Heart Failure II - Diagnosis & Treatment (complete)

Question 1

What are the major symptoms associated with heart failure as it relates to decreased cardiac output?

Answer 1

Fatigue

• Symptoms of decreased organ perfusion
• Decreased muscle perfusion (Fatigue, tiredness, sleepiness)
• Decreased gut perfusion (Anorexia, wasting)
• Decreased kidney perfusion (reduced urine output, progressive renal dysfunction/cardiorenal syndrome)
• exercise intolerance (inability to augment CO to meet increasing demands)

Question 2

What are the major symptoms associated with heart failure as it relates to increased pulmonary venous pressure?

Answer 2

• Dyspnea on exertion
• Orthopnea (SOB when lying flat)
• Paroxysmal nocturnal dyspnea (PND) => delayed SOB, waking pts from sleep
• Acute pulmonary edema

Question 3

Describe orthopnea

Answer 3

Lost venous blood pooling in legs

Question 4

Describe PND

Answer 4

• Classically pts gets out of bed => walks around to relieve symptoms
• mobilization of edema from tissue through lymphatics back to blood stream

Question 5

What are the major symptoms associated with heart failure as it relates to increased central venous pressure?

Answer 5

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

Question 6

Describe the New York Heart Association Functional Classes

Answer 6

I: Asymptomatic
II: Symptomatic w/ moderate exertion
III: Symptomatic w/ minimal exertion
IV: Symptomatic at rest

Question 7

Describe the ACC/AHA Heart Failure Stages

Answer 7

A: At high risk for HF but w/o structural heart disease or symptoms of HF (e.g. pts w/ HTN or CAD)

B: Structural heart disease but w/o symptoms of HF

C: Structural heart disease with prior or current symptoms of HF

D: Refractory HF requiring specialized interventions

Question 8

What are the precipitating factors which make HF symptoms worse?

Answer 8

Increased circulating volume (preload)

• Na load in diet
• Renal failure

Increased pressure (afterload)

• Uncontrolled HTN (LV)
• Worsening aortic stenosis
• PE (RV)

Worsened contractility (inotropy)

• myocardial ischemia
• Initiation of negative inotropy (B-blocker, CCB)

Arrhythmia

• Bradycardia
• A Fib

Increased metabolic demands
- Fever, infection, anemia, hyperthyroidism, preggers

Non-adherence w/ HF meds IMPORTANT

Question 9

Describe the variable clinical course of HF

Answer 9

• A non-linear course
• Usually episodic exacerbations w/ significant symptoms
• Pts rarely stay at a single NYHA class over time
• Usual course: progressive decline over time

Question 10

What are the signs of low flow?

Answer 10

• Cool extremities
• Tachycardia
• Low pulse pressure

Question 11

Why are cool extremities a sign of low flow?

Answer 11

• peripheral vasoconstriction

- redirects existing blood flow to vital organs (rather than periphery)

Question 12

Why is tachycardia a sign of low flow?

Answer 12

Shows compensation for low SV

Question 13

Why is low pulse pressure a sign of low flow?

Answer 13

Reflects low output

Question 14

What are the signs of elevated left-sided filling pressures?

Answer 14

• Rales (fluid in lungs, wet aveoli)
• Hypoxia
• Tachypnea
• Sitting bolt upright
• Popping open of alveoli

Question 15

What are the signs of elevated right-sided pressures?

Answer 15

• Edema (follow gravity => legs, sacrum, scrotum)
• Hepatic congestion
• Hepatomegaly
• Jugular venous distention (JVD)

Question 16

Describe jugular venous distention

Answer 16

• Indicates an increased of central venous pressure

- When person is lying flat jugular vein will appear full => transmits pressure changes in RA as waves

Question 17

Describe S3 gallops as a sign for heart failure

Answer 17

• rapid expansion of ventricular walls in early diastole
• HFrEF/dilated heart
• Ken-tuc-key (S1-S2-S3)

Question 18

Describe S4 gallops as a sign for heart failure

Answer 18

• atria contracting forcefully in an effort to overcome abnormally stiff or hypertrophic LV
• Ten-ne-ssee (S4-S1-S2)

You CANNOt have S4 w/o coordinated atrial contraction

Question 19

What types of imaging studies are most helpful in making a diagnosis of HF?

Answer 19

• Chest X-Ray
• EKG
• Echocardiogram

Question 20

How are CXR used to diagnose HF?

Answer 20

• Show enlarged cardiac silhouette in HFrEF
• Increased upper lobe vascular markings w/ acute decompensation
• Fluffy infiltrates of pulm edema
• pleural effusions

Question 21

How are EKGs used to diagnose HF?

Answer 21

• No direct diagnosis possible
• Can infer HF from other findings
• Q waves: prior MI
• Increased voltage: LVH
• Arrhythmia

Question 22

How are echos used to diagnose HF?

Answer 22

You can get this info from echos:

• LVEF
• Chamber size
• LV wall thickness
• Measures relaxation
• Valvular anatomy/function
• fillings pressures
• pulmonary pressures

Real time, non-invasive, no radiation, inexpensive

Question 23

Describe right heart catheterization as a way to diagnose HF

Answer 23

• Plastic catheter put into major veins => floated through right heart into pulm a.
• Has balloon on end
• Measures pressures: CVP/RA, RV, PA, PCWP
• Measures flow, CO
• Resistances can be calculated from the above info

Question 24

Describe natriuretic peptides

Answer 24

Secreted by myocardium in response to:

• Primary: ventricular stretch
• Secondary: hyperadrenergic state, RAAS activation, ischemia

Question 25

How is BNP used to diagnose HF?

Answer 25

• Measured to rule out HF IMPORTANT (think pertinent negatives)
• Normal levels = <100 pg/mL
• unlikely to have HF with low BNP levels
• inconclusive at high levels