Heart Failure II -Clinical Manifestations & Dx Flashcards
What are the 3 major Sx in HF?
- Decreased cardiac output: Sx of decreased organ perfusion
- Increased pulmonary venous pressure: breathlessness
- increased venous pressure: edema
Sx of reduced cerebral perfusion?
Sleepiness and confusion
sx of reduced gut perfusion?
Anorexia and wasting (cachexia)
What Sx are observed as a result of increased pulmonary venous pressure?
breathlessness, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, acute pulmonary edema
What are the 2 forms of positional SOB?
Orthopnea: SOB when flat
Paroxysmal nocturnal dyspnea (PND): SOB upon waking up during the night
What are the Sx of increased central venous pressure (right sided pressure)?
- peripheral swelling/dependent edema
- Ascites
- hepatic congestion
- intestinal congestion
What are some of the precipitating factors producing acute or worsening symptoms?
- Increased circulating volume (preload): sodium load in diet
- Non-adherence with HF medications
What are the signs of low flow?
- Cool extremities (peripheral vasoconstriction)
- Tachycardia
- low pulse pressure
signs of increased left sided pressure:
- Rales (pulmonary crackles, sounds like velcro)
- Hypoxia
- tachycardia
- Sitting bolt upright
Signs of increased right sided pressure:
- edema
- hepatic congestion/hepatomegaly
- Jugular venous distention
Jugular distention could be a sign of what?
increased central venous pressure (CVP)
T or F: JVP=CVP=R atrial filling pressure
True, assumes no blockage or valve inbetween
T or F: triphasic wave form is found in jugular venous pressure
True, a wave= atrial contraction
What does the C wave represent?
closing of the tricuspid valve early in systole
What does the V wave represent?
Movement of the RV annulus and tricuspid valve backward at the very end of systole
What does the A wave represent?
atrial contraction
What is the cause of S3?
caused by rapid expansion of the ventricular walls in early diastole
What is the cause of S4?
caused by atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic LV
What is a summation gallop?
At high heart rates, the S3 and S4 sounds combine to make a single “third” sound.
Characteristics of S3
- Can be present in normal young people; abnormal after age 40
- Typical of HFrEF / dilated heart
- Cadence of “Ken-tuc-ky” (S1-S2-S3)
Characteristics of S4
- Usually abnormal
- Cadence of “Ten-ne-ssee” (S4-S1-S2)
- Absent in AFIB
Basis of The New York Heart Association (NYHA) classification system
based largely on the assessment of symptoms.
Basis of The new American College of Cardiology and American Heart Association (ACC/AHA)
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�
Co-existing conditions which predispose to HF:
- HEART DISEASE: Coronary, Valve Disease, Hypertension, Other
- CARDIAC RISK DISORDERS: Diabetes, Renal Failure
- ABSENCE OF NON-HF CAUSES OF DYSPNEA
DDx for HF S&S:
Pulmonary disease (COPD, asthma, pneumonia, pulmonary embolus, primary pulmonary hypertension) Sleep apnea Obesity Deconditioning Anemia Renal failure Hepatic failure Venous stasis / lymphedema Depression
What is the purpose of doing HF labs/studies?
- 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
What are the CXR findings in HF?
- Enlarged cardiac silhouette in HFrEF
- Increased upper lobe vascular markings with acute decompensation
What is acute pulmonary edema?
- Acute intense shortness of breath
- Occurs once fluid retention / left atrial pressure overwhelms compensatory mechanisms (e.g. lymphatic fluid return)
B-type natriuretic is secreted by the myocardium in response to what?
- Primary: ventricular stretch (measure of preload)
- Secondary: hyperadrenergic state, RAAS activation, ischemia
What are the 2 forms of BNP assays?
-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
Reasons BNP is elevated
HF, PE, Sepsis
Clinical use of BNP
- “rule out symptomatic HF”
- negative predictive value of BNP is more useful (a low BNP makes HF unlikely as the cause of symptoms)
Can you make a direct Dx of HF by looking at EKG?
No, but you can Infer possibility of HF from other findings
What is LVEF?
- 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%
what imaging methods are available to measure LVEF?
Ultrasound (echocardiography)
Nuclear (MUGA or SPECT)
MRI
CT
List uses of Echocardiography
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)
Advantages of Echocardiography
Real time
Non-invasive
No radiation
Relatively “inexpensive”
What is Right heart catheterization (Swan-Ganz catheter)?
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
Use of right heart catheterization (Swan-Ganz catheter)
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.
What hemodynamic measure can be obtained from a PA catheter?
- Pressures (CVP/RA, RV, PA, PCWP)
- Flow = cardiac output
- Fick CO (oxygen consumption measure)
- Thermodilution CO (timed flow measure)
What is the pressure across a body capillary bed?
ΔP = CO x R
ΔP = mean arterial BP – central venous pressure
Systemic vascular resistance = ΔP / cardiac output (in woods units)
