Heart failure diagnosis

Question 1

3 Major types of symptoms in Heart failure

Answer 1

Decreased cardiac output (decreased organ perfusion), increased pulmonary venous pressure (left sided), and increased central venous pressure (right sided)

Question 2

Symptoms of low flow (decreased CO)

Answer 2

↓ cerebral perfusion:sleepiness, confusion, ↓ muscle perfusion: Fatigue, weakness, ↓ gut perfusion: Anorexia, Wasting (cachexia), ↓ kidney perfusion: Reduced urine output,Progressive renal dysfunction

Question 3

Symptoms of ↑ left-sided pressure

Answer 3

↑ Pulmonary venous pressure: Breathlessness (dyspnea), Dyspnea on exertion, Orthopnea, Paroxysmal nocturnal dyspnea, Acute pulmonary edema

Question 4

What is orthopnea

Answer 4

Immediate shortness of breath when lying flat due to blood from veins in legs pooling near lungs

Question 5

What is paroxysmal nocturnal dyspnea?

Answer 5

Shortness of breath that wakes patient from sleep. Due to mobilization of edema from tissues through lymphatics and back into bloodstream where it goes to the lungs

Question 6

Symptoms of ↑ right-sided pressure

Answer 6

↑ Central venous pressure (RV failure):Peripheral swelling / dependent edema, Ascites, Hepatic congestion, Intestinal congestion (protein-losing enteropathy)

Question 7

Factors that worsen symptoms of HF

Answer 7

Increased preload, increased afterload, worsened contractility, arrhythmia, increased metabolic demands, non-adherence with HF meds

Question 8

Causes of increased preload

Answer 8

sodium in diet, renal failure

Question 9

Causes of increased afterload

Answer 9

Uncontrolled hypertension (LV), worsening aortic stenosis (LV) or PE (RV)

Question 10

causes of worsened contractility

Answer 10

Myocardial ischemia or Initiation of negative inotrope (beta-blocker or calcium channel blocker)
Arrhythmia (rate)
Myocardial ischemia or Initiation of negative inotrope (beta-blocker or calcium channel blocker)
Arrhythmia (rate)
Myocardial ischemia or Initiation of negative inotrope (beta-blocker or calcium channel blocker)
Arrhythmia (rate)

Question 11

Causes of arrhythmia

Answer 11

bradycardia, atrial fibrillation

Question 12

New York Heart Association (NYHA) classification system for HF

Answer 12

I- asymptomatic, II- symptomatic with moderate exertion, III- symptomatic with minimal exertion, IV- symptomatic at rest

Question 13

American College of Cardiology and American Heart Association (ACC/AHA) classification guidelines for HF

Answer 13

A- high risk (HTN, CAD), B- structural heart disease without HF symptoms, C- structural heart disease with symptoms of HF, D- refractory heart failure

Question 14

Clinical signs of HF

Answer 14

Pulmonary (rales), Systemic (jugular venous distension, hepato-jugular reflux, edema, hepatic congestion), cardiac (gallps) and cool extremities

Question 15

Signs of low flow

Answer 15

Cool extremities, tachycardia, low pulse pressure

Question 16

Signs of increased left sided pressure

Answer 16

Rales, hypoxia, tachypnea, sitting bolt upright

Question 17

what are rales

Answer 17

pulmonary crackles- sounds like velcro pulling apart on inspiration. Due to wet alveoli opening

Question 18

Signs of increased right sided pressure

Answer 18

Edema, Hepatic congestion/hepatomegaly, Jugular venous distension

Question 19

Waves of jugular venous pressure

Answer 19

triphasic wave: A wave: atrial contraction, C wave: closing of the tricuspid valve early early in systole, V wave: movement of the RV annulus and tricuspid valve backward at the very end of systole (before the valve opens)

Question 20

What is a gallop?

Answer 20

Extra heart sounds. S3, S4 or all 4 (summation gallop)

Question 21

S3

Answer 21

Caused by rapid expansion of the ventricular walls in early diastole. Normal in young people. Abnormal after age 40. Typical of reduced ejection fraction HF (dilated heart). S1-S2-S3 (Ken-tuc-ky)

Question 22

S4

Answer 22

Caused by atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic LV. Abnormal. S4-S1-S4 (Ten-ne-ssee). Absent in aFib

Question 23

summation gallop

Answer 23

S4-S1-S2-S3

Question 24

Co-existing conditions which predispose to HF

Answer 24

Heart disease (coronary, valve, hypertension), cardiac risk disorders (diabetes, renal failure)

Question 25

Cardiac imaging studies in HF show what?

Answer 25

Chest x ray shows enlarged cardiac silhouette in HFrEF and increased upper lobe vascular markings with acute decompensation. Also, pulmonary edema
Chest x ray shows enlarged cardiac silhouette in HFrEF and increased upper lobe vascular markings with acute decompensation. Also, pulmonary edema

Question 26

What are Natriuretic peptides

Answer 26

B-type natriuretic is secreted by the myocardium in response to ventricular stretch (primary) or hyperadrenergic state, RAAS activation, ischemia (secondary)

Question 27

Labs that test for natriuretic peptides

Answer 27

BNP (directly tests for protein, 20 minute half life) or NT-proBNP( N-terminus breakdown product of BNP, inactive, half life 120 minutes). Both increase with age

Question 28

Diagnostic use of BNP

Answer 28

Elevated BNP is most often due to HF (other reasons include sepsis, PE). Clinically used to rule out symptomatic HF- a low BNP makes HF unlikely.

Question 29

Use of EKG in HF

Answer 29

EKG can infer the possibility of HF from other findings but does NOT directly diagnose HF. EKG can detect: -Prior myocardial infarction (e.g. Q waves), LVH (increased voltage), Diffuse conduction disease from fibrosis or myocardial damage (e.g. LBBB), Arrhythmia (AFib, ventricular ectopy)

Question 30

Equation for ejection fraction

Answer 30

EF= (end diastolic- end systolic volume)/ end diastolic volume %

Question 31

Methods for measuring reduced ejection fraction

Answer 31

ultrasound (echocardiography), nuclear (MUGA or SPECT), MRI, CT

Question 32

What is right heart catheterization

Answer 32

Catheter inserted into major vein then floated through right heart into pulmonary artery. The catheter has a balloon that can occlude pulmonary artery branch to measure the post-capillary wedge pressure(equivalent of the left atrial pressure)

Question 33

What types of measurements can be made with a pulmonary artery catheter?

Answer 33

Pressures (CVP/RA, RV, PA, PCWP) and flow= cadiac output (Fick CO measures oxygen consumption, thermodilution CO measures timed flow). Resistances can further be calculated from pressures and flow.