Tuesday, September 17, 2013

How to Make Diagnosis of Heart Failure

History or Anamnesis
              There are three primary objectives of the history when interviewing a patient with Heart Failure:
           1. Identify etiology of Heart Failure
           2. Asses progression and severity of illness
           3. Assess volume status

First, it is important to identify factors that may have contributed to the etiology of the Heart Failure. For patient with presentation of Heart Failure, questioning should probe the likehood of ischemic heart disease (history of MI, chest pain, risk factors), myocarditis or viral cardiomyopathy (recent viral illness or upper respiratory symptoms, rheumatologic disease history of symptoms), genetic cardiomyopathy (family history of Heart Failure or sudden death) toxic cardiomyopathy (alcohol or drug abuse, history of chemotherapy), and peripartum cardiomyopathy (recent pregnancy). In Addition, the presence of hypertension and/or diabetes should be elicited. For patients with a known cardiomyopathy presenting with an acute decompensation, it is important to identify the potential triggers of the exacerbation. A helpful mnemonic is "patients who are frequently hospitalized for Heart Failure eventually VANISH".

         1. Valvular disease
         2. Arrytmia (Atrial fibrillation)
         3. Noncompliance (medications, diet)
         4. Ischemia or infection
         5. Substance abuse
         6. Hypertension

             The second critical area to asses in patients with new-onset or established Heart Failure is their current functional status and the rate of decline in their activity level. Important questions to ask include what they can do before becoming short of breath currently (How far can they walk? How many flights of stairs can they climb?) and how this compares with what they were able to do 6 to 12 months prior. The answers to these questions allow patients to be categorized into a New York Heart Association (NYHA) functional class and an American Heart Association Heart Failure stage, which helps direct therapy and asses prognosis.
               
              The Third important issue to address with history is patient volume status. The inability to lie flat (orthopnea) and waking up at the night short of breath (paroxysmal nocturnal dyspnea) are very suggestive of volume overload in patients with CHD (Chronic Heart Failure). In addition, changes in body weight should always be discussed with the patient, as increased weight often signifies fluid retention even in the absence of other congestive symptoms. Other manifestations of increased fluid load include abdominal bloating and/or right upper-quadrant pain and lower extremity edema.


Physical Examinations
              The primary function of the physical exam in patients with Heart Failure is to asses volume status. However, the physical exam can also provide important clues as to the etiology of cardiac dysfunction. For example, the presence of a murmur or a pericardial knock may indicate a primary valvular process or pericardial constriction, respectively. In examining a patient, it is important to recognize that the clinical manifestations of heart failure and volume overload can be highly variable. Common exam findings suggesting systolic dysfunction and volume overload include jugular venous distention, a diffuse and laterally displaced point of maximum impuls (PMI), an S3 gallop, a mitral regurgitation (MR) murmur at the apex, pulmonary crackles, diminished carotid upstrokes, ascites, pulsatile hepatomegaly, and lower extremity edema.

              In assessing volume status by physical exam, it is useful to characterize the patient as hypovolemic, euvolemic, or volume-overloaded. Jugular venous distention is the most specific and reliable physical exam indicator of volume everload and is best assesed with a penlight and the patient positioned 45 degrees. The jugular venous  pulse can be distinguished from carotid pulsations by the biphasic appearance of the latter. It is important to remember that elevated neck veins can also be seen with pulmonary hypertension, servere tricuspid regugitation, and pericardial diseases such as tamponade and constriction. Pulmonary crackles may be present on lung exam and indicate fluid extravasation into the alveoli due to elevated left vebtricular end-diastolic pressure (LVEDP). This exam finding is often mistakenly considered mandatory for the diagnosis of Decompensated Heart Failure. In reality, crackles signify either rapid increases in LVEDP or severe volume overload; they are present in only 40% to 50% of Heart Failure patients with elevated filling pressure.

                In patients with chronic cardiomyopathy, the gradual increase in LVEDP is compensated for by increased lymphatic drainage; thus crackels are very late sign of decompensation, Lower extremity edema is another marker of fluid overload when present; however, the sensivity for predicting elevated filling pressures is poor, at 46%. In addition, saome patients can have predominantly abdominal congestive symptoms without any evidence of peripheral or pulmonary edema, Insummary, the physical exam is a critical component of volume assesment; however, it is important to know the limitations of common physical exam findings.

8 comments:

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