Diagnosis & Treatment of Heart Failure

Question 1

Major pathophysiological characteristics that lead to symptoms of heart failure (3)

Answer 1

• decreased cardiac output
• increased pulmonary venous pressure
• increased central venous pressure

Question 2

Heart failure symptoms associated w/decreased cardiac output

Answer 2

• FATIGUE
• Symptoms of decreased organ perfusion
  
  • Muscle→fatigue, tiredness/sleepiness
  • Gut→anorexia, wasting (cachexia)
  • Kidney→↓urine output, renal dysfunction
  • Exercise intolerance→inability to augment cardiac output to meet increasing demands of stress/exercise.

Question 3

Heart failure symptoms associated w/increased pulmonary venous pressure

Answer 3

• **DYSPNEA **(breathlessness)
• Dyspnea on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea (PND)
• Acute pulmonary edema

Question 4

Heart failure symptoms associated w/increased central venous pressure

Answer 4

• Peripheral swelling/dependent** EDEMA**
• Ascites
• Hepatic congestion
• Intestinal congestion (protein-losing enteropathy)

Question 5

Orthopnea definition

Answer 5

• SOB when lying flat
• 1) fluid normally accumulates in lower lobes of lungs (due to gravity) –> allows breathing from upper lobes
  
  • lying down –> fluid disperses throughout lungs –> dyspnea
• 2) increased venous return b/c decreased gravity pull on returning blood –> increased congestion & SOB

Question 6

Paroxysmal nocturnal dyspnea (PND) definition

Answer 6

• delayed SOB, waking patients from sleep
• mobilization of edema from tissue through lymphatics back into blood stream

Question 7

Symptoms/causes of acute pulmonary edema

Answer 7

• acute, intense shortness of breath
• “fluffy” infiltrates on an CXR
• occurs once fluid retention/left atrial pressure overwhelms compensatory mechanisms→fluid spills from the pulmonary vasculature into the interstitial space and then into the alveoli→hypoxia

Question 8

NY Heart Association functional classification scheme of heart failure

Answer 8

• I: asymptomatic
• II: symptomatic with moderate exertion
• III: symptomatic with minimal exertion
• IV: symptomatic at rest

Question 9

ACC/AHA Heart Failure Stage Classification system

Answer 9

• A: At high risk for heart failure but without structural heart disease or symptoms of heart failure
• B: Structural heart disease but without symptoms of heart failure.
• C: Structural heart disease with prior or current symptoms of heart failure.
• D: refractory heart failure requiring specialized interventions.

Question 10

Common precipitants of worsening heart failure/symptoms (6)

Answer 10

• Increased circulating volume (Preload)→sodium load in diet, renal failure
• Increased pressure (afterload)→uncontrolled hypertension (LV), worsening aortic stenosis (LV), pulmonary embolism (RV)
• Worsened contractility (inotropy)→myocardial ischemia, initiation of negative inotrope (beta-blocker or calcium channel blocker)
• Arrhythmia (rate)→bradycardia, atrial fibrillation
• Increased metabolic demands→fever, infection, anemia, hyperthyroidism, pregnancy
• NON-ADHERENCE WITH HF MEDICATIONS.

Question 11

Characteristics of clinical course of heart failrure

Answer 11

• clinical course = variable, non-linear
• marked by episodic exacerbations with significant symptoms (sometimes requiring hospitalization), with intervening periods of relative stability.
• Patients rarely stay at a singly NYHA class over time; they may move between functional classes depending on a number of factors
• usual course is an average of progressive decline over time.

Question 12

Key pathophysiological problems that lead to signs of heart failure (4)

Answer 12

• low flow/cardiac output
• elevated left-sided filling pressures
• elevated right-sided pressures
• abnormal contractions –> extra heart sounds

Question 13

Signs of low flow (3)

Answer 13

• Cool extremities—peripheral vasoconstriction to redirect what existing blood flwo there is to vital organs.
• Tachycardia—compensate for low stroke volume
• Low pulse pressure—reflection of low output.

Question 14

Signs of elevated left-sided filling pressures

Answer 14

• rales (pulmonary crackles)—fluid in the lungs, wet alveoli opening
• Hypoxia
• Tachypnea
• Comfortable only when upright, tri-podding
• Popping open of alveoli

Question 15

Signs of elevated right-sided pressures (3)

Answer 15

• Edema—dependent=follows gravity
• Hepatic congestion/hepatomegaly
• Jugular venous distention (JVD) = ↑ central venous pressure

Question 16

Characteristics of Jugular Venous Pressure (JVP)

Answer 16

• JVP = CVP = right atrial pressure
• Normal < 5 cm H2O.
• With a person lying flat or a person with JVD in HF, the jugular vein (internal and external) will fill with blood.
• JVD –> visibily full neck veins on visual examination.
• Jugular venis will transmit pressure changes in the right atrium as waves, visible fluctuations in the vein size and in the meniscus.

Question 17

Types of abnormal heart sounds encountered in HF (2)

Answer 17

Gallops

• S3 gallop—rapid expansion of the ventricular walls in early diastole
  
  • HFrEF/dilated heartKen-tuc-ky (S1-S2-S3)
• S4 gallop—atria contracting forcefully in an effort to overcome abnormally stiff or hypertrophic LV
  
  • Ten-ne-ssee (S4-S1-S2)

Question 18

Major types of laboratory/imaging studies & tests used in dx of HF

Answer 18

• lab tests: natriuretic peptides
  
  • BNP (B-type natriuretic)
  • NT-proBNP
• imaging studies
  
  • CXR
  • Electrocardiogram (EKG)
  • Echocardiography
• Catheterization

Question 19

BNP & NT-proBNP definition

Answer 19

• BNP=B-type natriuretic peptide –> secreted by myocardium in response to:
  
  • Primary: ventricular stretch
  • Secondary: hyperadrenergic state, RAAS activation, ischemia
• BT-proBNP: n-terminus breakdown product of BNP
  
  • remains in blood longer and is easier to measure

Question 20

Primary dx use of BNP/pro-BNP

Answer 20

• clincally used to rule out HF
• used as a comparison to base BNP levels
• multiple root causes that can lead to elevated BNP

Question 21

Dx of HF via CXR

Answer 21

• Enlarged cardiac silhouette = HFrEF
• ↑upper lobe vascular markings = acute decompensation
• fluffy infiltrates = pulmonary edema
• pleural effusions

Question 22

Dx of HF via EKG

Answer 22

• No direct diagnosis of HF can be made w/EKG
• Can infer possibility of HF from other findings:
  
  • Q waves—prior MI
  • Increased voltage—LVH
  • Arrhythmia (AF, PVCs), non-sustained ventricular tachycardia (NSVT)

Question 23

Dx of HF via Echo

Answer 23

• Provides information on a number of different factors:
• LVEF
• chamber size (dilation), LV wall thickness (hypertrophy)
• measures of relaxation (diastology)
• valvular anatomy and function
• filling pressures, pulmonary pressures.
• Advantages: real time, non-invasive, no radiation, inexpensive

Question 24

Characteristics of right heart catherization

Answer 24

• A plastic catheter is placed into a major vein and floated through the right heart and into the pulmonary artery
• A balloon on the end helps blood flow carry it to the lungs.
  
  • Balloon allows a branch of the pulmonary artery to be occluded so that the downstream pressure can be measured = left atria pressure / left sided filling pressure

Question 25

Measurements that can be obtained from right heart catheterization

Answer 25

• ​Measure pressures—CVP/RA, RV, PA, PCWP
• Measure flow/CO
• Resistances can be calculated from pressures and flow.