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Investigating The Heart Failure Patient
- 1. INVESTIGATING THE HEART FAILURE PATIENT BY DR KIMTO OCHE EMMANUEL DEPARTMENT OF INTERNAL MEDICINE JUTH CARDIOLOGY UNIT 110/24/2020 1
- 2. OBJECTIVES Overview of Heart failure Investigation as part of managing HF Patients The relevance of the different investigations The specific and non-specific Heart failure investigations 10/24/2020 2
- 3. OUTLINE • Introduction • Clinical vignette • Definition • History • Epidemiology • Etiology • Classification • Pathophysiology • Clinical features • Investigation • Diagnosis • Treatment • Future trend • Conclusion 10/24/2020 3
- 4. CLINICAL VIGNETTE • A 70 year old male known hypertensive diagnosed 2years ago, not regular with his medications • Cough and breathlessness of 4weeks • Bilateral leg swelling of 2weeks • Cough was productive of non bloody frothy sputum • Breathlessness initially on mild exertion and progressed to at rest with orthopnoea and PND 10/24/2020 4
- 5. • o/e–elderly man in respiratory distress, afebrile, pale, anicteric, acyanosed, not dehydrated, no significant lymphadenopathy with bilateral pitting pedal oedema up to the knees • CNS- Conscious, nil CND, nil FND • CVS-PR-100bpm, regular, moderate volume • BP-100/70mmHg, distended neck veins, JVP- raised, AB-6LICS AAL, apical heave HS-S1, S2 + S3, 3/6 psm 10/24/2020 5
- 6. • Chest-RR-30cpm, fine creps bi-basally • Abd-Full, moves with respiration ,right hypochonrial tenderness -liver enlarged by 6cm below right costal margin, tender and smooth. So Ko • ASST–CCF 2o HHDx precipitated by poor drug compliance 10/24/2020 6
- 7. • Pcv-30% • U/E, FBC-essentially normal • Abd uss–Normal except for minimal ascites • CXR-Cardiomegaly of biventricular configuration, unfolded aorta, upper lobe diversion 10/24/2020 7
- 8. • ECG- Tachycardia LVH left axis deviation prolong QT • Echo-EF–29% all chambers dilated with thickened LV posterior wall, evidence of mitral and tricuspid regurgitation, systolic and diastolic dysfunction 10/24/2020 8
- 9. • IV Frusemide 80mg dly • Tabs Aldactone 25mg dly • Tabs Lisinopril 2.5mg dly • Tabs Digoxin 0.25mg dly • Tabs Vasoprin 75mg dly • Patient did well after 1week of admission and was discharged to see 2/52 in MOPD 10/24/2020 9
- 10. INTRODUCTION • ‘‘Nothing matters but the facts. Without them, the science of investigation is nothing more than a guessing game.’’ -Blake Edward 10/24/2020 10
- 11. • Heart failure is the end pathway for myriad of diseases that affect the heart • Clinical syndrome that occurs in patients with inherited or acquired abnormality • Present as constellation of signs and symptoms leading to frequent hospitalization and poor quality of life 10/24/2020 11
- 12. DEFINITION A condition in which the heart fails to discharge its contents adequately A pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolizing tissues 10/24/2020 12
- 13. HISTORY • Luke 14:1-6 (Dropsy) • Leonardo da Vinci (1452–1519) investigated coronary arteries • Descriptions of heart failure exist from ancient Egypt, Greece, and India • Romans were known to use the foxglove as medicine 10/24/2020 13
- 15. 10/24/2020 15
- 16. EPIDEMIOLOGY • Global problem with > 20million people affected • 2% prevalence in adult population of developed countries • Prevalence rises with age and affects 6-10% people over 65yrs • Incidence is higher in men than women 10/24/2020 16
- 17. Contributory Studies • According to Cardiovascular Co-Morbidity in Adults with COPD: Prevalence, Associated Factors and Impact on Outcomes Over 450 Days (Amusa et. al) Pulmonary hypertension (45.5%), Systemic hypertension (38.2%), Arrhythmias (40%) and Heart failure (30.9%) were the commonest co- morbid CVD 10/24/2020 17
- 18. • According to Heart Failure with Recovered Ejection Fraction: Report of a Case in Jos, Nigeria (Okeahialam et. al) It is possible depending on the etiology and background myocardial condition for some HF cases to recover EF with treatment 10/24/2020 18
- 19. • According to Cardiovascular Abnormalities In HIV Infected Patients At The Jos University Teaching Hospital (G. A. Amusa) Increased cardiovascular disease risk factors and cardiovascular abnormalities are common findings in HIV infected persons 10/24/2020 19
- 20. • According to Anxio-depressive symptoms in patients with Cardiac Failure in Jos University Teaching Hospital (JUTH) (Obindo et. al) Prevalence of Depression and Anxiety in the study population was 36.7% and 42.2% respectively 10/24/2020 20
- 21. • According to Pattern of heart failure in Abuja, Nigeria: an echocardiographic study (Ojibidi et. al) The commonest cause of heart failure identified was hypertension in 61.5% of the patients; 75.5% had systolic heart failure, whereas 23.5% had heart failure with preserved ejection fraction 10/24/2020 21
- 22. • According to Contemporary Profile of Acute Heart Failure in Southern Nigeria: Data From the Abeokuta Heart Failure Clinical Registry (Okechukwu et. al) Hypertensive heart failure was the most common etiological cause of heart failure, responsible for 78.5% of cases. Dilated cardiomyopathy (7.5%), cor pulmonale (4.4%), pericardial disease (3.3%), rheumatic heart disease (2.4%), and ischemic heart disease were less common (0.4%) causes 10/24/2020 22
- 23. • According to Update on rheumatic heart disease in Kano: Data from the Aminu Kano Teaching Hospital echocardiography registry (Umar et. al) The commonest lesions were mixed mitral valve disease and aortic regurgitation (26.9%) followed by combination of mitral and aortic regurgitation (25%), and pure mitral regurgitation in 17.3%. Complications of RHD observed included secondary pulmonary hypertension (50%), left ventricular dysfunction (40.4%), atrial fibrillation (AF) (8.7%), infective endocarditis (1.9%), and intra cardiac thrombus (1.9%) 10/24/2020 23
- 24. • According to Predictors of Rehospitalization in Patients Admitted With Heart Failure in Abeokuta, Nigeria: Data From the Abeokuta Heart Failure Registry (Okechukwu et. al) Worsening HF (24 cases, 75%) was the commonest reason for readmission. Among others, factors associated with rehospitalization included presence of mitral regurgitation (odds ratio [OR] 2.37, 95% CI 1.26e4.46), age $60 years (OR 2.04, 95% CI 0.96e3.29), presence of tricuspid regurgitation (OR 1.77, 95% CI 0.86e3.61), and presence of atrial fibrillation (OR 1.34, 95% CI 0.59e3.03) 10/24/2020 24
- 25. ETIOLOGY • Any condition that leads to an alteration of cardiac structure and function predisposes to heart failure, viz: Hypertension • Rheumatic heart disease • Cardiomyopathy (dilated) • Ischaemic heart disease • Cardiomyopathy (undilated) • Anaemia • Thyrotoxicosis 10/24/2020 25
- 26. • Valvular heart disease • Congenital heart disease • Alcohol and drugs • Hyperdynamic circulation • Right heart failure • Tricuspid incompetence • Arrhythmias • Pericardial disease 10/24/2020 26
- 27. CLASSIFICATION NYHA Functional Classification for Congestive Heart Failure • The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying heart disease, useful for preoperative assessment 10/24/2020 27
- 28. • Class I: no symptoms on ordinary physical activity • Class II: slight limitation of physical activity by symptoms • Class III: less than ordinary activity leads to symptoms • Class IV: inability to carry out any activity without symptoms 10/24/2020 28
- 29. AHA/ACC CLASSIFICATION • Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder • Stage B: a structural heart disorder but no symptoms at any stage • Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment • Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care 10/24/2020 29
- 31. 10/24/2020 31
- 34. DIAGNOSIS • The diagnosis of Heart Failure is largely clinical • And the Framingham Criteria has been formulated for this purpose 10/24/2020 34
- 35. FRAMINGHAM CRITERIA Major criteria • Paroxysmal nocturnal dyspnea • Neck vein distention • Rales • Radiographic cardiomegaly • Acute pulmonary edema S3 gallop • Increased central venous pressure • Hepatojugular reflux • Weight loss >4.5 kg in 5 days in response to treatment Minor criteria • Bilateral ankle edema • Nocturnal cough • Dyspnea on ordinary exertion • Hepatomegaly • Pleural effusion • Decrease in vital capacity by one third from maximum recorded • Tachycardia 10/24/2020 35
- 36. INVESTIGATION SPECIFIC (Non-invasive and Invasive) • Chest X-ray • Electrocardiogram • Echocardiography • Stress echocardiography • Radionuclide imaging • Cardiac MRI • Positron emission tomography (PET) • Natriuretic peptide • Cardiac catheterization • Coronary angiography • Endomyocardial biopsy 10/24/2020 36
- 37. NON-SPECIFIC (General) • Full Blood Count • Electrolyte Urea and Creatinine • Urinalysis • Fasting Blood Sugar • Random Blood Sugar • Liver Function Test • Fasting Lipid Profile • Thyroid Function Test • Serology • Toxicology • Air Blood Gases 10/24/2020 37
- 39. CHEST X-RAY Chest x-ray findings: • Alveolar edema (bat wings) • Kerley B lines Cardiomegaly • Dilated prominent upper lobe pulmonary vessels Pleural effusion Fissural edema 10/24/2020 39
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- 43. Kerley B lines 10/24/2020 43
- 45. Dilated Upper lobe vessels 10/24/2020 45
- 48. ELECTROCARDIOGRAM (ECG) • ECG findings are not diagnostic, but an abnormal ECG can be of help, especially showing previous: Atrial arrhythmias Chamber enlargements Conduction abnormalities Ischaemic heart diseases Ventricular arrhythmias Miscellaneous • An entirely normal ECG is uncommon in chronic HF 10/24/2020 48
- 50. ATRIAL ARRHYTHMIAS • Atrial Fibrillation • Atrial Flutter • Sinus Arrhythmia • Sinus Bradycardia • Sinus Tachycardia 10/24/2020 50
- 56. CHAMBER ENLARGEMENTS • Left Atrial Enlargement • Left Axis Deviation • Left Ventricular Hypertrophy • Right Atrial Enlargement • Right Axis Deviation • Right Ventricular Hypertrophy 10/24/2020 56
- 63. CONDUCTION ABNORMALITIES • Atrioventricular Block • Bifascicular Block • Left Bundle Branch Block • Right Bundle Branch Block • Trifascicular Block 10/24/2020 63
- 66. Left Bundle Branch Block 10/24/2020 66
- 67. Right Bundle Branch Block 10/24/2020 67
- 69. ISCHAEMIC HEART DISEASE • Anterior Wall ST Segment Elevation MI • Inferior Wall ST Segment Elevation MI • Posterior Wall MI 10/24/2020 69
- 70. Anterior Wall ST Segment Elevation MI 10/24/2020 70
- 71. Inferior Wall ST Segment Elevation MI 10/24/2020 71
- 72. Posterior Wall MI 10/24/2020 72
- 73. VENTRICULAR ARRHYTHMIAS • Asystole • Premature Ventricular Contractions • Ventricular Fibrillation • Ventricular Tachycardia 10/24/2020 73
- 78. MISCELLANEOUS • Atrial Septal Defect • Brugada Syndrome • Digoxin Effect • Pericarditis • Hypertrophic Obstructive Cardiomyopathy 10/24/2020 78
- 84. 24HOURS HOLTER MONITORING • It is used if arrhythmia is suspected as the cause of heart failure • It is similar to the ECG, but records heart rate and rhythm for 24hours 10/24/2020 84
- 85. 10/24/2020 85
- 86. ECHOCARDIOGRAPHY (ECHO) • ECHO can help evaluate: chamber dimensions valve function EF wall motion abnormalities LV hypertrophy pericardial effusion Intracardiac thrombi tumors and calcifications within the heart valves 10/24/2020 86
- 87. • Doppler echocardiography accurately detects valvular disorders and shunts • Doppler studies of mitral and pulmonary venous inflow often help identify and quantify LV diastolic dysfunction • Measuring LV EF can distinguish between predominant diastolic dysfunction (EF > 0.50) and systolic dysfunction (EF < 0.40) 10/24/2020 87
- 93. STRESS ECHOCARDIOGRAPHY • Stress echocardiography has no radiation hazard • It is reliable for detecting ischaemia as a cause of persistent but reversible cardiac dysfunction and • In determining the viability of akinetic myocardium in patients with heart failure 10/24/2020 93
- 96. • Radionuclide imaging also can help assess systolic and diastolic function • Previous MI, and • Inducible ischemia or myocardial hibernation 10/24/2020 96
- 97. 10/24/2020 97
- 98. CARDIAC MAGNETIC RESONANCE IMAGING (MRI) • Sir Peter Mansfield made the famous breakthrough at the University of Nottingham in 1977 • Subsequently used in cardiology for diagnosis • Cardiac MRI provides accurate images of cardiac structures 10/24/2020 98
- 100. POSITRON EMISSION TOMOGRAPHY (PET) • When other tests cannot provide satisfactory results • PET scanning can be used, especially to identify potentially viable muscle that is hibernating • The importance of identifying the pathology is that appropriate treatment may restore the function • It can determine myocardial blood flow and cellular metabolism very precisely 10/24/2020 100
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- 102. NATRIURETIC PEPTIDE • Serum Brain Natriuretic Peptide (BNP) levels are high in HF>100pg/ml • BNP>400pg/ml_poor prognosis • N-terminal pro-brain natriuretic peptide (NT-pro- BNP), an inactive moiety created when pro BNP is cleaved, can be used similarly. 0-74yrs<125pg/ml; 75yrs<450pg/ml • BNP it is very important in protecting the heart 10/24/2020 102
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- 104. CARDIAC CATHETERIZATION • The history of cardiac catheterization dates back to • Stephen Hales (1677-1761) and • Claude Bernard (1813-1878) • Both used it on animal models 10/24/2020 104
- 105. • Dr. Werner Forssmann (1929)_ first clinical application • Inserted a catheter into the vein of his forearm • guided it fluoroscopically into his right atrium, and • took an X-ray picture of it 10/24/2020 105
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- 111. CORONARY ANGIOGRAPHY • André Cournand and Dickinson Richards (1940s)_ diagnostic • Mason Sones (1960s)_ selective coronary angiography • It is indicated when CAD is suspected or the etiology of HF is uncertain 10/24/2020 111
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- 113. ENDOMYOCARDIAL BIOPSY • It is sometimes done when an infiltrative cardiomyopathy is strongly suspected but cannot be confirmed with noninvasive imaging 10/24/2020 113
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- 116. FULL BLOOD COUNT (FBC) • Anaemia-IDA, Megaloblastic • Polycythaemia • Infection-Hep virus, Retrovirus, Adenovirus, CMV, Staph aureus, Mycobacterium, Corynebacterium diphtheriae, Plasmodium sp • Infestation-Trichinella, Taenia solium, Echinococcus, Schistosoma, Toxocara, Ascaris 10/24/2020 116
- 117. RENAL FUNCTION TEST (E/U/Cr) • Kidney disease-AKI, CKD • Drug metabolism and excretion • Drug efficacy and toxicity • Dyselectrolytaemia-hyponatraemia, hypokalaemia • Prognostication 10/24/2020 117
- 118. FASTING BLOOD SUGAR (FBS) • Etiology of HF • Rule out DM • Baseline • Prognostication 10/24/2020 118
- 119. LIVER FUNCTION TEST (LFT) • To rule out liver pathology in preparation for treatment • Differential diagnosis • Congestive hepathopathy (Cardiac cirrhosis) • Hepatic enzymes derangement • Nutritional status • Drug efficacy and toxicity 10/24/2020 119
- 120. FASTING LIPID PROFILE (FLP) • Rule out differential diagnosis e.g Nephrotic syndrome • Etiology of HF • Co-morbidity • Prognostication 10/24/2020 120
- 121. THYROID FUNCTION TEST (TFT) • Etiology • Exacerbating factor • Prognosis 10/24/2020 121
- 122. SEROLOGY • Rule out immunosuppression • Etiology-Hep C and B, Retrovirus • Viral myocarditis-Coxackievirus, Parvovirus, Herpes • Drug toxicity-Zidovudine 10/24/2020 122
- 123. TOXICOLOGY • Etiology-Cannabis, Cocaine, Amphetamine, Alcohol 10/24/2020 123
- 124. AIR BLOOD GASES (ABG) • To assess blood PH and oxygenation • Etiology-Cardiac or non-cardiac 10/24/2020 124
- 126. Non-pharmacological Lifestyle modifications • Patient education • Dietary modifications i.e. low salt intake • Weight reduction • Exercise • Cessation of smoking • Reduction/cessation of alcohol consumption 10/24/2020 126
- 127. Pharmacological The principles of treatment: • Reduce afterload (diuretics) • Reduce preload (nitrates) • Increase force of contractility (digoxin) • Treat underlying cause (depends on cause) 10/24/2020 127
- 128. • Diuretics • ACEIs/ARBs • Beta blockers • Alpha antagonists • Direct acting vasodilators • Aldosterone antagonists • Cardiac glycosides • Anticoagulants • Anti-arrhythmic drugs 10/24/2020 128
- 129. Surgical • Revascularisation • Implantable cardiac defibrillators • Cardiac transplant 10/24/2020 129
- 131. CONCLUSION • Heart failure is a global problem • Early and accurate diagnosis HF is key in its management and outcome 10/24/2020 131
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- 133. REFERENCES • Harrison’s Principles of Medicine • Emedcine.medscape.com/article • Medical students’ lecture notes • Slideshare on heart failure • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542986/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117316/ • https://www.ajol.info/index.php/njpsyc/article/view/69913 • https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA. 116.023518 • https://www.sciencedirect.com/science/article/pii/S2213177 91400095X 10/24/2020 133