ABSTRACT
LVEF = stroke volume (end-diastolic volume – end-systolic volume) / end-diastolic volume › When LVEF is decreased: stroke volume is maintained by increasing end-diastolic volume (eccentric LVH)
SYMPTOMS SIGNS
• Dyspnea • Orthopnea • PND (1-2 h after going to bed; resolution in 15-30 min) • HExercise tolerance • Tiredness • Lower limb edema • Peripheral edema • Nocturnal cough • Wheezing • Weight gain • Loss of appetite • RUQ pain • Nocturia
• Cachexia • Hypotension; OH; Narrow pulse pressure • Pulsus alternans; H Pulse amplitude • Tachycardia • Tachypnea • Cheyne-Stokes breathing • JVD ; HJ reflux • Lateralized and widened apex • Left parasternal heave / Signs of PHT • Decreased S1 • S3 - S4 (± palpable) • AV valve regurgitation • Crackles • Wheezing • Signs of pleural effusion • Hepatomegaly (± pulsatile) • Peripheral edema (leg edema; scrotum; presacral; ascites) • Cold extremities • Confusion / Decreased level of consciousness
NYHA I
No limitation in ordinary physical activity (no tiredness, dyspnea or palpitations)
≥ 7 METs • Climbing one flight of stairs with a bag of groceries • Shoveling snow • Bicycling; Skiing; Jogging/walking (8 kph)
He ar
tf ai
lu re
NYHA II
Slight limitation during physical activity; ordinary physical activity causes symptoms (tiredness, dyspnea, palpitations)
5-7 METs • Climbing one flight of stairs without stopping • Walking briskly on level ground (6.5 kph) • Gardening; Dancing
NYHA III
Marked limitation during physical activity; comfortable at rest; less than ordinary activity causes symptoms (tiredness, dyspnea, palpitations)
2-5 METs • Showering without a break • Getting dressed without a break • Walking briskly on level ground (4 kph) • Making a bed • Bowling; Golf
NYHA IV Inability to carry on any physical activity without discomfort ± symptoms at rest
< 2 METs • Unable to perform the activities of NYHA III
Paget’s disease; AV stula; Beriberi
He ar
tf ai
lu re
WORK-UP: CBC; Electrolytes (including Ca2+/Mg2+); Creatinine - BUN; LFTs; Blood glucose; HbA1c; TSH; Urinalysis; Lipids › If necessary: CK; Iron assessment; HIV; ANA; RF; Urine metanephrines; SPEP - UPEP; Uric acid; CRP; Troponin; Polysomnography
ECG: Sinus tachycardia; arrhythmia (AF; PVCs; NSVT); Conduction disorder / LBBB; LVH; LAH; Q waves; ischemia; low voltage QRS › AV block: Drug-induced; myocardial infarction; myocarditis; sarcoidosis; familial cardiomyopathy (LMNA; SCN5A); Lyme disease
CXR: prominent hila; Kerley B lines (fine horizontal linear opacities extending to the pleura); peribronchial edema; interstitial / alveolar edema; redistribution to apices; pleural effusion; fluid in the fissure; cardiomegaly; other cause of dyspnea
CORONARY ANGIOGRAPHY (± FFR): rule out significant CAD › Noninvasive evaluation (MIBI-P; stress echocardiography; coronary CT angiography) possible if few risk factors / low pre-test probability / low impact of the result on management
STRESS TEST / 6MWT / VO2MAX: A) Objective evaluation of functional class; B) Rule out ischemia; C) Pre-transplant (VO2max); D) Prescription of exercise; E) Prognosis; F) Distinguish cardiac from pulmonary cause › VO2max < 12 mL O2/kg/min associated with poorer survival than in patients with a heart transplant › 6MWT: normal > 600 m; < 350 m roughly equivalent to NYHA III
BIOPSY: g Chapter 5 BNP: released by the failing heart or in response to hemodynamic stress; reflects wall stress and filling pressures › Increases with age; decreases with obesity › DDx G: CRF; arrhythmia; ACS; pulmonary embolism; severe COPD / PHT; sepsis; cirrhosis › Indications: A) Identify the cause of dyspnea (cardiac versus non-cardiac); B) Prognosis • BNP-guided management of heart failure remains controversial; studies report divergent results
ACUTE HEART FAILURE UNLIKELY
NT-proBNP < 300 pg/mL (NPV 98 %)
BNP < 100 pg/mL
PROBABLE ACUTE HEART FAILURE
NT-proBNP > 450 pg/mL (< 50 years) > 900 pg/mL (50-75 years) > 1800 pg/mL (> 75 years)
BNP > 500 pg/mL
› Variation: a change of > 30% in BNP level should call for more intesive follow-up / treatment
He ar
tf ai
lu re
SEATTLE HEART FAILURE MODEL: https://depts.washington.edu/shfm HEART FAILURE SURVIVAL SCORE PROGNOSTIC FACTORS: Demographics; Etiology; Comorbidities; NYHA; Hemodynamics (LVEF; PAP; Wedge; Cardiac index; Transpulmonary gradient); Exercise stress test (BP; 6MWT; VO2max; Anaerobic threshold; Ve/VCO2 slope > 35); Anemia; Hyponatremia; QRS duration; BNP; Troponin...
