Heart Failure II - Diagnosis & Treatment

Question 1

3 major pathophysiology causes of HF

Answer 1

↓ Cardiac output
↑ Pulmonary venous pressure
↑ Central venous pressure (Right-sided)

Question 2

Decreased CO (low flow) can result in what 5 major effects

Answer 2

↓ cerebral perfusion

↓ muscle perfusion

↓ gut perfusion

↓ kidney perfusion

exercise intolerance

Question 3

INCREASED LEFT-SIDED FILLING PRESSURES = ??

And how can that present?

Answer 3

↑ Pulmonary venous pressure

• Breathlessness (dyspnea)
• Dyspnea on exertion

Question 4

In HF what one major cost of a small increase in stroke volume?

Answer 4

LARGE RISE IN END-DIASTOLIC PRESSURE

Question 5

Orthopnea

Answer 5

Immediate SOB when lying flat

Relates to lost venous pooling of blood in the legs

Question 6

Paroxysmal nocturnal dyspnea (PND)

• what is it?
• how is it resolved?

Answer 6

attacks of severe shortness of breath and coughing that generally occur at night

– Delayed SOB, which wakes patients from sleep
– Classically patient gets out of bed and ambulates to relieve symptoms
– Relates to mobilization of edema from tissue through lymphatics back into blood stream

Question 7

Acute pulmonary edema

• what is it?
• symptom?
• x - ray findings?

Answer 7

– Occurs once fluid retention / left atrial pressure overwhelms compensatory mechanisms (e.g. lymphatic fluid return)
– Fluid spills from the pulmonary vasculature into the interstitial space and then into the alveoli, producing hypoxia

– Acute intense shortness of breath
– Increase vascular prominence on CXR (chest x ray) first, followed by“fluffy” infiltrates

Question 8

INCREASED RIGHT-SIDED FILLING PRESSURES = ?

Answer 8

• Peripheral swelling / dependent edema
• Ascites
• Hepatic congestion
• Intestinal congestion (protein-losing enteropathy)

Question 9

SIGNS OF ELEVATED LEFT-SIDED FILLING PRESSURES

Answer 9

  Rales (pulmonary crackles)
    - Sounds like Velcro pulling apart on inspiration, Due to wet alveoli opening
 Hypoxia
 Tachypnea
 Breath better Sitting bolt upright
 Popping open of alveoli

Question 10

SIGNS OF ELEVATED RIGHT-SIDED PRESSURES

Answer 10

 Edema
= follows gravity (legs, sacrum, scrotum)
 Hepatic congestion / hepatomegaly
 Jugular venous distention (JVD) = ↑ central
venous pressure (CVP)

Question 11

Normal JVP vs abnormal

Answer 11

Normal is < 5 cm H2O, so jugular vein is typically collapsed – with a person standing up, only the carotid pulsation should be visible (brisk upstroke during systole only)

 With a person with JVD in HF, the jugular vein (internal and external) fill with blood. Thus the neck veins will appear full on visual examination. More importantly, they will transmit pressure changes in the right atrium as waves.

Question 12

S3 cause by?

• what is it?
• type of HF?
• cadence

Answer 12

S3 gallop is thought to be caused by rapid expansion of the ventricular walls in early diastole
- Typical of HFrEF / dilated heart
 Cadence of “Ken-tuc-ky” (S1-S2-S3)

Question 13

S4 cause by?

• what is it?
• type of HF?
• cadence

Answer 13

S4 gallop is caused by atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic LV
 Usually abnormal
 Cadence of “Ten-ne-ssee” (S4-S1-S2)
 By definition, absent in atrial fibrillation

Question 14

CHEST RADIOGRAPHY (CXR)
in HF

Answer 14

• Enlarged cardiac silhouette in HFrEF
• Increased upper lobe vascular markings with acute decompensation
• Fluffy infiltrates of pulmonary edema (not on this image)
• Pleural effusions

Question 15

B-type natriuretic (BNP) is secreted by the myocardium in response to

Answer 15

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

Question 16

Ejection Fraction (EF)

Answer 16

END-DIASTOLIC – END SYSTOLIC VOLUME
_________________________
END-DIASTOLIC VOLUME

*note EDV-ESV = SV

Question 17

SV with regards to ESV and EDV

Answer 17

SV = EDV-ESV

Question 18

RIGHT HEART CATHETERIZATION

Answer 18

AKA Pulmonary Artery (PA) Catheter, or a Swan-Ganz catheter (or “Swan”)

• A plastic catheter introduced into one of the major veins and then “floated” through the right heart into the pulmonary artery

Question 19

Hemodynamic equivalent of Ohms law

Answer 19

V=IR
ΔP = CO x R

*note: ΔP = mean arterial BP – central venous pressure

Question 20

Difference betwn Diuretics and vasodilators

Answer 20

Diuretics are used to keep volume normal (sodium retention is common)

Vasodilators are used to maintain normal blood pressure