Diagnosis & Treatment of Heart Failure Flashcards Preview

CVPR: CV Unit I > Diagnosis & Treatment of Heart Failure > Flashcards

Flashcards in Diagnosis & Treatment of Heart Failure Deck (25):

Major pathophysiological characteristics that lead to symptoms of heart failure (3)

  • decreased cardiac output
  • increased pulmonary venous pressure
  • increased central venous pressure


Heart failure symptoms associated w/decreased cardiac output

  • 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.


Heart failure symptoms associated w/increased pulmonary venous pressure

  • DYSPNEA (breathlessness)
  • Dyspnea on exertion
  • Orthopnea
  • Paroxysmal nocturnal dyspnea (PND)
  • Acute pulmonary edema



Heart failure symptoms associated w/increased central venous pressure

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


Orthopnea definition

  • SOB when lying flat
  • 1) fluid normally accumulates in lower lobes of lungs (due to gravity) --> allows breathing from upper lobes
    • lying down --> fluid disperses throughout lungs --> dyspnea
  • 2) increased venous return b/c decreased gravity pull on returning blood --> increased congestion & SOB


Paroxysmal nocturnal dyspnea (PND) definition

  • delayed SOB, waking patients from sleep
  • mobilization of edema from tissue through lymphatics back into blood stream


Symptoms/causes of acute pulmonary edema

  • acute, intense shortness of breath
  • “fluffy” infiltrates on an CXR
  • 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



NY Heart Association functional classification scheme of heart failure

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


ACC/AHA Heart Failure Stage Classification system

  • A: At high risk for heart failure but without structural heart disease or symptoms of heart failure

  • B: Structural heart disease but without symptoms of heart failure.

  • C: Structural heart disease with prior or current symptoms of heart failure.

  • D: refractory heart failure requiring specialized interventions.


Common precipitants of worsening heart failure/symptoms (6)

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


Characteristics of clinical course of heart failrure

  • clinical course = variable, non-linear
  • 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 
  • usual course is an average of progressive decline over time.


Key pathophysiological problems that lead to signs of heart failure (4)

  • low flow/cardiac output
  • elevated left-sided filling pressures
  • elevated right-sided pressures
  • abnormal contractions --> extra heart sounds


Signs of low flow (3)

  • 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.


Signs of elevated left-sided filling pressures

  • rales (pulmonary crackles)—fluid in the lungs, wet alveoli opening
  • Hypoxia
  • Tachypnea
  • Comfortable only when upright, tri-podding
  • Popping open of alveoli


Signs of elevated right-sided pressures (3)

  • Edema—dependent=follows gravity
  • Hepatic congestion/hepatomegaly
  • Jugular venous distention (JVD) = ↑ central venous pressure


Characteristics of Jugular Venous Pressure (JVP)

  • 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.

  • JVD --> visibily full neck veins on visual examination.

  • Jugular venis will transmit pressure changes in the right atrium as waves, visible fluctuations in the vein size and in the meniscus.


Types of abnormal heart sounds encountered in HF (2)


  • S3 gallop—rapid expansion of the ventricular walls in early diastole
    • HFrEF/dilated heartKen-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)




Major types of laboratory/imaging studies & tests used in dx of HF

  • lab tests: natriuretic peptides
    • BNP (B-type natriuretic)
    • NT-proBNP
  • imaging studies
    • CXR
    • Electrocardiogram (EKG)
    • Echocardiography 
  • Catheterization


BNP & NT-proBNP definition

  • BNP=B-type natriuretic peptide --> secreted by myocardium in response to:
    • Primary: ventricular stretch

    • Secondary: hyperadrenergic state, RAAS activation, ischemia

  • BT-proBNP: n-terminus breakdown product of BNP

    • remains in blood longer and is easier to measure


Primary dx use of BNP/pro-BNP

  • clincally used to rule out HF
  • used as a comparison to base BNP levels 
  • multiple root causes that can lead to elevated BNP


Dx of HF via CXR

  • Enlarged cardiac silhouette = HFrEF

  • ↑upper lobe vascular markings = acute decompensation

  • fluffy infiltrates = pulmonary edema

  • pleural effusions


Dx of HF via EKG

  • No direct diagnosis of HF can be made w/EKG
  • Can infer possibility of HF from other findings:
    • Q waves—prior MI
    • Increased voltage—LVH
    • Arrhythmia (AF, PVCs), non-sustained ventricular tachycardia (NSVT)



Dx of HF via Echo

  • Provides information on a number of different factors:
  • 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


Characteristics of right heart catherization

  • 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


Measurements that can be obtained from right heart catheterization

  • ​Measure pressures—CVP/RA, RV, PA, PCWP
  • Measure flow/CO
  • Resistances can be calculated from pressures and flow.