HF II - Dx and Tx

Question 1

Major symptoms associated with heart failure due to decreased cardiac output

Answer 1

 FATIGUE
 Symptoms of decreased organ perfusion
 Muscle→fatigue, tiredness/sleepiness
 Gut→anorexia, wasting (cachexia)
 Kidney→↓urine output, renal dysfunction
 Exercise intolerance→inability to augment cardiac output to meet increasing demands of stress/exercise.

Question 2

Major symptoms associated with heart failure due to increased pulmonary venous pressure

Answer 2

 DYSPNEA (breathlessness)
 Dyspnea on exertion
 Orthopnea→SOB when lying flat (blood pooling in legs now pulling in abdomen/thorax)
 Paroxysmal nocturnal dyspnea (PND)→delayed SOB, waking patients from sleep→mobilization of edema from tissue through lymphatics back into blood stream.
 Acute pulmonary edema: acute, intense shortness of breath; occurs once fluid retention/left atrial pressure overwhelms compensatory mechanisms→fluid spills from the pulmonary vasculature into the interstitial space and then into the alveoli→hypoxia
 “fluffy” infiltrates on an CXR

Question 3

Major symptoms associated with heart failure due to increased central venous pressure

Answer 3

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

Question 4

New York Heart Association Functional Class

Answer 4

o I: asymptomatic
o II: symptomatic with moderate exertion
o III: symptomatic with minimal exertion
o IV: symptomatic at rest

Question 5

ACC/AHA HF Stage

Answer 5

o A: At high risk for heart failure but without structural heart disease or symptoms of heart failure
o B: Structural heart disease but without symptoms of heart failure.
o C: Structural heart disease with prior or current symptoms of heart failure.
o D: refractory heart failure requiring specialized interventions

Question 6

Common precipitants of worsening heart failure

Answer 6

o Increased circulating volume (Preload)→sodium load in diet, renal failure
o Increased pressure (afterload)→uncontrolled hypertension (LV), worsening aortic stenosis (LV), pulmonary embolism (RV)
o Worsened contractility (inotropy)→myocardial ischemia, initiation of negative inotrope (beta-blocker or calcium channel blocker)
o Arrhythmia (rate)→bradycardia, atrial fibrillation
o Increased metabolic demands→fever, infection, anemia, hyperthyroidism, pregnancy
o NON-ADHERENCE WITH HF MEDICATIONS

Question 7

Variable clinical course of heart failure

Answer 7

o HF is marked by a non-linear course. It is typically marked by episodic exacerbations with significant symptoms (sometimes requiring hospitalization), with intervening periods of relative stability. Patients rarely stay at a singly NYHA class over time; they may move between functional classes depending on a number of factors that dictate cardiac function and symptomatology. However, the usual course is an average of progressive decline over time.

Question 8

Physical signs of heart failure and their relation to underlying pathology: Signs of low flow:

Answer 8

 Cool extremities—peripheral vasoconstriction to redirect what existing blood flwo there is to vital organs.
 Tachycardia—compensate for low stroke volume
 Low pulse pressure—reflection of low output.

Question 9

Physical signs of heart failure and their relation to underlying pathology: Signs of elevated left-sided filling pressures

Answer 9

	rales (pulmonary crackles)—fluid in the lungs, wet alveoli opening.
	Hypoxia
	Tachypnea
	Sitting bolt upright
	Popping open of alveoli

Question 10

Physical signs of heart failure and their relation to underlying pathology: Signs of elevated right-sided pressures

Answer 10

 Edema—dependent=follows gravity
 Hepatic congestion/hepatomegaly
 Jugular venous distention (JVD) = ↑ central venous pressure
 JVP = CVP = right atrial pressure
 Normal < 5 cm H2O.
 With a person lying flat or a person with JVD in HF, the jugular vein (internal and external) will 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, visible fluctuations in the vein size and in the meniscus.

Question 11

Physical signs of heart failure and their relation to underlying pathology: Gallops

Answer 11

 S3 gallop—rapid expansion of the ventricular walls in early diastole
 HFrEF/dilated heart
 Ken-tuc-ky (S1-S2-S3)
 S4 gallop—atria contracting forcefully in an effort to overcome abnormally stiff or hypertrophic LV
 Ten-ne-ssee (S4-S1-S2)

Question 12

Natriuretic peptides

Answer 12

 B-type natriuretic (BNP) is secreted by the myocardium in response to
 Primary: ventricular stretch
 Secondary: hyperadrenergic state, RAAS activation, ischemia
 BNP: cutoff for diagnosis is relative (100 pg/mL)
 NT-proBNP: n-terminus breakdown product of BNP (sticks around longer and easier to measure)
 Use of BNP/NT-proBNP: clinically used to rule out HF, very unlikely that you have HF if you have a low BNP. Hard to rule-in, lots of causes (even ones associated secondarily with HF) that can raise BNP

Question 13

CXR:

Answer 13

 Enlarged cardiac silhouette in HFrEF
 ↑upper lobe vascular markings with acute decompensation
 fluffy infiltrates of pulmonary edema
 pleural effusions

Question 14

Electrocardiogram (EKG)

Answer 14

 No direct diagnosis of HF
 Infer possibility of HF from other findings
 Q waves—prior MI
 Increased voltage—LVH
 Arrhythmia (AF, PVCs), non-sustained ventricular tachycardia (NSVT)

Question 15

Echocardiography

Answer 15

 Provides: LVEF, chamber size (dilation), LV wall thickness (hypertrophy), measures of relaxation (diastology), valvular anatomy and function, filling pressures, pulmonary pressures.
 Advantages: real time, non-invasive, no radiation, inexpensive

Question 16

Right heart catheterization

Answer 16

o A plastic catheter is placed into a major vein and floated through the right heart and into the pulmonary artery. A balloon on the end helps blood flow carry it to the lungs.
 Balloon allows a branch of the pulmonary artery to be occluded so that the downstream pressure can be measured = left atria pressure / left sided filling pressure.
o Measure pressures—CVP/RA, RV, PA, PCWP
o Measure flow/CO
o Resistances can be calculated from pressures and flow