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Flashcards in Heart Failure Diagnosis Deck (50)
1

3 Major Symptoms of Heart Failure

1) decr cardiac output due to decr organ perfusion

2) incr pulm venous pressure (left sided) --> breathlessness

3) incr central venous pressure (right sided) --> edema

2

Symptoms of Low Flow

1) decr cerebral perfusion (confusion)
2) decr muscle perfusion (fatigue)
3) decr gut perfusion (anorexia/wasting)
4) decr kidney perfusion (decr urine output and renal dysfunction)

3

Effect of low flow on Starling Curve

Shift curve downward due to decr SV for a given pressure

4

Symptoms of Left sided pressure/increased pulm venous pressure

1) breathlessness (dyspnea)

2) dyspnea on exertion

3) orthopnea

4) paroxysmal noctural dyspnea

5) acute pulm edema due to fluid retention/incr LA pressure so fluid from pulm vasculature enters interstitial space and then alveoli (hypoxia)

5

Effect of incr left sided pressure on Starling curve

given point shifts right due to incr pressure

6

Difference between orthopnea and paroxysmal noctural dyspnea

Orthopnea = immediate SOB lying flat

Paroxysmal Nocturnal dyspnea= delayed SOB wake from sleep and walk around

7

Why does walking around improve paroxysmal nocturnal dyspnea

Mobilizing edema from tissue through lymph back into blood stream

8

Why does orthopnea occur?

lost venous pooling of blood in the legs

9

Symptoms of incr right sided pressure/incr central venous pressure

1) peripheral edema in lower extrem (older)
2) ascites (younger)
3) Hepatic congestion
4) intestinal congestion

10

Right sided failure = Effect of Edema in HF on Starling forces

Increased central venous pressure upsets balance between Starling forces

now increase oncotic P so pump more fluid into interstitum

11

Factors that lead to worse symptoms

1) incr circulating volume (preload) with sodium

2) increased pressure (afterload)

3) decr inotropy

4) arrhythmia

5) incr metabolic demands (fever, infection)

6) non-adherence with HF meds

12

examples of increased pressure (afterload) that can worsen symptoms

1) uncontrolled HTN
2) worse aortic stenosis
3) pulm embolism

13

examples of decr inotropy that can worsen symptoms

1) MI
2) beta blocker or Ca2+ channel blocker

14

NYHA class
1
2
3
4

1) asymptomatic

2) symptomatic with mod exertion

3) symptomatic with minimal exertion

4) symptomatic at rest

15

AHA/ACC HF stage 1

at risk for HF but not structural heart disease or symptoms

16

AHA/ACC HF stage 2

structural heart disease (prior MI, LVH and low EF) but no signs/symptoms of HF

17

AHA/ACC HF stage 3

structural heart disease with prior/current signs and symptoms (HFpEF) and (HFrEF)

18

AHA/ACC HF stage 4

Refractory HF

marked symptoms at rest

19

What is important about HF course?

variable course

episodic exacerbations and rarely single NYHA over time

but usually progressive decline over time

20

Physical exam
Signs of low flow

1) cool extremities - peripheral vasocosntriction to redirect flow to vital organs

2) tachycardia- compensate for low SV

3) low pulse pressure - low output

21

Physical Exam
Signs of elevated left sided pressure

1) rales due to wet alveoli opening

2) hypoxia

3) tachypnea

4) bolting upright

22

PHysical exam
signs of elevated right sided pressures

1) edema - follows gravity (legs, sacrum, scrotum)

2) hepatic congestion

3) JVD = central venous pressure

23

what does JVD measure

RA filling pressure

24

What is JVD a sign of

increased central venous pressure

right heart failure

25

how many Waves in JVD

Triphasic= 3

26

A wave

atrial contraction

27

C wave

closing of the tricuspid valve early in systole

28

v wave

movement of RV annulus and tricuspid valve backward at the end of systole (before the valve opens)!

29

S4 heart sound

before S1

atria contract forcefully to overcome stiff/hypertrophic LV

30

S4 present in AFIB

NO NOT IN AFIB

31

S4 normal or abnormal?

abnormal

32

S3 heart sound cause

rapid expansion of vnetricular walls in early diastole

sudden stop in LA filling

heart vibrates during passive filling

33

S3 normal or abnormal?

normal in young
abnormal after 40 y/o

34

S3 sign of?

HFrEF or dilated heart

35

what is summation gallop?

all 4 heart sounds

36

Preexisting conditions to HF

Coronary, valve disease, HTN

Diabetes, Renal failure

37

How can CXR help in HF

Enlarged heart in HFrEF

increased upper lobe vascular markings with acute decompensation

38

What does acute pulm edema look like on CXR

fluffy infiltrate due to LA pressure overwhelming lymph return

39

What is BNP secreted in response to?

Ventricular stretch (measure of preload)

Hyperadrenergic state, RAAS, ischemia

40

What are assays of BNP

BNP- Normal <100

NT-proBNP= N terminus breakdown of BNP (inactive)
~ 6x BNP

41

BNP relationship with age

incr age, incr BNP

42

How is BNP used?

low BNP makes HF unlikely

in chronic HF, elev BNP not as useful

43

Signs of HF in EKG

no direct diagnosis

1) prior MI (Q waves)
2) LVH (incr voltage)
3) diffuse disease from fibrosis or myocardial damage (LBBB)
4) arrhythmia (AFib, ventricular ectopy)

44

Equation for EF

EF= (end diastolic volume - end systolic volume) / end diastolic volume

HFrEF = dilated + decr SV

45

Advantages of echocardiogram

real-time
non-invasive
no radiation
cheap

46

Right heart cath using Swan-Ganz

1) cath insert into major vein and floated to right heart into pulm artery

2) blocks branch of pulm artery to measure downstream pressure (wedge pressure = LA pressure)

47

what is wedge pressure equal to?

LA pressure/left sided filling pressure

48

PA Catheter measures what 2 things?

Pressures

Flow
- fick CO
- thermodilution CO

49

In HF, what is the Fick CO and what is Thermodilution CO

Oxy sat aorta - oxy sat vein

Fick: In HF, lower oxy sat in vein because lower CO

Thermodilution: Longer time fo cold water to reach pulm artery because lower CO

50

How to calculate resistance based on pressures and flow

dP = CO * R

Calculate resistance in pulm bed based on Difference between PA pressure and Wedge pressure

Calculate resistance in systemic based on difference between aortic pressure and central venous pressure