Heart Failure II: Diagnosis & Treatment Flashcards
What are the three major symptoms of HF and what causes them?
- Fatigue (low CO)
- Breathlessness (Increased pulmonary venous pressure)
- Edema (increased central venous pressure)
What different systemic symptoms will someone with low flow experience?
- sleepiness, confusion (less cerebral perfussion)
- fatigue, weakness (less muscle perfusion)
- anorexia, wasting (less GI perfusion)
- reduced urine (less kidney perfusion)
Why would a patient with left sided pressure have difficulty breathing?
Increased left sided pressure leads to increased pulmonary venous pressure
What is orthopnea and what causes it?
immediate SOB when lying flat
-from lost venous pooling of blood in legs
What about PND (paroxysmal nocturnal dyspnea)?
SOB waking patients from sleep
- relates to mobilization of edema from tissue through lymphatics back into the blood stream
- patients have to get out of bed and walk to relieve symptoms
Your patient has peripheral swelling, ascites, and hepatic/ intestinal congestion. What’s wrong?
RV failure causing increased central venous pressure
Why do patients get edema?
Hydrostatic pressure (fluid leaving blood) is much greater than encotic pressure (fluid returning to blood) which builds up in tissues
What NYHA functional class is a patient that is symptomatic with moderate exertion?
Class II
What NYHA functional class is a patient who is symptomatic at rest?
Class IV
Class I: asymptomatic
Class II: symptomatic with moderate exercise
Class III: symptomatic with minimal exercise
What ACC/ AHA Stage (letters) is someone at high risk for heart failure but without structural heart disease or symptoms of heart failure (ie. hypertension, coronary heart disease)?
Stage A
What ACC/ AHA Stage (letters) is someone with structural heart disease with prior or current symptoms of heart failure?
Stage C
Stage A: high risk, no structural changes/ symptoms
Stage B: structural heart change, no symptoms
Stage D: heart failure requiring specialized intervention
What would be the goal of therapy for your patient who had a previous MI (stage B)?
- prevent symptoms
- prevent further remodeling
Your patient has heart failure. What precipitating factors are you worried about that would worsen the condition?
- Increased preload = Na in diet, renal failure
- increased afterload = hypertension, stenosis, PE
- worsened inotropy = MI, beta blocker
- arrythmia = bradycardia, A fib
- ^ metabolic demands = fever, anemia, pregnancy
- NON COMPLIANCE WITH MEDS
You suspect your patient has low flow from underlying HF. What signs are you looking for? why?
- Cold extremities: vasoconstriction to redirect blood flow
- Tachycardia: compensate for low SV
- Low pulse pressure: reflection of low output
While auscultating a patient you hear sounds in the lung that sound like velcro. What is that called? What causes it?
Rales
-Due to wet alveoli opening (fluid in lungs from ^ left-sided pressure)
What else would you expect to see with increased left-sided pressure?
- Hypoxia
- Tachypnea
- Sitting bolt upright
**Lung problems
In addition to edema and hepatomegaly, what else would you look for with a patient with suspected increased right-sided pressure?
Jugular Venous Distension (JVD)
-usually
What are the 3 different waves on the jugular venous pressure diagram?
A wave: atrial contraction
C wave: closing of tricuspid valve (beginning of RV systole)
V wave: movement of RV annulus and tricuspid valve backwards (end of RV systole)
Tom is 25 years old. After listening to his heart you hear a S1-S2-S3 abnormal sound with the cadence of “kentucky”. What is this called? Is this concerning?
S3 gallop
No. Abnormal in people > 40 yrs
What causes an S3 gallop?
- Thought to be caused by rapid expansion of ventricular walls in early diastole (as blood Slosh-ing-in to ventricle)
- Typical in HFrEF / DILATED heart
You hear an abnormal sound with the cadence of “Tennessee”. What is it?
S4 gallop (S4-S1-S2)
- caused by atria contracting against LV
- usually abnormal
- becomes louder the STIFFER the LV
What do you call the gallop that occurs in tachycardia and combines S3/ S4 to one loud diastolic sound?
Summation gallop
Regurgitation AV murmurs are common with what condition?
HFrEF
If someone has HF, what other comorbitities are you worried about?
Coronary disease, valve disease, hypertension
Diabetes, renal failure
*if a patient has none of these but has shortness of breath, you should think of something besides HF
Okay, but if they still have SOB, what other things are on your differential diagnosis?
- Pulmonary disease (COPD, asthma, pneumonia, PE)
- Sleep apnea
- obesity
- deconditioning
- anemia
- renal/hepatic failure
- venous stasis
- depression
What sorts of tests/ procedures should you order to rule in HF?
- Echocardiogram
- 12 lead ECG
- Blood chemistry
- CBC
- Natriuretic peptide measurement
- chest x ray
Also helpful: cardiac MRI, coronary angiography, myocardial perfusion imaging, right heart catheterization, exercise testing
An old guy goes to a brazilian steakhouse and shows up in the ER. What would you find on the chest x-ray?
=Fluid in alveoli (acute pulmonary edema)
Chest x-ray could also show enlarged heart in HFrEF
What are B-type natriuretic peptides (BNP)?
Naturally secreted by myocardium in response to ventricular stretch (measure of preload)
Secondary: hyperadrenergic state, RAAS activation
What are the uses of BNP assays?
Elevations are mostly due to HF
-BUT negative predictive value is more useful (low BNP makes HF unlikely as diagnosis)
T/F: EKG’s are used to diagnose HF
False
-infer possibility of HF from other findings
Your patient with HFrEF has an end-diastolic volume of 200ml, and an end-systolic volume of 150 ml. Calculate the ejection fraction? Is this number concerning?
25% (normal is 60%)
EF = (ED volume - ES volume) / ED volume
**Not too concerning. Could have higher volumes from cardiac dilation, but the SV doesn’t change much
There’s a big list of things that an echocardiogram can do if you want to look (they’re intuitive), but what are the advantages?
- Real time
- Non-invasive
- No radiation
- relatively inexpensive
How does the Swanz-Ganz catheterization work?
Plastic catheter with a balloon that you run down a vein to measure flow/ pressure in heart/ lungs
What hemodynamic measures can you get from a PA catheter or Swanz-Ganz?
Pressure
Flow
=>Calculate resistance!
Arterial BP = CO x R
[like V = IR]
