TOPIC17: acute heart failure (etiology, symptoms, diagnosis)

Question 1

what is AHF?

Answer 1

• abrupt onset and rapid progression, making no time for adaptive and compensatory mechanisms to take place
• medical emergency and high risk for death

Question 2

etiology of AHF

Answer 2

1) Acute coronary syndrome/ CAD
2) Valvular disease - endocarditis/ aortic dissection
3) myopathies
4) arrythmias
5) HTN
6) Non cardiac origin:
- COPD, pulmonary embolism
- drug abuse
- renal failure, volume overload,anemia
- infection, sepsis
- tamponade
- thyrotoxicosis

Question 3

Pathomechanism of AHF

Answer 3

• etiology (mentioned) causes impaired cardiac function –> HF (pump function of the heart impaired, decreased CO
• HF basically causes decreased blood supply to an increased demand
• Decreased CO causes peripheral vasoconstriction–> heart works harder to maintain circulatory homeostasis
• congestion of venous and pulmonary systems causes hypovolemia
• tissue hypoxia due to pulm. congestion and hypovolemia/decreased tissue perfusion
• excess strain to the heart which cannot function properly/at all to meet the demands.

Question 4

Symptoms of RHF

Answer 4

-Due to impaired RV function or due to resistance/obstruction in front of the RV( pulmonary embolism or LVF with backward failure)

signs:

1) peripheral edema and ascites
2) distention/pulsation of neck veins
3) portal HTN with hepatomegaly and GI congestion causing nausea and anorexia
4) facial engorgement, epistaxis, nocturia and depression

Question 5

Symptoms of LHF

Answer 5

-Due to impaired LV function or due to resistance/ obstruction in front of the LV (aortic stenosis or HTN)

signs:

1) pulmonary congestion and edema
2) dyspnea on exertion, orthopnea, paroxismal nocturnal dyspnea
3) decreased SpO2
4) cough and wheezing (Pulm edema)
5) blood in sputum
6) fatigue, muscle wasting, weight loss and poor exercise tolerance
7) cold extremeties

Question 6

Diagnosis of AHF

Answer 6

1)Medical history (family history, symptoms, complaints)

2) Physical examination:
- BP(hypotension), HR(inc) ,JVP, RR,SpO2
- AUSCULTATION: crackles in lungs, S3 gallop, possible murmurs

3) Blood test + ABG:
- BNP and other cardiac markers if MI is the cause
- CRP
- Complete blood count
- electrolytes and glucose
- liver, renal and thyroid parameters

4) ECG:
- Look for hypertrophy/strain signs
- possible arrythmias
- conduction abnormalities
- ischemia/infarction (previous or ongoing)

5)CXR:
-ABCDE for LVF
A: alveolar edema
B: Kerley B-lines (interstitial edema)
C: cardiomegaly
D: Dilated prominent upper lobe vessels
E: pleural effusion

5) ECHO:
- confirms diagnosis
- estimates SV,EF,EDV, wall motion
- shows possible valvular damage or pericardial disease

6) ANGIO:
- in case of coronary causes of HF

(MPBECEA)

7) state/stage use NYHA, Forrester’s hemodynamic stages & clinical classification

Question 7

Killip classification of AHF in AMI

Answer 7

• Low Killip class means pt. is less likely to die within 30 days after MI due to AHF
• High Killip class means pt, is at high risk of dying within 30 days after MI

Class I: no congestive HF
Class II: Rales/Crackles, S3 and pulm. venous HTN( increased JVP)
Class III: Pulm. edema (acute)
Class IV: cardiogenic shock (SBp<90 and evidence of peripheral vasoconstriction) –> oliguria, cold extremities and altered consciousness