MRI.
identify the cause and severity of heart fialure. distinguish between systolic and diastolic. 50-70% EF is normal. <40 % EF if heart fialure.
: differentiate between respa nd cardiac cause. size of the heart is more than 50% of the chest. interstitial oedema kerly b lines, peribrnchial cuffing, hazy contour of vessels, ,fluid in the horisotal fissure. air bronchograms, cotton wall appearance. upper lobe diversion.
FBE WCC decomp heart failure, UnE: hyponatraemia, renal failure acute recomp and assess organ dysfunction, also need baseline electrolytes, LFTs for RHF, lactate: indicator of end organ ischaemia, BNP: B type naturietic peptide from increased wall tension in the artia.
signs of ischaemia, sinus tachy or AF
start with general inspection
peripheral: vasoconstriction, pallor and diaphoresis.
oedema: in legs, scrotum, ascites, sacral.
Abdomen: tircuspid regurgitation causing liver to be tender adn pulsatile and can cuase the JVP to increase (hepato jugular reflux)
Lungs: crepitations, coarse creps. pleural effusion: stony dull to percussion can be caused by right heart failure.
murmurs: valvulopathy causing heart failure. S3 gallop rhythm in reduced ejection fraction heart failure after S2 heaps of blood left in ventricle and causes the 3rd sound. during diastole.
Apex beat: displaced to the lateral side.
JVP: elevated , kausmalls sign JVP goes high when breathing in due to right ventrcular failure.
SOB, BMI, swelling, change in colour jaundice, cyanosis or pallor, pulse resting sinus tachycardia, weak rapid and thready, AF common in failure. narrow pulse pressure.
Whats making this worse
What is the cause of the heart failure
How bad is the heat failure
NYHA heat criteria. 4 classes. 1 no limitation, 2 slight limitation, 3 symptoms on minimil exertion, and class 4 SOB at rest (high 4 year mortality of 64%)
Is this heart failure, ddx inc COPD and other causes of fluid overload.
Left heart failure
dysopnea, orthopnea, PND, end organ perfusion symptoms like fatigue, renal symptoms like nocturia inthe early stages and then oliguria. cerebral symptoms like confusion memory impairment or anxiety. angina is common from ischaemic heart disease. palpitations.
right heart failure
peripheral oedema, pulsatile liver, GIT symptoms, nausea, indigestion.