Heart Failure Diagnosis Flashcards
3 Major Symptoms of Heart Failure
1) decr cardiac output due to decr organ perfusion
2) incr pulm venous pressure (left sided) –> breathlessness
3) incr central venous pressure (right sided) –> edema
Symptoms of Low Flow
1) decr cerebral perfusion (confusion)
2) decr muscle perfusion (fatigue)
3) decr gut perfusion (anorexia/wasting)
4) decr kidney perfusion (decr urine output and renal dysfunction)
Effect of low flow on Starling Curve
Shift curve downward due to decr SV for a given pressure
Symptoms of Left sided pressure/increased pulm venous pressure
1) breathlessness (dyspnea)
2) dyspnea on exertion
3) orthopnea
4) paroxysmal noctural dyspnea
5) acute pulm edema due to fluid retention/incr LA pressure so fluid from pulm vasculature enters interstitial space and then alveoli (hypoxia)
Effect of incr left sided pressure on Starling curve
given point shifts right due to incr pressure
Difference between orthopnea and paroxysmal noctural dyspnea
Orthopnea = immediate SOB lying flat
Paroxysmal Nocturnal dyspnea= delayed SOB wake from sleep and walk around
Why does walking around improve paroxysmal nocturnal dyspnea
Mobilizing edema from tissue through lymph back into blood stream
Why does orthopnea occur?
lost venous pooling of blood in the legs
Symptoms of incr right sided pressure/incr central venous pressure
1) peripheral edema in lower extrem (older)
2) ascites (younger)
3) Hepatic congestion
4) intestinal congestion
Right sided failure = Effect of Edema in HF on Starling forces
Increased central venous pressure upsets balance between Starling forces
now increase oncotic P so pump more fluid into interstitum
Factors that lead to worse symptoms
1) incr circulating volume (preload) with sodium
2) increased pressure (afterload)
3) decr inotropy
4) arrhythmia
5) incr metabolic demands (fever, infection)
6) non-adherence with HF meds
examples of increased pressure (afterload) that can worsen symptoms
1) uncontrolled HTN
2) worse aortic stenosis
3) pulm embolism
examples of decr inotropy that can worsen symptoms
1) MI
2) beta blocker or Ca2+ channel blocker
NYHA class 1 2 3 4
1) asymptomatic
2) symptomatic with mod exertion
3) symptomatic with minimal exertion
4) symptomatic at rest
AHA/ACC HF stage 1
at risk for HF but not structural heart disease or symptoms
AHA/ACC HF stage 2
structural heart disease (prior MI, LVH and low EF) but no signs/symptoms of HF
AHA/ACC HF stage 3
structural heart disease with prior/current signs and symptoms (HFpEF) and (HFrEF)
AHA/ACC HF stage 4
Refractory HF
marked symptoms at rest
What is important about HF course?
variable course
episodic exacerbations and rarely single NYHA over time
but usually progressive decline over time
Physical exam
Signs of low flow
1) cool extremities - peripheral vasocosntriction to redirect flow to vital organs
2) tachycardia- compensate for low SV
3) low pulse pressure - low output
Physical Exam
Signs of elevated left sided pressure
1) rales due to wet alveoli opening
2) hypoxia
3) tachypnea
4) bolting upright
PHysical exam
signs of elevated right sided pressures
1) edema - follows gravity (legs, sacrum, scrotum)
2) hepatic congestion
3) JVD = central venous pressure
what does JVD measure
RA filling pressure
What is JVD a sign of
increased central venous pressure
right heart failure
how many Waves in JVD
Triphasic= 3
A wave
atrial contraction
C wave
closing of the tricuspid valve early in systole
v wave
movement of RV annulus and tricuspid valve backward at the end of systole (before the valve opens)!
S4 heart sound
before S1
atria contract forcefully to overcome stiff/hypertrophic LV
S4 present in AFIB
NO NOT IN AFIB
S4 normal or abnormal?
abnormal
S3 heart sound cause
rapid expansion of vnetricular walls in early diastole
sudden stop in LA filling
heart vibrates during passive filling
S3 normal or abnormal?
normal in young
abnormal after 40 y/o
S3 sign of?
HFrEF or dilated heart
what is summation gallop?
all 4 heart sounds
Preexisting conditions to HF
Coronary, valve disease, HTN
Diabetes, Renal failure
How can CXR help in HF
Enlarged heart in HFrEF
increased upper lobe vascular markings with acute decompensation
What does acute pulm edema look like on CXR
fluffy infiltrate due to LA pressure overwhelming lymph return
What is BNP secreted in response to?
Ventricular stretch (measure of preload)
Hyperadrenergic state, RAAS, ischemia
What are assays of BNP
BNP- Normal <100
NT-proBNP= N terminus breakdown of BNP (inactive)
~ 6x BNP
BNP relationship with age
incr age, incr BNP
How is BNP used?
low BNP makes HF unlikely
in chronic HF, elev BNP not as useful
Signs of HF in EKG
no direct diagnosis
1) prior MI (Q waves)
2) LVH (incr voltage)
3) diffuse disease from fibrosis or myocardial damage (LBBB)
4) arrhythmia (AFib, ventricular ectopy)
Equation for EF
EF= (end diastolic volume - end systolic volume) / end diastolic volume
HFrEF = dilated + decr SV
Advantages of echocardiogram
real-time
non-invasive
no radiation
cheap
Right heart cath using Swan-Ganz
1) cath insert into major vein and floated to right heart into pulm artery
2) blocks branch of pulm artery to measure downstream pressure (wedge pressure = LA pressure)
what is wedge pressure equal to?
LA pressure/left sided filling pressure
PA Catheter measures what 2 things?
Pressures
Flow
- fick CO
- thermodilution CO
In HF, what is the Fick CO and what is Thermodilution CO
Oxy sat aorta - oxy sat vein
Fick: In HF, lower oxy sat in vein because lower CO
Thermodilution: Longer time fo cold water to reach pulm artery because lower CO
How to calculate resistance based on pressures and flow
dP = CO * R
Calculate resistance in pulm bed based on Difference between PA pressure and Wedge pressure
Calculate resistance in systemic based on difference between aortic pressure and central venous pressure
