Heart Failure II -Clinical Manifestations & Dx

Question 1

What are the 3 major Sx in HF?

Answer 1

• Decreased cardiac output: Sx of decreased organ perfusion
• Increased pulmonary venous pressure: breathlessness
• increased venous pressure: edema

Question 2

Sx of reduced cerebral perfusion?

Answer 2

Sleepiness and confusion

Question 3

sx of reduced gut perfusion?

Answer 3

Anorexia and wasting (cachexia)

Question 4

What Sx are observed as a result of increased pulmonary venous pressure?

Answer 4

breathlessness, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, acute pulmonary edema

Question 5

What are the 2 forms of positional SOB?

Answer 5

Orthopnea: SOB when flat

Paroxysmal nocturnal dyspnea (PND): SOB upon waking up during the night

Question 6

What are the Sx of increased central venous pressure (right sided pressure)?

Answer 6

• peripheral swelling/dependent edema
• Ascites
• hepatic congestion
• intestinal congestion

Question 7

What are some of the precipitating factors producing acute or worsening symptoms?

Answer 7

• Increased circulating volume (preload): sodium load in diet
• Non-adherence with HF medications

Question 8

What are the signs of low flow?

Answer 8

• Cool extremities (peripheral vasoconstriction)
• Tachycardia
• low pulse pressure

Question 9

signs of increased left sided pressure:

Answer 9

• Rales (pulmonary crackles, sounds like velcro)
• Hypoxia
• tachycardia
• Sitting bolt upright

Question 10

Signs of increased right sided pressure:

Answer 10

• edema
• hepatic congestion/hepatomegaly
• Jugular venous distention

Question 11

Jugular distention could be a sign of what?

Answer 11

increased central venous pressure (CVP)

Question 12

T or F: JVP=CVP=R atrial filling pressure

Answer 12

True, assumes no blockage or valve inbetween

Question 13

T or F: triphasic wave form is found in jugular venous pressure

Answer 13

True, a wave= atrial contraction

Question 14

What does the C wave represent?

Answer 14

closing of the tricuspid valve early in systole

Question 15

What does the V wave represent?

Answer 15

Movement of the RV annulus and tricuspid valve backward at the very end of systole

Question 16

What does the A wave represent?

Answer 16

atrial contraction

Question 17

What is the cause of S3?

Answer 17

caused by rapid expansion of the ventricular walls in early diastole

Question 18

What is the cause of S4?

Answer 18

caused by atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic LV

Question 19

What is a summation gallop?

Answer 19

At high heart rates, the S3 and S4 sounds combine to make a single “third” sound.

Question 20

Characteristics of S3

Answer 20

• Can be present in normal young people; abnormal after age 40
• Typical of HFrEF / dilated heart
• Cadence of “Ken-tuc-ky” (S1-S2-S3)

Question 21

Characteristics of S4

Answer 21

• Usually abnormal
• Cadence of “Ten-ne-ssee” (S4-S1-S2)
• Absent in AFIB

Question 22

Basis of The New York Heart Association (NYHA) classification system

Answer 22

based largely on the assessment of symptoms.

Question 23

Basis of The new American College of Cardiology and American Heart Association (ACC/AHA)

Answer 23

focus more on underlying disease and the need to treat early in the disease process, even before overt symptoms of heart failure are present. compliment the NYHA�

Question 24

Co-existing conditions which predispose to HF:

Answer 24

• HEART DISEASE: Coronary, Valve Disease, Hypertension, Other
• CARDIAC RISK DISORDERS: Diabetes, Renal Failure
• ABSENCE OF NON-HF CAUSES OF DYSPNEA

Question 25

DDx for HF S&S:

Answer 25

``` Pulmonary disease (COPD, asthma, pneumonia, pulmonary embolus, primary pulmonary hypertension) Sleep apnea Obesity Deconditioning Anemia Renal failure Hepatic failure Venous stasis / lymphedema Depression ```

Question 26

What is the purpose of doing HF labs/studies?

Answer 26

- Confirm the diagnosis of HF: Rule in HF, Rule out other potential causes - Characterize HF: Type (e.g. systolic v. diastolic), Severity - Assess response to therapy

Question 27

What are the CXR findings in HF?

Answer 27

- Enlarged cardiac silhouette in HFrEF | - Increased upper lobe vascular markings with acute decompensation

Question 28

What is acute pulmonary edema?

Answer 28

- Acute intense shortness of breath | - Occurs once fluid retention / left atrial pressure overwhelms compensatory mechanisms (e.g. lymphatic fluid return)

Question 29

B-type natriuretic is secreted by the myocardium in response to what?

Answer 29

- Primary: ventricular stretch (measure of preload) | - Secondary: hyperadrenergic state, RAAS activation, ischemia

Question 30

What are the 2 forms of BNP assays?

Answer 30

-BNP: Normal? (<100) -NT-proBNP: N-terminus breakdown product of BNP Inactive Half life ~120 minutes (BNP 20 minutes) ~6 times the BNP -Both decrease w/ age

Question 31

Reasons BNP is elevated

Answer 31

HF, PE, Sepsis

Question 32

Clinical use of BNP

Answer 32

- “rule out symptomatic HF” | - negative predictive value of BNP is more useful (a low BNP makes HF unlikely as the cause of symptoms)

Question 33

Can you make a direct Dx of HF by looking at EKG?

Answer 33

No, but you can Infer possibility of HF from other findings

Question 34

What is LVEF?

Answer 34

- L Ventricle ejection fraction, Gross measure of systolic function - Normal = (100 ml – 40 ml) / 100 ml = 60% - HFrEF = (200 ml – 150 ml) / 200 ml = 25%

Question 35

what imaging methods are available to measure LVEF?

Answer 35

Ultrasound (echocardiography) Nuclear (MUGA or SPECT) MRI CT

Question 36

List uses of Echocardiography

Answer 36

Provides: - LVEF (systolic function) - Chamber size (dilation) - LV wall thickness (hypertrophy) - Measures of relaxation (diastology) - Valvular anatomy and function - Estimated filling pressures (LA, CVP) - Estimated pulmonary pressures (pulmonary hypertension)

Question 37

Advantages of Echocardiography

Answer 37

Real time Non-invasive No radiation Relatively “inexpensive”

Question 38

What is Right heart catheterization (Swan-Ganz catheter)?

Answer 38

A plastic catheter introduced into one of the major veins and then “floated” through the right heart into the pulmonary artery. Has a balloon on the end of it to help blood flow carry it into the lungs

Question 39

Use of right heart catheterization (Swan-Ganz catheter)

Answer 39

The balloon also allows a branch of the pulmonary artery to be occluded so that the downstream pressure (post-capillary wedge pressure [PCWP]) can be measured, which is equivalent to the left atrial pressure / left-sided filling pressure.

Question 40

What hemodynamic measure can be obtained from a PA catheter?

Answer 40

- Pressures (CVP/RA, RV, PA, PCWP) - Flow = cardiac output - Fick CO (oxygen consumption measure) - Thermodilution CO (timed flow measure)

Question 41

What is the pressure across a body capillary bed?

Answer 41

ΔP = CO x R ΔP = mean arterial BP – central venous pressure Systemic vascular resistance = ΔP / cardiac output (in woods units)