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C34 Cardiology and Cardiac Surgery
Does this Dyspneic Patient in the Emergency Department have Congestive Heart Failure? JAMA 2005;294:1944-1956
Heart Failure Toronto Notes 2019 Heart Failure
• seealsoCCSHeartFailureGuidelines2012fordetails(freemobileappsavailableoniOSandAndroid platforms in the CCS app stores) as well as the CCS Heart Failure Guidelines Compendium available at CCS.ca
Congestive Heart Failure
Low-Output HF
due to decreased cardiac output
Systolic Dysfunction
Injury and ischimia in myocardium
Infarcation and inflammation
Thin, weakened muscle
Ineffective ventricular contraction
Diastolic Dysfunction
Infiltration and fibrosis
Thick, stiffened myocardium
ineffective ventricular filling
Initial clinical judgment
Past Medical History Heart failure
Myocardial infarction
Coronary artery disease
Symptoms
Paroxysmal nocturnal dyspnea
Orthopnea
Dyspnea on exertion
Physical Exam
Third heart sound
Jugular venous distension Rales
Lower extremity edema
Chest Radiograph
Pulmonary venous congestion Interstitial edema
Cardiomegaly
ECG
Atrial fibrillation
Any abnormal finding
LR+ (95% CI)
4.4 (1.8-10.0)
5.8 (4.1-8.0) 3.1 (2.0-4.9) 1.8 (1.1-2.8)
2.6 (1.5-4.5) 2.2 (1.2-3.9) 1.3 (1.2-1.4)
11 (4.9-25) 5.1 (3.2-7.9) 2.8 (1.9-4.1) 2.3 (1.5-3.7)
12 (6.8-21) 12 (5.2-27) 3.3 (2.4-4.7)
3.8 (1.7-8.8)
2.2 (1.6-3.1)
LR– (95% CI)
0.45 (0.28-0.73)
0.45 (0.38-0.53) 0.69 (0.58-0.82) 0.68 (0.48-0.96)
0.7 (0.54-0.91) 0.65 (0.45-0.92) 0.48 (0.35-0.67)
0.88 (0.83-0.94) 0.66 ( 0.57-0.77) 0.51 (0.37-0.70) 0.64 (0.47-0.87)
0.48 (0.28-0.83) 0.68 (0.54-0.85) 0.33 (0.23-0.48)
0.79 (0.65-0.96) 0.64 (0.47-0.88)
Figure 39. Congestive heart failure
Table 13. Signs and Symptoms of Left vs. Right Heart Failure
Decompensation
- Deteroriation of heart function
- Heart unable to maintain blood circulation
Left-Sided HF
Right-Sided HF
Biventricular HF
Forward Failure
- Inability to maintain cardiac output
Backward Failure
- Elevated ventricular filling pressures - Pulmonary vascular congestion
- Fluid accumulation in lungs, apnea,
shortness of breath, fatigue, weakness
Backward Failure
- Elevated ventricular filling pressures
- Vascular congestion in vena cava
- Fluid accumulation in lower
extremities (edema in feet, ankles, legs, lower back, liver, abdomen), nausea
- Due to long-term left-sided failure leading to right-sided failure
- Disorders affecting entire myocardium
Dichotomies of Heart Failure
Low Cardiac Output (Forward)
Venous Congestion
(Backward)
Pathophysiology
Left Failure
Fatigue
Syncope
Systemic hypotension Cool extremities
Slow capillary refill Peripheral cyanosis Pulsus alternans Mitral regurgitation S3
Dyspnea, orthopnea, PND Cough
Crackles
Right Failure
Left failure symptoms if decreased RV output leads to LV underfilling Tricuspid regurgitation
S3 (right-sided)
Peripheral edema
Elevated JVP with abdominojugular reflux, and Kussmaul’s sign
Hepatomegaly
Pulsatile liver
• Forward vs. backward
• Left-sided vs. right-sided
• Systolic vs. diastolic dysfunction • Low output vs. high output
Use Ejection Fraction to Grade LV Dysfunction
• Grade I (EF >60%) (Normal)
• Grade II (EF = 40-59%)
• Grade III (EF = 21-39%) • Grade IV (EF ≤20%)
• mostcommoncausesareischemicheartdisease,hypertensionandvalvularheartdisease
• myocardialinsultcausespumpdysfunction/impairedfillingleadingtomyocardialremodelling
■ pressure overload (e.g. AS or HTN) leads to compensatory hypertrophy (concentric remodelling) and eventually interstitial fibrosis
■ volume overload (e.g. aortic insufficiency) leads to dilatation (eccentric remodelling)
■ both processes lead to maladaptive changes contributing to disease process
• resultsindecreasedvolumecardiacoutputresultinginactivationoftheSNSandRAAS
• Na+ and water retention, increasing preload and afterload, tachycardia perpetuates cycle of increasing
Increased Cardiac Workload
- Myocardial stress - Volume overload - Pressure overload
High-Output HF
due to increased cardiac demand
Compensation
- Increased heart rate and myocardial contractility - Increased blood volume
Systemic Response
- Activation of SNS and RAAS activity
cardiac demand, and decompensation
Decompensation
© Kelly Speck 2016