unit 12 Heart Failure

• what is an RNA (hint it is a diagnostic tool)?


  RNA is a type of nuclear cardiology, radionuclide angiography.

  a radioactive substance (normally technetium) is injected into the blood by IV and tags RBCs

  the tracer releases gamma rays which is tracked by scanners (gamma cameras)

  this shows the heart's chambers in motion, see how much blood is pumped out (ejection fraction)

  Your doctor can match these recordings with the electrocardiogram (ECG). An ECG is a recording of the heart's electrical activity.

  may see a reduced ejection fraction, abnormallities in contraction, etc
• what can SPECT and PET scans show in ischaemia?


  myocardial ischemia

  myocardial dysfuncitonn
• How does a PET scan work?

  PET Scan of the Heart:

  • inject a radiopharmaceutical, (glucose analogue labeled with a positron-emitting isotope), into bloodstream. radiotracer is taken up by metabolically active tissues, like heart muscle.
  • images of heart's metabolic activity and blood flow.
  • show areas of increased or decreased metabolic activity
  • Applications: assess myocardial perfusion, detect areas of ischemia or infarction, evaluate myocardial viability, and guide treatment decisions in patients with heart disease.
• how does a SPECT scan work?

  SPECT imaging involves the detection of gamma rays emitted from a radioactive tracer injected into the body (technetium). The gamma camera rotates around the patient, capturing multiple 2D images from different angles. These images are then reconstructed to create a 3D representation of the distribution of the tracer within the body.
• • Radionuclide Angiography: Radionuclide angiography, also known as cardiac blood pool imaging, is a type of nuclear imaging that focuses specifically on the heart's chambers and blood vessels. It involves the injection of a radioactive tracer, such as technetium-99m (Tc-99m) labeled red blood cells or albumin, into the bloodstream. The tracer mixes with the blood and allows visualization of the heart's chambers and blood flow dynamics using a gamma camera.
• how does the heart remodel in HF? what are the 3 things you can normally see in remodellling of the heart?

  progressive remodelling of the heart under the neuronal, hormonal etc signals it is sent -> there is a change in the structure and ability to carry out function

  1. hypertorphy - not the same as what is seen in a healthy heart
  2. myocyte apoptosis
  3. interstitial fibrosis

  • remodelling occurs over a long period of time
  • initial to compensate for an insult to the heart
  • the remodelling is what compromises HF in the end
  • dilation of the heart loosens it and makes it more difficult to pump
• what is the difference between diastolic and systolic heart failure?

  • diastolic heart failure - see a hypertrophied heart, the heart loses its ability to relax properly and therefore cannot refill with blood, there is an increased pressure in the chambers opposing this and there is an increased filling pressure in the pulmonary circulation. EJ is preserved so diastolic HF is known as HFpEF
  • systolic heart failure - see a dilated heart, the left ventricle cannot contract properly during SYSTOLE, can see a reduced Left ventricular Ejection Fraction
• systolic heart failure -> there is a problem with systole, cannot contract properly, cannot get blood out properly causing a reduced ejection fraction

  diastolic HF -> the heart cannot relax properly/diastole, cannot refill properly but can still eject so will see normal or mildly reduced ejection fraction
• there are 4 classifications in the New York Heart Association (NYHA) classification system of symptom severity, outline these classifications:


  here

  
• your patient is comfortable at rest, they do not find it difficult to do daily activities and do not experience dysponea, palpitations or fatigue. What class are they in according to the New York Heart Association?

  their symptoms fit in with class I
• your patient is comfortable at rest however there is a marked limitation in physical activity (noticbale), when they are carrying out less than normal physical activity they experience dysponea, palpitations and fatigue. How would you classify them according to the New York Heart Association?

  their symptoms fit with Class III
• Your patient is comfortable at rest and when you ask them to carry out normal physical exercises they display a slight limitation of physical activity and experience fatigue, dysponea and palpitations. How would you classify them according to the New York Heart Association?

  their symptoms fit in with a Class II
• your patient has noticable symptoms of heart failure at rest, they have dysponea and are fatigued despite not doing anything. They are in discomfort at rest and any physical activity makes it much worse.

  How would you classify them according to the New York Heart Association?

  their symptoms are consistent with Class IV
• After investigating your patient you see they have signs and symptoms consistent with heart failure. You carry out an echocardiogram and find that there is a reduced LV ejection. What type of heart failure does your patient have, how many and what are the criteria for this?


  Heart failure with reduced ejection fraction (HF-REF)

  3 criteria

  • signs consistent with heart failure
  • symptoms consistent with heart failure
  • there is reduced ejection fraction
• After investigating a patient you see they have signs (tachycardia, 3rd and 4th heart sounds, tender hepatomegaly, etc) and symptoms (dysponea, paroxysmal noctural dysponea) consistent with heart failure. Their ejection fraction is slightly reduced and they have evidence for an atrial enlargement.

  Wha ttype of heart failure do they have, how many criteria are there for this and what are they?

  heart failure with preserveed
• your patient has signs (tachycardia, hepatomegaly, etc) and symptoms (dysponea, paroxysmal nocturnal dysponea) of heart failure. Their ejection fraction is slightly reduced and have evidence for atrial enlargement. Wha type of heart failure do they have, how many criteria are there for this and what are they?


  
heart failure with preserved ejection fraction (HF-PEF)

  4 criteria:

  • signs of heart failure
  • symptoms of heart failure
  • normal or MILDLY reduced ejection fraction
  • evidence for structural abnormalities -> left ventricular hypertrophy, left atrial enlargement or diastolic dysfunction
• the chest X-ray shows a feature of heart failure, what is it and why does it occur?

  Kerley B lines

  occur due to the thickening of interlobular septa which is the connective tissue between the lobules in the lungs and this is normally caused by pulmonary oedema.

  HF -> increased pressure in the pulmonary circulation which causes increased fluid leakage from the capillaries to the interstitium -> thickens the connective tissue

  
• what causes cardiomegaly in heart failure?

  persistent insult -> cardiac remodelling -> cardiac hypertrophy, fibrosis and dilated hypertrophy
• what causes pulmonary oedema in heart failure?

  due to the reduced ability of the heart to pump blood around the body there is an increase in the pressure of the chambers of the heart -> then there is an increase in the pulmonary filling pressure -> reduced pulmonary circulation flow -> under pressure the fluid is pushed out into the alveolar spaces
• most common arrhythmias in heart failure?


  A fib - see no p waves

  A flutter - saw tooth shaped
• how does stress echocardiography work? - dobutamine for contractile reserve, what does it show


  • used to measure the contractile reserve of the heart which is how much more contractility can the heart provide under physiological stress/exercise?
  • If there is a sufficient increase in the contractility of the heart there is a possibility to improve heart health through revascularisation or medicine
  • uses dobutamine which is a beta agonist and can act on the heart to produce a similar physical response to what exercise would -> heart failure patients are in no state to be doing intense exercise
• after a consultation with a patient with heart failure you are to give them advice on their condition, what lifestyle advice would you give them?

  • dietary modification
  • physical activity, exercise training, habilitation
  • smoking
  • education
  • driving
• when managing a a patient with heart failure what should you be monitoring? how would you monitor these factors?

  • cardiac rhythm - ECGs, holter
  • fluid status - weight, clinical assessment, serum creatinine and electrolytes
  • functionality status - NYHA functional class, exercise tolerance test, echocardiography
• what is the heart block poem for heart block


  here mobitz I and II refer to the PR prolongation

  
• what is diagnostic limbo?


  Diagnostic limbo, also known as the "diagnostic odyssey," refers to the prolonged period during which a patient experiences uncertainty and frustration due to the lack of a definitive diagnosis for their medical condition.

  • physical effects - it can cause a delayed onset of treatment, further deterioration in health, affect health outcomes
  • emotional effects - anxiety, stress, loss of control, anger
  • coping mechanism - seeking information, obsessive, hypochondriac?
• what is biological disruption and how does it link with chronic illness?


  refer to destabilisation, questioning and reorganisation of identity after the onset of chronic illness.
• what is narrative reconstruction? how does it apply to chronic illness?

  •Narrative reconstruction: In its routine form, refers to observations, comments and practical consciousness in daily life; and in its reconstructed form, how people make sense of their illness is always within the context of their personal biographies.
• what are the four types of stigma? How do people try and manage stigma?

  oDiscredited: visible or known stigma, hard to conceal.

  oDiscreditable stigma: not known or not visible difference, can be managed or hidden (diabetes, addiction).

  oEnacted stigma: external/actual stigma, first-hand experience of unfair treatment.

  oFelt stigma: internal or self-stigmatization.

  •passing, covering and withdrawing.
• Advanced care planning what are the three things that make up an advnaced care plan?

  1. what do you want to happen? statement of wishes and preferences
  2. what do you not want to happen? Advance decisions to refuse treatment
  3. who will speak for you? proxy or LPOA

  
• what is normal ejection fraction?

  what is borderline ejection fraction?

  what is REDUCED ejection fraction?

  1. normal - 50-70%
  2. borderline - 41% - 49%
  3. REDUCED - ≤40%
• what is the role of the community palliative care nurse specialists?

  ·Visit patient at home.·Give advice on symptom control medication.

  ·Provide support to patient and family.

  ·Work collaboratively with GP and heart failure specialist nurses.

  ·Refer for other hospice services if appropriate.
• what does a day hospice do?

  ·Patients attend weekly.

  ·Social interaction.

  ·Access to physiotherapy and relaxation which may help breathlessness.

  ·Access to psychological support.

  ·Review by palliative care nurses and doctors if required.Provides respite one day a week for informal carers in the home.
• what does a day hospice do?


  ·Patients attend weekly.

  ·Social interaction.

  ·Access to physiotherapy and relaxation which may help breathlessness.

  ·Access to psychological support.

  ·Review by palliative care nurses and doctors if required.Provides respite one day a week for informal carers in the home.
• what does a hospice at home do?


  ·Health care assistants provide ‘shifts’ in the patient’s home in last days/weeks of life to

  support people to die at home where this is their wish.
• what is the role of the palliative care inpatient unit?


  ·Patients may be admitted for symptom control.

  ·Patients in palliative phase may be admitted to hospice rather than hospital with fluid overload.

  ·Diuretics may be titrated: if no response to medical management, then can switch to palliative focus and end of life care.

  ·Patients may also be admitted specifically for end of life care.
• why does fibrosis occur in heart remodelling?

  increased afterload causes increased pressure on the heart walls

  • the walls undergo hypertrophy and fribrotic remodelling to compensate for this and increase the thickness of the left ventricular wall
  • however this causes wall stiffness and decreased compliance
  • imapirs ventricular contraction and refilling
  • compensatory mechanism becomes maladaptive and the ECM degenerated
  • left with CHAMBER DILATION and WALL THINNING
  • both of these increase tension on the wall further
• when looking at a CXR what might indicate that a patient has heart failure?

  A - alveolar oedema -> pulmonary oedema or congestion

  B - Kerly B lines

  C - Cardiomegaly (cardiothoracic ratio is greater than 50%)

  D - diversion of vessels -> upper zone vessel enlargement

  E - effusion -> pleural effusion
• what are the differentiating features between right and left-sided heart failure?

  right:

  • ascites
  • enlarges, tender liver (nutmeg liver) with nodules
  • excessive nocturnal urination
  • increased JVP
  • swelling of feet, legs and ankles

  Left:

  • dyspnoea
  • orthopnoea
  • paroxysmal nocturnal dyspnoea
  • pulmonary oedema and congestion (crackles)
  • exercise intolerance
• what is BNP?

  why is it released?

  how does it compare to NT-proBNP?

  here

  
• Cardiothoracic ratio is something that can be measures on a CXR, what does it indicate and what is abnormal?


  •Cardiac diameter/thoracic diameter

  •Normal values range = 0.42 - 0.50

  •> 0.50 is abnormal, may indicate cardiomegaly 

  •Very good indicator for heart failure (specific)

  •Not all heart failure presents with heart failure (insensitive)