Heart Failure II: Diagnosis & Treatment

Question 1

What are the three major symptoms of HF and what causes them?

Answer 1

1. Fatigue (low CO)
2. Breathlessness (Increased pulmonary venous pressure)
3. Edema (increased central venous pressure)

Question 2

What different systemic symptoms will someone with low flow experience?

Answer 2

• sleepiness, confusion (less cerebral perfussion)
• fatigue, weakness (less muscle perfusion)
• anorexia, wasting (less GI perfusion)
• reduced urine (less kidney perfusion)

Question 3

Why would a patient with left sided pressure have difficulty breathing?

Answer 3

Increased left sided pressure leads to increased pulmonary venous pressure

Question 4

What is orthopnea and what causes it?

Answer 4

immediate SOB when lying flat

-from lost venous pooling of blood in legs

Question 5

What about PND (paroxysmal nocturnal dyspnea)?

Answer 5

SOB waking patients from sleep

• relates to mobilization of edema from tissue through lymphatics back into the blood stream
• patients have to get out of bed and walk to relieve symptoms

Question 6

Your patient has peripheral swelling, ascites, and hepatic/ intestinal congestion. What’s wrong?

Answer 6

RV failure causing increased central venous pressure

Question 7

Why do patients get edema?

Answer 7

Hydrostatic pressure (fluid leaving blood) is much greater than encotic pressure (fluid returning to blood) which builds up in tissues

Question 8

What NYHA functional class is a patient that is symptomatic with moderate exertion?

Answer 8

Class II

Question 9

What NYHA functional class is a patient who is symptomatic at rest?

Answer 9

Class IV

Class I: asymptomatic
Class II: symptomatic with moderate exercise
Class III: symptomatic with minimal exercise

Question 10

What ACC/ AHA Stage (letters) is someone at high risk for heart failure but without structural heart disease or symptoms of heart failure (ie. hypertension, coronary heart disease)?

Answer 10

Stage A

Question 11

What ACC/ AHA Stage (letters) is someone with structural heart disease with prior or current symptoms of heart failure?

Answer 11

Stage C

Stage A: high risk, no structural changes/ symptoms
Stage B: structural heart change, no symptoms
Stage D: heart failure requiring specialized intervention

Question 12

What would be the goal of therapy for your patient who had a previous MI (stage B)?

Answer 12

• prevent symptoms

- prevent further remodeling

Question 13

Your patient has heart failure. What precipitating factors are you worried about that would worsen the condition?

Answer 13

• Increased preload = Na in diet, renal failure
• increased afterload = hypertension, stenosis, PE
• worsened inotropy = MI, beta blocker
• arrythmia = bradycardia, A fib
• ^ metabolic demands = fever, anemia, pregnancy
• NON COMPLIANCE WITH MEDS

Question 14

You suspect your patient has low flow from underlying HF. What signs are you looking for? why?

Answer 14

1. Cold extremities: vasoconstriction to redirect blood flow
2. Tachycardia: compensate for low SV
3. Low pulse pressure: reflection of low output

Question 15

While auscultating a patient you hear sounds in the lung that sound like velcro. What is that called? What causes it?

Answer 15

Rales

-Due to wet alveoli opening (fluid in lungs from ^ left-sided pressure)

Question 16

What else would you expect to see with increased left-sided pressure?

Answer 16

• Hypoxia
• Tachypnea
• Sitting bolt upright

**Lung problems

Question 17

In addition to edema and hepatomegaly, what else would you look for with a patient with suspected increased right-sided pressure?

Answer 17

Jugular Venous Distension (JVD)

-usually

Question 18

What are the 3 different waves on the jugular venous pressure diagram?

Answer 18

A wave: atrial contraction
C wave: closing of tricuspid valve (beginning of RV systole)
V wave: movement of RV annulus and tricuspid valve backwards (end of RV systole)

Question 19

Tom is 25 years old. After listening to his heart you hear a S1-S2-S3 abnormal sound with the cadence of “kentucky”. What is this called? Is this concerning?

Answer 19

S3 gallop

No. Abnormal in people > 40 yrs

Question 20

What causes an S3 gallop?

Answer 20

• Thought to be caused by rapid expansion of ventricular walls in early diastole (as blood Slosh-ing-in to ventricle)
• Typical in HFrEF / DILATED heart

Question 21

You hear an abnormal sound with the cadence of “Tennessee”. What is it?

Answer 21

S4 gallop (S4-S1-S2)

• caused by atria contracting against LV
• usually abnormal
• becomes louder the STIFFER the LV

Question 22

What do you call the gallop that occurs in tachycardia and combines S3/ S4 to one loud diastolic sound?

Answer 22

Summation gallop

Question 23

Regurgitation AV murmurs are common with what condition?

Answer 23

HFrEF

Question 24

If someone has HF, what other comorbitities are you worried about?

Answer 24

Coronary disease, valve disease, hypertension
Diabetes, renal failure

*if a patient has none of these but has shortness of breath, you should think of something besides HF

Question 25

Okay, but if they still have SOB, what other things are on your differential diagnosis?

Answer 25

- Pulmonary disease (COPD, asthma, pneumonia, PE) - Sleep apnea - obesity - deconditioning - anemia - renal/hepatic failure - venous stasis - depression

Question 26

What sorts of tests/ procedures should you order to rule in HF?

Answer 26

- Echocardiogram - 12 lead ECG - Blood chemistry - CBC - Natriuretic peptide measurement - chest x ray Also helpful: cardiac MRI, coronary angiography, myocardial perfusion imaging, right heart catheterization, exercise testing

Question 27

An old guy goes to a brazilian steakhouse and shows up in the ER. What would you find on the chest x-ray?

Answer 27

=Fluid in alveoli (acute pulmonary edema) Chest x-ray could also show enlarged heart in HFrEF

Question 28

What are B-type natriuretic peptides (BNP)?

Answer 28

Naturally secreted by myocardium in response to ventricular stretch (measure of preload) Secondary: hyperadrenergic state, RAAS activation

Question 29

What are the uses of BNP assays?

Answer 29

Elevations are mostly due to HF | -BUT negative predictive value is more useful (low BNP makes HF unlikely as diagnosis)

Question 30

T/F: EKG's are used to diagnose HF

Answer 30

False | -infer possibility of HF from other findings

Question 31

Your patient with HFrEF has an end-diastolic volume of 200ml, and an end-systolic volume of 150 ml. Calculate the ejection fraction? Is this number concerning?

Answer 31

25% (normal is 60%) EF = (ED volume - ES volume) / ED volume **Not too concerning. Could have higher volumes from cardiac dilation, but the SV doesn't change much

Question 32

There's a big list of things that an echocardiogram can do if you want to look (they're intuitive), but what are the advantages?

Answer 32

- Real time - Non-invasive - No radiation - relatively inexpensive

Question 33

How does the Swanz-Ganz catheterization work?

Answer 33

Plastic catheter with a balloon that you run down a vein to measure flow/ pressure in heart/ lungs

Question 34

What hemodynamic measures can you get from a PA catheter or Swanz-Ganz?

Answer 34

Pressure Flow =>Calculate resistance! Arterial BP = CO x R [like V = IR]