Term
64 M h/o smoking, dyslipidemia, HTN, presents with 3 weeks progressive cough, DOE and mild LE edema.
PE: Diaphoretic, tachypneic, HR 100, BP 90/70
Whats going on? |
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Definition
Cold (poor perfusion/low cardiac index) and Wet (volume overload/ high PCW) HF
1) Smoking, dyslipidemia and HTN are suggestive of CAD, which can cause HF with preserved OR reduced EF
2) Cough, DOE and LE edema suggest volume overload, as does increased resipiration rate (diaphoresis)
3) Tachypnea and hypotension are consistent with poor perfusion |
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Term
| What questions could you ask a patient to distinguish between volume overload and poor perfusion causes of HF? |
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Definition
1) Volume overload
- Edema?
- PND or orthopnea?
- Cough or DOE?
- Ascites or weight gain?
- Poly/nocturia?
2) Poor perfusion
- Fatigue or lack of appetite?
- Low urine output?
- Depression? |
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Term
| What PE findings support the diagnosis of volume overload? |
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Definition
1) Pulmonary rales
2) Ascites
3) JVD
4) Peripheral edema
5) Elevated respiratory rate |
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Term
| What PE findings suggest poor perfusion HF? |
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Definition
1) Cool, mottled extremities
2) Poor mentation
3) Hypotension
4) Tachycardia |
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Term
| What are some popular biomarkers used to determine HF severity? |
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Definition
1) BNP
2) Troponin I
3) Uric Acid |
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Term
| What changes on Echo can help you determine whether HF is systolic or non-systolic? |
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Definition
1) Systolic HF will have diminished LV EF (LV dilation)
2) Increased LV thickness and enlarged LA suggests diastolic HF |
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Term
| Why perform coronary angiography? |
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Definition
Left access is arterial and right access is venous
Atherosclerotic disease that could be causing ischemia! |
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Term
| Why use a Swan-Ganz Catheter? |
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Definition
Measure filling pressures (fed through Right heart and PA to pulmonary capillaries ) to help determine left atrial pressure (indirect measure)
Gives you hemodynamic profiles!
1) volume status (higher means wet)
2) contractile state
3) pulmonary and systemic vascular tone |
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Term
| What pharmacological strategies should be employed for systolic HF? |
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Definition
Remember, systolic HF will have decreased EF (<45%), because you can't pump the blood.
1) Fluid removal for volume overload
- Diuretics and ultrafiltration
2) Vasodilation
- Nitro, sodium nitroprusside, ACEi, Hydralazine
3) Inotropic therapy
- Dobutamine, milrinone |
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Term
| What should be done for a patient with decompensated HF who cannot be stabilized with pharmacotherapy alone? |
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Definition
Mechanical support
1) IABP for short-term
- timed to cardiac cycle
- Limited by vascular complications, infection, tachyarrhythmias and bed-rest
2) LVAD for long-term
- gets blood from LV and return it to aorta
- can be "bridge" to transplant or "destination therapy" |
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Term
73F h/o type II DM, HTN, Obesity and longstanding, slowly progressive DOE presents with acute SOB after returning from weekend at Mountaineer Casino.
PE: Tachypneic, HR 100 Afib, BP 190/90
What is your diagnosis? |
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Definition
Seems like volume overload with elevated cardiac filling pressures and preserved LV systolic function.
1) h/x of DM, HTN and Obesity are risk factors for LVH, non-systolic HF.
2) Trip suggests dietary/medication non-adherance?
3) DOE, SOB suggest volume overload |
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Term
| Why are patients with non-systolic HF so sensitive to volume changes? |
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Definition
1) Steep LVEDV:CO curve, such that small drops in LVEDV cause huge drops in CO.
2) Takes very little volume to increase LVEDP (pulmonary HTN) |
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Term
| What 2 problems in non-systolic HF are caused by A fib? |
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Definition
Can't fill it up!
1) Loss of "atrial kick" gives impeded filling
2) Loss of diastolic filling time from rapid heart rate also impedes filling |
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Term
| What pharmacological strategies should be employed for non-systolic HF? |
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Definition
1) Fluid removal for volume overload
- usually modest with diuretics
2) Treat contributors
- HTN
- Ischemia
- Dysrhythmia
** Look for dietary or medication non-adherence and non-cardiac co-morbidities** |
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Term
46F longstanding PH on epoprostenol presents with abdominal bloating, BLE edema and syncope after climbing one flight of stairs.
PE: Tachypneic, HR 100, BP 90/50, ++ ascites and edema, loud P2, + RV lift |
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Definition
RHF from pulmonary hypertension from excessive pre-load and afterload
Epoprostenol (Prostacyclin) will cause vasoconstriction.
1) Ascited, Edema and SOE suggest volume overload
** Syncope is poor sign in pulmonary hypertension and suggests RHF**
2) Tachypnea and Hypotension suggest poor perfusion
3) Loud P2 suggests elevated pulmonary pressure and lift indicates elevated RV pressure |
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Term
| What pharmacological strategies should be employed for RHF? |
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Definition
1) Fluid removal
- Difficult given pre-load-dependence of abnormal RV
2) Pulmonary vasodilators
- PAH specific (ERA-endothelin-receptor agonist, PDE5i, prostacyclin)
3) Inotropes
- Milrinone preferred for pulmonary |
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