Heart failure diagnosis Flashcards
3 Major types of symptoms in Heart failure
Decreased cardiac output (decreased organ perfusion), increased pulmonary venous pressure (left sided), and increased central venous pressure (right sided)
Symptoms of low flow (decreased CO)
↓ cerebral perfusion:sleepiness, confusion, ↓ muscle perfusion: Fatigue, weakness, ↓ gut perfusion: Anorexia, Wasting (cachexia), ↓ kidney perfusion: Reduced urine output,Progressive renal dysfunction
Symptoms of ↑ left-sided pressure
↑ Pulmonary venous pressure: Breathlessness (dyspnea), Dyspnea on exertion, Orthopnea, Paroxysmal nocturnal dyspnea, Acute pulmonary edema
What is orthopnea
Immediate shortness of breath when lying flat due to blood from veins in legs pooling near lungs
What is paroxysmal nocturnal dyspnea?
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
Symptoms of ↑ right-sided pressure
↑ Central venous pressure (RV failure):Peripheral swelling / dependent edema, Ascites, Hepatic congestion, Intestinal congestion (protein-losing enteropathy)
Factors that worsen symptoms of HF
Increased preload, increased afterload, worsened contractility, arrhythmia, increased metabolic demands, non-adherence with HF meds
Causes of increased preload
sodium in diet, renal failure
Causes of increased afterload
Uncontrolled hypertension (LV), worsening aortic stenosis (LV) or PE (RV)
causes of worsened contractility
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)
Causes of arrhythmia
bradycardia, atrial fibrillation
New York Heart Association (NYHA) classification system for HF
I- asymptomatic, II- symptomatic with moderate exertion, III- symptomatic with minimal exertion, IV- symptomatic at rest
American College of Cardiology and American Heart Association (ACC/AHA) classification guidelines for HF
A- high risk (HTN, CAD), B- structural heart disease without HF symptoms, C- structural heart disease with symptoms of HF, D- refractory heart failure
Clinical signs of HF
Pulmonary (rales), Systemic (jugular venous distension, hepato-jugular reflux, edema, hepatic congestion), cardiac (gallps) and cool extremities
Signs of low flow
Cool extremities, tachycardia, low pulse pressure
Signs of increased left sided pressure
Rales, hypoxia, tachypnea, sitting bolt upright
what are rales
pulmonary crackles- sounds like velcro pulling apart on inspiration. Due to wet alveoli opening
Signs of increased right sided pressure
Edema, Hepatic congestion/hepatomegaly, Jugular venous distension
Waves of jugular venous pressure
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)
What is a gallop?
Extra heart sounds. S3, S4 or all 4 (summation gallop)
S3
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)
S4
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
summation gallop
S4-S1-S2-S3
Co-existing conditions which predispose to HF
Heart disease (coronary, valve, hypertension), cardiac risk disorders (diabetes, renal failure)
Cardiac imaging studies in HF show what?
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
What are Natriuretic peptides
B-type natriuretic is secreted by the myocardium in response to ventricular stretch (primary) or hyperadrenergic state, RAAS activation, ischemia (secondary)
Labs that test for natriuretic peptides
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
Diagnostic use of BNP
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.
Use of EKG in HF
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)
Equation for ejection fraction
EF= (end diastolic- end systolic volume)/ end diastolic volume %
Methods for measuring reduced ejection fraction
ultrasound (echocardiography), nuclear (MUGA or SPECT), MRI, CT
What is right heart catheterization
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)
What types of measurements can be made with a pulmonary artery catheter?
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.
