Heart failure 2013 Diagnostic Procedures

Congestive Heart Failure

2. Diagnostic procedures

March 2013 ghennersdorf DGK ESC SES 1

Medical Science Tanzania Cardiology Lectures

Prof. Hennersdorf SES

Procedures

• Clinical pathways

• Echocardiography

• Biochemistry

• Hemodynamics

• Imaging: Angiography, MRI


Procedures


General signs and symptoms


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


Mostly used functional definition of CHF throughout the world!

NYHA


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)


Pulmonary edema/orthopnea


Pulmonary edema

Swelling by fluid retention


Pulmonary edema

Swelling by fluid retention


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


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


Physical examination: heart sounds


S4 S3OSS1 S2

Sound

ECG

Physical examination: heart sounds


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


Physical examination: ergometry equipment


Exercise device

ECG Cart

Emergency Kit (necessary)

http://images.google.de/imgres?imgurl=http://www.absperr-schilder-technik.de/artikelbilder/Rettungsschild_Automatisierter_externer_Defibrillator_AED_nachleuchtend_38.0155_g.jpg&imgrefurl=http://www.absperr-schilder-technik.de/EverGlow_Langnachleuchtende_Sicherheits_Kennz_Rettungsschild_Automatisierter_externer_Defibrillator_AED_nachleuchtend-25573-336743.html&h=290&w=290&sz=6&hl=de&start=35&tbnid=_6QNXCbq3rMJoM:&tbnh=115&tbnw=115&prev=/images?q=defibrillator&start=18&ndsp=18&svnum=10&hl=de&lr=&newwindow=1&rls=GGLD,GGLD:2005-10,GGLD:de&sa=N

Procedures


Echocardiography

Underlying disease Cardiomyopathy Valve disease CHD (Stress Echo) Pathophysiology: LV filling patterns


Left heart failure: US LVDD*


*left ventricle diast. Diameter, norm <50<mm

Left heart failure: US TMF*


A normal transmitral filling

B early diastolic dysfunction

C progredient diastolicDysfunction

DT deceleration time

A B

C

*Transmitral flow

Left heart failure: US MI


Left heart failure: US TR*


Eval. systolic PA pressure *Tricuspid

regurgitation

Procedures


Chest XRay CXR


normal finding

Chest XR CXR


Pulmonary edema

Chest XR CXR


Pulmonary edema after successful therapy

Pulmonary edema before therapy

Angiography indications

Underlying disease (CHD) with therapeutic consequences (PCI, CABG)

Intervention (cardiogenic shock)


Left heart failure, hemo + angio


Angio

hemodynamics

+

Left ventricle shape, size and function Pumping, blood delivery, work

Left heart failure: right heart hemodynamics


SWAN GANZ Catheter PA Pressure monitoring

Left heart failure, hemodynamics


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


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*


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


Regional scar

Regional scar

Anterior wall infarction

Diastole

Systole

Diastole

Systole

EF < 20%red linesshow normalcontraction

Dilated cardiomyopathy

Angiography diagnose: LV shape


normal

Regional scar

Regional scar

Diastole

Systole

infarctionEF 70%

CHF and MRI

• Dimensions• Contractility, Viability• Valve function


MRI crossectionalsequence of dilated LV

Procedures


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


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


CHF Diagnose: stepwise procedure


1st step: clinical approach, additional ECG, CXR

2nd step: echocardiography

3rd step: blood tests (BNP)

4th step: exclude CHD (card-CT, Cathlab)

The End


Health & Medicine

Heart failure 2013 Diagnostic Procedures