Congestive Heart Failure
2. Diagnostic procedures
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Medical Science Tanzania Cardiology Lectures
Prof. Hennersdorf SES
Procedures
• Clinical pathways
• Echocardiography
• Biochemistry
• Hemodynamics
• Imaging: Angiography, MRI
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Procedures
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General signs and symptoms
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Definition of Heart Failure CHF
New York Heart Association (NYHA) I no visible signs and symptoms II signs and symptoms at high level exercise III signs and symptoms at low level exercise IV no physical exercise possible, bed rest
necessary
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Mostly used functional definition of CHF throughout the world!
NYHA
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NYHA II NYHA III NYHA IV
NYHA I without clinical signs and symptoms
Physical examination: general
• Dyspnea (rest, exercise), Orthopnea• Weight gain, swelling of the legs• Nocturia• Tachycardia (Palpitation)• Fatigue• Sweating• Nausea, vomiting, cough• Anorexia• Cachexia (cardiac)
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Pulmonary edema/orthopnea
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Pulmonary edema
Swelling by fluid retention
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Pulmonary edema
Swelling by fluid retention
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Physical examination: acute vs. chronic
• acute– Severe symptoms– No weight gain due to rapid onset– Tachycardia
• Chronic– Less severe symptoms (NYHA classes)– Weight gain– Nausea, vomiting, cough– Anorexia– Cachexia
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Physical examination: special
• Palpation– Precordial heave– Cardiac apex localization (outside the midclavicular
line)
• Auscultation– 3rd, 4th heart sound– Mitral systolic murmur– pulmonary rales
• Prominent jugular vein (positive pulse; TI)• Hepatojugular reflux
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Physical examination: heart sounds
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S4 S3OSS1 S2
Sound
ECG
Physical examination: heart sounds
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S3S1 S2
Sound
ECG
midsystolic murmur
Physical examination: functional tests
6-min walk: Pt. is forced to walk as he likes walking, standing, running etc. The achieved distance is documentedand should reach >350 (female) - 400 (male) mweak but reproducible relation to peak O2-consumption
Ergometry: objective measurement of workload, but also used for rehabilitation in special cases or postoperatively (HTX): sitting or supine, treadmill preferred
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Physical examination: ergometry equipment
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Exercise device
ECG Cart
Emergency Kit (necessary)
Procedures
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Echocardiography
Underlying disease Cardiomyopathy Valve disease CHD (Stress Echo) Pathophysiology: LV filling patterns
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Left heart failure: US LVDD*
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*left ventricle diast. Diameter, norm <50<mm
Left heart failure: US TMF*
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A normal transmitral filling
B early diastolic dysfunction
C progredient diastolicDysfunction
DT deceleration time
A B
C
*Transmitral flow
Left heart failure: US MI
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Left heart failure: US TR*
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Eval. systolic PA pressure *Tricuspid
regurgitation
Procedures
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Chest XRay CXR
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normal finding
Chest XR CXR
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Pulmonary edema
Chest XR CXR
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Pulmonary edema after successful therapy
Pulmonary edema before therapy
Angiography indications
Underlying disease (CHD) with therapeutic consequences (PCI, CABG)
Intervention (cardiogenic shock)
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Left heart failure, hemo + angio
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Angio
hemodynamics
+
Left ventricle shape, size and function Pumping, blood delivery, work
Left heart failure: right heart hemodynamics
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SWAN GANZ Catheter PA Pressure monitoring
Left heart failure, hemodynamics
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Measurements:
Cardiac outputVentricular filling pressures, Vascular resistancesWork loadWork capacity
Limited clinical value, limited use to invasive cases (Cathlab,OP), potentially harmful!
HF parameter by heart catheterization
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Some hemodynamic values
Cardiac output/index norm 2-2.5 l(min/m2)Stroke work norm 21 mjouleenddiastolic pressure norm 12 mm HgVascular bed resistances (norm)
TPR 1200 dyn*sec*cm-5
PVR 70 dyn*sec*cm-5
Clinical use limited to ICU controlduring vasoactive therapy e.g. of cardogenic shock
CHF parameter by angiography*
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Ejection fraction EF
EF = ---------------EDV**
EDV**-ESV***x 100 (%)
Norm = 70%Reduced = <40%Low= <20%
Strongest predictors of survival and prognosis
*today fairly achieved by echocardiography **Enddiastolic volume/area*** endsystolic volume/area
Angiography diagnose: LV shape
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Regional scar
Regional scar
Anterior wall infarction
Diastole
Systole
Diastole
Systole
EF < 20%red linesshow normalcontraction
Dilated cardiomyopathy
Angiography diagnose: LV shape
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normal
Regional scar
Regional scar
Diastole
Systole
infarctionEF 70%
CHF and MRI
• Dimensions• Contractility, Viability• Valve function
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MRI crossectionalsequence of dilated LV
Procedures
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Biochemistry
Red, white BC Blood sedimentation rate Electrolytes Urinalysis, Kreatinine Enzymes (GOT, GPT, LDH, CK, CKMB, Troponine) CRP (Inflammation) Epinephrine/Norepinephrine levels scientific Peptide (BNP/ANP) levels mostly scientific, but probably
prognostic
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Value: diagnostic, prognostic, therapy control
Biochemistry: BNP/NT-proBNP
BNP= brain natriuretic peptide (delivered in myocardial atrial tissue during atrial stress)regulating hormone in order to reduce atrial stress
Inactive precursor of BNP = NT-proBNP Blood test after 10 min valid Mostly valid to exclude CHF under clinical conditions
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CHF Diagnose: stepwise procedure
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1st step: clinical approach, additional ECG, CXR
2nd step: echocardiography
3rd step: blood tests (BNP)
4th step: exclude CHD (card-CT, Cathlab)
The End
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