heart failure 2013 diagnostic procedures

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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