CVPR 03-27-14 09-10am Heart Failure-Diagnosis - Allen

Question 1

HF symptoms associated with decreased Cardiac Output

Answer 1

Decreased organ perfusion, FATIGUE

Question 2

HF symptoms associated with increased Pulmonary Venous Pressure (Left-sided)

Answer 2

—> increases pressure in the lungs —> Breathlessness (DYSPNEA)

Question 3

HF symptoms associated with increased Central Venous Pressure (Right-sided)

Answer 3

Edema (ascites, pleural edema/effusion, swelling in ankles/legs)

Question 4

HF symptoms associated with Low Flow

Answer 4

1. Decreased cerebral perfusion (sleepiness, confusion); 2. Decreased muscle perfusion (fatigue, weakness); 3. Decreased gut perfusion (anorexia, wasting/cachexia); 4. Decreased kidney perfusion (RAAS activation, reduced urine output, progressive renal dysfunction)

Question 5

HF symptoms associated with increased Left-Sided Pressure

Answer 5

Increased Pulmonary venous pressure –> breathlessness (dyspnea), dyspnea on exertion, orthopnea (dyspnea when lying flat), paroxysmal nocturnal dyspnea, acute pulmonary edema

Question 6

Positional Shortness of Breath - Orthopnea

Answer 6

Immediate SOB when lying flat; in HF, relates to lost venous pooling of blood in legs —> when lie down, no longer gravity working against heart —> rt. atrial filling pressure immediately goes up —> rt. ventricular contractions thus go up, pushing more blood to lt side —> if lt. ventrical is already stiff w/ already high pressure, back up of pressure in lungs

Question 7

Positional Shortness of Breath -Paroxysmal nocturnal dyspnea (PND)

Answer 7

Delayed SOB, waking pts from sleep; classically relieved by pt getting out of bed & ambulating; relates to mobilization of edema from tissue through lymphatics back into blood stream (over the day, gravity pools fluid in lower extremities, increasing pressure & causing edema; when lie flat, no longer this pressure –> fluid leaches back into veins over time, increasing venous pressure –> increases preload & thus rt. ventricular contraction, filling of dysfunctional lt side, pressure build up in lungs (but delayed b/c fluid must leach back in)

Question 8

HF symptoms associated with increased Right-Sided Pressure

Answer 8

Increased central venous pressure (RV failure) —> Peripheral swelling/dependent edema, Ascites, Hepatic congestion, Intestinal congestion (protein-losing enteropathy)

Question 9

Edema in HF

Answer 9

Increased central venous pressure (CVP) upsets the balance of Starling forces: Ventricular dysfunction —> Increased filling/venous pressure —> Hydrostatic pressure pushing water out of veins is greater than normal so that oncotic pressure can’t make up for it & pull water back into veins —> Edema

Question 10

Precipitating factors producing acute or worsening symptoms in HF

Answer 10

1. Increased circulating volume (preload)…..2. Increased pressure (afterload)…..3. Worsened contractility (inotropy)…..4. Arrhythmia (rate)…..5. Increased metabolic demands…..6. Non-adherence with HF meds!!!

Question 11

Factors that increase circulating volume (preload) & thus exacerbate HF

Answer 11

SODIUM LOAD IN DIET; Renal failure

Question 12

Factors that increase pressure (afterload)) & thus exacerbate HF

Answer 12

Uncontrolled HTN (LV); Worsening aortic stenosis (LV); Pulmonary embolism

Question 13

Factors that worsened contractility (inotropy) & thus exacerbate HF

Answer 13

Myocardial ischemia; Initiation of negative inotrope (beta-blocker, calcium channel blocker)

Question 14

Factors related to Arrhythmias (rate) that thus exacerbate HF

Answer 14

Bradycardia, Atrial fibrillation

Question 15

Factors that increase metabolic demands & thus exacerbate HF

Answer 15

Fever/infection, Anemia, Hyperthyroidism, Pregnancy

Question 16

NYHA HF rating

Answer 16

Based on assessment of symptoms: I Asymptomatic….II Symptomatic w/moderate exertion….III Symptomatic w/minimal exertion (going up flight of stairs)…..IV Symptomatic at rest

Question 17

American College of Cardiology and American Heart Association (ACC/AHA HF) Stages

Answer 17

A – High risk for HF (HTN, CAD) but w/out structural heart disease or symptoms of HF….. B – Structural heart disease but w/out symptoms of HF….. C – Structural heart disease w/prior or current symptoms of HF….. D – Refractory HF requiring specialized interventions…. Can move between stages (can move from C after a salty meal, back to B with treatment, etc)

Question 18

Importance of Symptoms

Answer 18

Symptoms decrease quality of life, define the severity of the disease (which is one of the strongest predictors of death in HF), often determine therapy (e.g., more aggressive therapies for more advanced disease); Can treat heart disease before HF develops & prevent it!

Question 19

Clinical Course of HF

Answer 19

Nonlinear; Can look really bad after a big salty meal (Class C), but then go back to Class B w/no symptoms after treatment

Question 20

Signs of Low Flow in HF

Answer 20

1. Cool extremities (peripheral vasoconstriction to redirect scant existing blood flow to vital organs)….. 2. Tachycardia (Compensation for low SV)….. 3. Low pulse pressure = difference btwn systolic & diastolic pressure (reflection of low output; in late HF, go from HTN to Hypotension = bad sign of advanced disease)

Question 21

Signs of Increase Left-Sided Pressure in HF

Answer 21

1. Rales (pulmonary crackles, like Velcro, due to wet alveoli opening)….. 2. Hypoxia….. 3. Tachypnea….. 4. Sitting bolt upright (b/c of orthopnea, etc., & to optimize their lung capacity = tripod position)

Question 22

Signs of Increased Right-Sided Pressure in HF

Answer 22

1. Edema (follow gravity – lefts, sacrum, scrotum)…..2. Hepatic congestion / hepatomegaly….. 3. Jugular venous distention (JVD)

Question 23

Jugular venous pressure – defn.

Answer 23

JVP = CVP (central venous pressure ) = right atrial filling pressure………..Assuming no blockage or valve between; Normal is <5cm H20, so typically collapsed & not raised

Question 24

Jugular venous distension

Answer 24

= Increased central venous pressure (CVP) —> fills up normally collapsed jugular vein; measurement of rt atrial filling pressure

Question 25

Jugular venous pressure – Waves

Answer 25

Triphasic wave (distinguish from carotid): ….. A wave: atrial contraction; ….. C wave: closing of the tricuspid valve early early in systole; ….. V wave: movement of the RV annulus & tricuspid valve backward at the very end of systole (before the valve opens)

Question 26

Normal heart sounds

Answer 26

The sound made as the valves shut closed; S1 = lub = Mitral & Tricuspid….. S2 = dub = Aortic & Pulmonary

Question 27

Heart sounds in HF

Answer 27

In normal heart, lub-dub (S1, S2); In HF, Gallops (extra heart sounds due to abnormal heart)

Question 28

Gallops – S3

Answer 28

Thought to be caused by rapid filling/expansion of the ventricular walls in early diastole; Can be present in normal young people, but abnormal after age 40; Typical of HFrEF / dilated heart; Cadence of “Ken-tuc-ky” (S1-S2-S3, lub-dub-dub, S3 right after S2)

Question 29

Gallop - S4

Answer 29

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, dub-lub-dub, S4 right before S1); Absent in AFIB

Question 30

Gallop - “Summation gallop”

Answer 30

All 4 (S1-S2-S3-S4), S3 & S4 come together as loud sound?

Question 31

Keys to HF diagnosis

Answer 31

Hx (symptoms); PE (signs); Labs (testing)…Consider other possibilities (DDx) to help guide the evaluation

Question 32

Typical symptoms of HF

Answer 32

Breathlessness, Orthopnea, Paroxysmal nocturnal dyspnea [pretty specific to HF], Reduced exercise tolerance, fatigue, tireness, increased time to recover after exercise, ankle swelling

Question 33

Typical Signs of HF

Answer 33

Elevated jugular venous pressure, Hepatojugular reflux, Third heart sound (gallop rhythm), Laterally displaced apical impulse; Cardiac murmur

Question 34

Less typical symptoms of HF

Answer 34

Nocturnal cough, Wheezing, Weight gain (>2kg/wk), Weight loss (in advanced HF), Bloated feeling, Loss of appetite, Confusion (esp. in elderly), Depression, Palpatations, Syncope

Question 35

Less typical signs of HF

Answer 35

Peripheral edema (ankle, sacral, scrotal), Pulmonary crepitations, Reduced air entry & dullness to percussion at lung bases (pleural effusion), Tachycardia, Irregular pulse, Tachypnea (>16 breathes/min), Hepatomegaly, Ascites, Cachexia

Question 36

Relevant comorbidities of HF – Co-existing conditions which predispose to HF

Answer 36

Heart Disease (Coronary, Valve Disease, HTN, Other); Cardiac Risk Disorders (Diabetes, Renal Failure, etc.); Absence of Non-HF causes of dyspnea

Question 37

Differential Dx for HF signs & symptoms

Answer 37

Short of breath, tired, swelling <— Pulmonary disease (COPD, asthma, pneumonia, PE, primary pulmonary HTN)…..Sleep apnea…..Obesity…..Deconditioning…..Anemia…..Renal failure…..Hepatic failure…..Venous stasis / lymphedema….. Depression

Question 38

Purpose of Studies/Tests to Dx HF

Answer 38

1. Confirm Dx (Rule in / out HF vs. other potential causes); Characterize HF (Type, such as systolic or diastolic, and Severity); Assess response to therapy

Question 39

Chest radiography (CXR) in HF

Answer 39

Enlarged cardiac silhouette in HFrEF; Increased upper lobe vascular markings w/acute decompensation; Acute pulmonary effusion OR High EF

Question 40

Acute pulmonary edema – what is it

Answer 40

Acute intense shortness of break; occurs once fluid retention / left atrial pressure overwhelms compensatory mechanisms (e.g. lymphathic fluid return)

Question 41

Natriuretic peptide (BNP) – when released

Answer 41

B-type natriuretic is secreted by the myocardium in response to 1. Primary: ventricular stretch (measure of preload) and 2. Secondary: hyperadrenergic state, RAAS activation, ischemia

Question 42

Assays for Natriuretic Peptides (BNP)

Answer 42

Two assays (Both Increase W/Age) : 1. BNP - Normal? (<100; depends on pt)….. 2. NT-proBNP - N-terminus breakdown product of BNP, Inactive, Half life ~120 minutes (BNP 20 minutes), ~6 times the BNP

Question 43

Diagnostic use of BNP (Natriuretic Peptide Assay)

Answer 43

Best at ruling out HF through low (normal) BNP [negative predictive value] or assessing whether chronic HF is the reason for acute symptoms (less helpful to determine acute HF) ….1. Elevations most often due to HF (Other reasons ↑BNP include sepsis, PE, etc.)….. 2. Clinically = “rule out symptomatic HF” in pts w/chronic HF (decide if an elevated BNP is less useful to determine if new dyspnea is from acute HF decompensation or from some other process (e.g. COPD exacerbation)…..Thus the negative predictive value of BNP is more useful– a low BNP makes HF unlikely as the cause of symptoms)

Question 44

EKG in HF

Answer 44

No direct Dx of HF; Infer possibility of HF from other findings – Prior MI (e.g. Q waves), LVH (increased voltage), Diffuse conduction disease from fibrosis or myocardial damage (e.g. LBBB), Arrhythmia (AFib, ventricular ectopy)

Question 45

Ejection Fraction equation

Answer 45

(END-DIASTOLIC - END SYSTOLIC VOLUME) / END-DIASTOLIC VOLUME….. EX: Normal = (100 ml – 40 ml) / 100 ml = 60% ………. HFrEF = (200 ml – 150 ml) / 200 ml = 25% [Dilated & reduced SV)

Question 46

Cardiac imaging for LVEF

Answer 46

EF= Gross measure of systolic function [Normal = ~60%]…….Methods of measurement: Ultrasound (echocardiography), Nuclear (MUGA or SPECT), MRI, CT

Question 47

Echocardiography (Ultrasound) – Information it provides

Answer 47

1. LVEF (systolic function)….. 2. Chamber size (dilation)….. 3. LV wall thickness (hypertrophy)….. 4. Measures of relaxation (diastology)….. 5. Valvular anatomy & function….. 6. Estimated filling pressures (LA, CVP)….. 7. Estimated pulmonary pressures (pulmonary HTN)

Question 48

Echocardiography (Ultrasound) – Advantages

Answer 48

Real time, Non-invasive, No radiation, Relatively “inexpensive”

Question 49

Right heart catheterization (Swan-Ganz catheter)

Answer 49

Plastic catheter introduced into one of the major veins, then “floated” through the right heart into the pulmonary artery; Has a balloon on the end of it to help blood flow carry it into the lungs and which allows a branch of the pulmonary artery to be occluded so that the downstream pressure (post-capillary wedge pressure [PCWP]) can be measured, which is equivalent to the left atrial pressure / left-sided filling pressure.

Question 50

Hemodynamic measures – PA cather measurements

Answer 50

1. Pressures (CVP/RA, RV, PA, PCWP)….. 2. Flow = cardiac output (Fick CO = oxygen consumption measure; Thermodilution CO = timed flow measure)

Question 51

Hemodynamic measures – Calculating Resistances

Answer 51

Resistances can be calculated from pressures and flow (gained from catheter measurements) via Ohm’s law: V=IR / Hemodynamic equivalent: ΔP = CO x R…… Across a body capillary bed: ΔP = mean arterial BP – central venous pressure………..Systemic vascular resistance = ΔP / cardiac output (in woods units)