1. Medical Science Tanzania Cardiology Lectures
Congestive Heart Failure
2. Diagnostic procedures
Prof. Hennersdorf SES
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2. Procedures
• Clinical pathways
• Echocardiography
• Biochemistry
• Hemodynamics
• Imaging: Angiography, MRI
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3. Procedures
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4. General signs and symptoms
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5. 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!
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6. NYHA
NYHA II NYHA III NYHA IV
NYHA I without clinical signs and symptoms
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7. 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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8. Pulmonary edema/orthopnea
Pulmonary edema
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9. Swelling by fluid retention
Pulmonary edema
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10. Swelling by fluid retention
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11. 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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12. 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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13. Physical examination: heart sounds
S4 S1 S2 OS S3
Sound
ECG
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14. Physical examination: heart sounds
S1 S2 S3
midsystolic murmur Sound
ECG
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15. Physical examination:
functional tests
 6-min walk: Pt. is forced to walk as he likes walking,
standing, running etc. The achieved distance is
documented
and should reach
>350 (female) - 400 (male) m
weak 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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16. Physical examination:
Exercise device ergometry equipment
ECG Cart
Emergency Kit
(necessary)
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17. Procedures
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18. Echocardiography
 Underlying disease
 Cardiomyopathy
 Valve disease
 CHD (Stress Echo)
 Pathophysiology: LV filling patterns
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19. Left heart failure: US LVDD*
*left ventricle diast.
Diameter, norm
<50<mm
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20. Left heart failure: US TMF*
A B
C A normal transmitral filling
B early diastolic dysfunction
C progredient diastolic
Dysfunction
*Transmitral flow
DT deceleration time
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21. Left heart failure: US MI
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22. Left heart failure: US TR*
Eval.
systolic PA pressure *Tricuspid
regurgitation
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23. Procedures
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24. Chest XRay CXR
normal finding
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25. Chest XR CXR
Pulmonary edema
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26. Chest XR CXR
Pulmonary edema Pulmonary edema
before therapy after successful therapy
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27. Angiography indications
 Underlying disease (CHD) with therapeutic
consequences (PCI, CABG)
 Intervention (cardiogenic shock)
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28. Left heart failure, hemo + angio
Angio
+
hemodynamics
Left ventricle shape, size and function Pumping, blood delivery, work
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29. Left heart failure:
right heart hemodynamics
SWAN GANZ Catheter PA Pressure monitoring
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30. Left heart failure, hemodynamics
Measurements:
Cardiac output
Ventricular filling pressures,
Vascular resistances
Work load
Work capacity
Limited clinical value, limited use to invasive cases (Cathlab,OP),
potentially harmful!
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31. HF parameter by heart catheterization
Some hemodynamic values
Cardiac output/index norm 2-2.5 l(min/m 2)
Stroke work norm 21 mjoule
enddiastolic pressure norm 12 mm Hg
Vascular bed resistances (norm)
TPR 1200 dyn*sec*cm-5
PVR 70 dyn*sec*cm-5
Clinical use limited to ICU control
during vasoactive therapy
e.g. of cardogenic shock
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32. CHF parameter by angiography*
Ejection fraction EF
EDV**
EF = --------------- x 100 (%)
EDV**-ESV***
Norm = 70%
Strongest predictors
Reduced = <40%
Low= <20% of survival and prognosis
*today fairly achieved by echocardiography
**Enddiastolic volume/area
*** endsystolic volume/area
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33. Angiography diagnose: LV shape
Systole
Regional scar Diastole
EF < 20%
red lines
Diastole show normal
contraction
Regional scar
Systole
Anterior wall infarction
Dilated cardiomyopathy
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34. Angiography diagnose: LV shape
Regional scar
Diastole
Regional scar
Systole
EF 70%
normal infarction
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35. CHF and MRI
• Dimensions
• Contractility, Viability
• Valve function
MRI crossectional
sequence of dilated LV
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36. Procedures
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37. 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
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38. 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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39. 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)
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40. The End
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