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Flashcards in Diagnosis of Heart Failure Deck (66):
1

What are the three general classes of symptoms associated with heart failure?

• Decreased cardiac output
• Increased pulmonary venous pressure
• Increased central venous pressure

2

What is meant by exercise intolerance?

• Inability to augment cardiac output ot meet increasing demands of stress or excersice

3

What does decreased kidney perfusion look like?

• Reduced urine output
• Progressive renal dysfunction
• Cardiorenal syndrome

4

What does decreased gut perfusion look like?

• Anorexia
• Wasting (cachexia)

5

What does decreased muscle perfusion look like?

• Fatigue
• Tiredness/sleepiness
• Can't get enough energy

6

What four general classes of symptoms point to decreased cardiac output?

• Decreased muscle perfusion
• Decreased gut perfusion
• Decreased kidney perfusion
• Exercise intolerance

7

What does increased central venous pressure usually look like?

• Edema

8

What does increased pulmonary pressure usually look like?

• Breathlessness

9

What does decreased cardiac output usually look like?

• Fatigue

10

What are the classic presentation symptoms of increased left-sided filling pressures?

• Increased pulmonary venous pressure
○ Breathlessness (dyspnea)
○ Dyspnea on exertion

11

A small increase in stroke volume at the cost of large rise in End-diastolic pressure…that sounds like what?





• Syspnea on exertinon in HF

12

What is the radiographic evidence of acute pulmonary edema?

• Increase vascular prominence on CXR first, followed by fluffy infiltrates

13

What is going on in acute pulmonary edema?

• Acute intense shortness of breath
• Occurs once fluid retention/left atrial pressure overwhelms compensatory mechanisms
○ Like lymphatic fluid return
• Fluid spills from pulmonary vasculature into interstitial space and then into alveoli, producing hypoxia
• Increase vascular prominence on CXR first, followed by fluffy infiltrates

14

What is paroxysmal nocturnal dyspnea?

• PND = paroxysmal nocturnal dyspnea
• Delayed SOB, waking pts from sleep
• Classically, pt gets out of bed and ambulates to relieve symptoms
• Relates to mobilization of edema from tissue through lymphatics back into blood stream (raises blood volume and allows for greater pressure for right sided filling)

15

What is orthopnea?

• Immediate SOB when lying flat
• Due to lost venous pooling of blood in the legs

16

What usually coincides with increased right-sided filling pressures?






• Peripheral swelling/dependent edema
• Ascites
• Hepatic congestion
• Intestinal congestion
○ Protein-losing enteropathy

17

What can make heart failure symptoms worse by increasing metabolic demands?

• Fever, infection
• Anemia
• Hyperthyroidism
• pregnancy

18

What arrhytmias make symptoms of heart failure worse?

• Bradycardia
• Atrial fibrillation

19

What can worsen contractility in heart failure still further?

• Negative impact on inotropy
• Myocardial ischemia
• Initiation of negative inotrope
○ Beta-blocker or calcium channel blocker)

20

What can make afterload worse?

• Increased total pressure the heart is pushing against
• Uncontrolled hypertension (LV)
• Worsening aortic stenosis (LV)
• Pulmonary embolism (RV)

21

What can make increased circulating volume worse?

• This is the same as preload
• Sodium load in diet
• Renal failure

22

What is going on with edema in heart failure?

• Ventricular dysfunction leads to increased filling venous pressure
• This goes to hydrostatic pressure increase, leading to edema
• Some oncotic pressure resorbs some fluid but the bulk is left in the tissues

23

Is the progression of Heart Failure a linear course?

• Nope. It's a non-linear course
• Makrked by episodic exacerbations with significant symptoms with intervening periods of relative stability
• Usually move between classes/stages of disease

24

What are the signs of LOW flow you would see in a physical exam?


• Cool extremities
○ Peripheral vasoconstriction to redirect what existing blood flow there is to vital organs
• Tachycardia
○ Compensate for low stroke volume
• Low pulse pressure (diff btw systolic and diastolic pressure)
○ Reflection of low overall CO

25

What are you looking for in a JVD physical exam maneuver?

• Normal is less than 5cm H2O, meaning that when somebody is standing up, the jugular vein is normally collapsed
• Only carotid pulsation corresponding to systole should be visible
• In HF, with increased right pressures, the jugular veins fill with blood and have a specific pulsatile (waves) appearance

26

What are the signs of elevated right-sided pressures in heart failure patients?

• Edema
• Hepatic congestion/hepatomegaly
• Jugular venous distention (JVD)
○ Increased central venous pressure

27

What are the signs of elevated left-sided filling pressures you would see on a physical exam of a heart failure patient?

• Rales
○ Velcro pulling apart on inspiration
○ Due to wet alveoli opening
• Hypoxia
• Tachypnea
• Sitting bolt upright
• Popping open of alveoli

28

What accounts for the cool extremities you can notice in the physical exam of a patient with heart failure?

• Peripheral vasoconstriction to redirect what existing blood flow there is to vital organs

29

Jugular veins have a specific pulsatile appearance/character…what is it?

• A wave
○ Atrial contraction
• C wave
○ Closing of the tricuspid valve early in systole
• V wave
○ Movement of the RV annulus and tricuspid valve backward at end of systole (before valve opens)

30

S1 refers to what?


• A NORMAL heart sound
• Atrioventricular valve closures
• Mitral valve = M1
• Tricuspic valve = T1
• M1 occurs just before T1

31

What elements of a medical history are concerning for HF?

• Coronary disease, hypertention, valvular disease
• Diabetes, kidney disease
• Rule out non-HF cause of SOB

32

What three general factors play into your diagnosis of Heart Failure?

• Constellation of symptoms associated with the different types of HF
• Medical history and presence of conditions that lead to HF
○ Coronary disease, hypertention, valvular disease
○ Diabetes, kidney disease
○ Rule out non-HF cause of SOB
• Testing

33

What is going on behind an S4 heart sound?

• S4 'gallop'
• Atria working hard to overcome abnormally stiff or hypertrophic LV
• Always concerned when you hear this
• S4,1,2 (Tennessee)
• Absent in atrial fibrillation

34

When are you not concerned to hear an S3 heart sound?

• Present in normal young people
• Abnormal after age 40

35

What is thought to cause S3 heart sound?

• Rapid expansion of the ventricular walls in early diastole
○ Present in normal young people
○ Abnormal after age 40
• Indicative of HFrEF or DIlATED heart
• "kentucky cadence" (S1,2,3)

36

S2 refers to what?

• Aortic and pulmonary valve closures
• A2 and P2, A2 coming just a hair before T2
• During inhalation, a split S2 can normally be heard

37

What elements should be included in the differential diagnosis for Heart Failure?



• Pulmonary disease
• Sleep apnea
• Obesity
• Deconditioning
• Anemia
• Renal failure
• Hepatic failure
• Venous stasis/lymphedema
• Depression

38

What are the two different assays for natriuretic peptides?

• BNP
• NT-proBNP
○ especially increased in renal failure

39

What might elevated B-type natriuretic peptide (BNP) in the blood tell you as a clinician?

• Pt has inreased preload
• Pt has hyperadrenergic state, RAAS activation, ischemia
○ Marker released by myocardium primarily because of stretching by increased preload and secondarily because of the hyperadrenergic state and compensatory RAAS activation

40

B-type natriuretic is secreted by what and when?

• BNP = B-type natriuretic
• Released by myocardium
• Primarily because of ventricular stretch
○ So it's a measure of preload
• Secondarily because of hyperadrenergic state, RAAS activation, ischemia

41

What is the radiographic evidence of Heart Failure?

• Enlarged cardiac silhouette in HFrEF
• Increased upper lobe vascular markings with acute decompensation
• Fluffy infiltrates of pulmonary edema
• Pleural effusions

42

What are the studies/lab testing of HF designed to do?

• Confirm diagnosis of HF
○ Rule In
○ Rule out other potential causes
• Characterize HF
○ Type and severity
• Assess response to therapy

43

What elements go into the "pulmonary disease" portion of the heart failure differential diagnosis?

• COPD
• Asthma
• Pneumonia
• Pulmonary embolus
• Primary pulmonary hypertension

44

What is the practical use of the BNP/NT-proBNP test?


• Elevations are often due to HF
○ Other reasons = sepsis, PE
• You can use these to clinically rule out symptomatic HF
○ Negative predictive value is better
○ If they don't have elevated BNP, they probably don't have HF causing symptoms

45

Are you able, from the ECG alone, able to definitively diagnose the presence of heart failure?

• NO. there is no way to make a direct diagnosis of Heart Failure only from ECG findings
• You can, however, INFER it from other findings
○ Q wave presence
§ Prior myocardial infarction
○ Increased voltage
§ Evidence of LVH
○ LBBB = left bundle branch block
○ Arrhythmia evidence

46

What are some ECG findings that you can use to infer the likely presence of heart failure in a patient?

○ Q wave presence
§ Prior myocardial infarction
○ Increased voltage
§ Evidence of LVH
○ LBBB = left bundle branch block
○ Arrhythmia evidence
* AF, PVCs, NSVT

47

What is considered a "gross measure of systolic function"?


• Left ventricular ejection fraction = LVEF
• EF = (end diastolic - end systolic volume) / (end diastolic volume)
• This gives you a decimal that you have to convert into percent

48

What are the advantages of an echocardiogram in the diagnosis of heart failure?

• Real time
• Non-invasive
• No radiation
• "inexpensive" (relative)

49

What important diagnostic data does echocardiography provide?

• LVEF
• Chamber size
• LV wall thickness
• Measures of relaxation
• Valvular anatomy and function
• Estimated filling pressures
• Estimated pulmonary pressures

50

What would be a normal LVEF value as compered to one in HFrEF?

• HFrEF = Heart failure with reduced ejection fraction
• Normal = (100mL - 40mL) / 100mL = 0.6 = 60%
• HFrEF = (200mL - 150mL) / 200mL = 0.25 - 25%
○ Thus, you are comparing 60% LVEF vs. 25%

51

What are other names for a right heart catheterization?



• Process where plastic catheter is introduced into one of the major veins and then floated through the right heart into the pulmonary artery
• Balloon on end of catheter to help float it through blood stream to lungs
• Allows the determination of various pressures within the heart and also various flow measurements
• PA catheter, Swan-Ganz catheter, "Swan"

52

How can you use PA catheter measurements to determine resistances in the CV system?

• Ohms law and hemodynamic equivalent
○ V = IR,
○ deltaP = CO*R
• Across a capillary bed
○ deltaP = mean arterial BP - central venous pressure
○ Systemic vascular resistance
§ deltaP/CO

53

What are the two (general) major types of measurements that can be gained from a PA catheter?

• Pressures
○ CVP/RA
§ Central venous pressure or right arterial pressure
○ RV
§ Right ventricle
○ PA
§ Pulmonary artery
○ PCWP
§ Post capillary wedge pressure, artifact of the balloon on the catheter occluding a vessel
• Flow (equated to cardiac output)
○ Fick CO (oxygen consumption)
○ Thermodilution CO (timed flow)

54

What might be the difference in baseline heart rate btw. A normal and HF patient?





• HF = 110bpm
• Normal = 60bpm

55

What might be the difference in AORTIC PRESSURE btw a normal and HF patient?

• Normal = 120/80 weighted average - 93mmHg
• HF = 110/90 weighted average - 100mmHg

56

What might be the difference in POST CAPILLARY WEDGE PRESSURE btw a normal and HF patient?

• Normal = 7mmHg
• HF = 25mmHg

57

What might be the difference in PULMONARY ARTERY PRESSURE btw a normal and HF patient?

• Normal = average btw 25 and 10 = 12mmHg
• HF = average btw 55 and 30 - 40mmHg
○ It's not true arithmetic average because its weighted to diastole

58

What might be the difference in RIGHT ATRIUM PRESSURE btw a normal and HF patient?

• Normal = 3
• HF = 12mmHg

59

What might be the difference in baseline OXYGEN CONSUMPTION btw. A normal and HF patient?

• HF = 257 mL O2/min
• Normal = 257 mL O2/min
○ Often assumed 135 mL/min/m^2

60

What might be the difference in baseline HEMOGLOBIN btw. A normal and HF patient?

• HF = 13g/dL (just slightly less)
• Normal = 15 g/dL

61

What might be the difference in baseline BSA (body surface area?( btw. A normal and HF patient?

• HF = 1.9m^2
• Normal = 1.9m^2

62

What might be the difference btw a normal and HF patient in terms of oxygen saturation?



• Pulmonary artery O2 saturation
○ Normal = 70%
○ HF = 40%
• Aortic O2 saturation
○ Normal = 98%
○ HF = 92%

63

What might be the difference in resistance measurements btw a normal and HF patient?

• Systemic vascular resistance
○ 20 woods units - normal
○ 31 woods units - HF
• Pulmonary vascular resistance
○ 1.1 woods units - normal
○ 5.4 woods units - HF

64

What might be the difference in stroke volume btw a normal and HF patient?

• 77mL - normal
• 25mL - HF

65

What might be the difference in Cardiac Index (Fick determined) btw a normal and HF patient?

• 2.4 L/min/m2 - normal
• 1.5 L/min/m2 - HF

66

What might be the difference in Fick Cardiac output btw a normal and HF patient?

• 4.6 L/min - normal
• 2.8 L/min - HF