the problem in epidemic proportions to be encountered early in CV Practice by investigations

1. Heart Failure
CONCLAVE

2. Investigations: for Heart Failure
Dr. Nagula Praveen,
MD,DM (Cardiology)

4. CASE
 A 65-year male, hypertensive, smoker, came with worsening shortness of breath of two days. He experienced
chest pain prior to the onset of dyspnea, consulted local doctor was advised medications which relieved the
discomfort for the day.
 Medications were telmisartan 40mg, metoprolol 25 mg.
 At presentation, patient profusely sweating, dyspneic,SP02 – 88% on room air
 Pulse 110/min
 BP – 90/60mm Hg
 LVS3,Systolic murmur over the apex.
 Bilateral crepitations over the lung fields.

5. What to Expect??
 Whether HF is present?
 Underlying etiology?
 Type of heart failure?
 Severity of HF?
 Identify comorbidities.
 Clinical response to treatment.
 Prognostication.

6. 6

7. Physical examination findings
Abdomen: hepatojugular reflux, ascites
Extremities: cool, dependent edema
Heart: bradycardia/tachycardia, laterally displaced poin
t of maximal impulse, third heart sound (gallop or murm
ur)
Lungs: labored breathing, rales
Neck: elevated jugular venous pressure
Skin: cyanosis, pallor
 Patient history and physical examination are useful to evaluate for alternative or reversible causes
Symptoms
Symptoms for
alternative causes
Physical examination findings
Abdomen: distended, hepatosplenomegaly, tender, ascites
(liver disease)
Extremities: joint inflammation/warmth (rheumatologic
disease)
Heart: irregular rate or rhythm (arrhythmia)
Lungs: wheezing (pulmonary disease)
Neck: thyromegaly /nodule (thyroid disease)
Skin: cyanosis (anemia), jaundice (liver failure)
King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012 Jun 15;85(12):1161-8. PMID: 22962896..
History and Physical Examination

8.  Complete blood count (CBC) (anaemia)
 Iron studies
 Urinalysis (renal causes)
 Electrolyte levels (electrolyte imbalance)
 Renal function test (renal causes)
 Fasting blood glucose levels
 Lipid profile
 Thyroid stimulating hormone (TSH) levels (thyroid disorders)
 Complete metabolic profile for levels of serum electrolytes including calcium and magnesium (diuretics, cause of arrhythmia)
 Blood urea nitrogen
 Serum creatinine
 Liver function tests (hepatic congestion, volume overload)
Davies MK, Gibbs CR, Lip GY. ABC of heart failure: investigation. BMJ: British Medical Journal. 2000 Jan 29;320(7230):297
Laboratory Tests to rule out Heart Failure

9. 12-lead ECG is recommended in all patients
presenting with signs and symptoms of HF
A normal ECG may exclude HF in nearly 90%
of the cases
King, M., Kingery, J. E., & Casey, B. (2012). Diagnosis and evaluation of heart failure. American Family Physician, 85(12), 1161-1168.
12-lead electrocardiography (ECG)

10. • Heart rate
• PR interval
• QRS duration
• QT interval
• Pathological Q waves
• Evidence of left atrial (LA) overload
• Left ventricular (LV) hypertrophy
• Bundle branch block
• Helps to understand the etiology of the disease, e.g., presence of ST-segment deviation, T-wave
inversion or pathologic Q-waves might indicate the presence of CAD
• Provides information about the prognosis of the disease
• Helps understand the indications for therapy, e.g., anticoagulation for AF, pacing for bradycardia
• Indicates presence of ventricular tachyarrhythmia
Role of ECG in HF Diagnosis
12-Lead Electrocardiography (ECG)
Davies MK, Gibbs CR, Lip GY. ABC of heart failure: investigation. BMJ: British Medical Journal. 2000 Jan 29;320(7230):297.
Specific points to be noted in an ECG
In identifying HF resulting from left ventricular systolic dysfunction
*Electrocardiographic abnormalities are defined as atrial fibrillation, evidence of previous myocardial infarction, left ventricular hypertrophy, bundle branch block, and left
axis deviation
Value of electrocardiography*
Normalized
amplitude
Seconds
Normal CHF
Seconds
Normalized
amplitude

11.  Cardiac enlargement (cardiothoracic ratio >50%), a poor correlation between the cardiothoracic ratio and left ventricular function
 Presence of cardiomegaly – due to severity of hemodynamic disturbance and its duration
 Increased cardiothoracic ratio due to left or right ventricular dilatation
 Echocardiography - to distinguish reliably between these different causes
 In left sided failure, pulmonary venous congestion occurs initially in the upper zones.
 Frank pulmonary oedema occurs due to pulmonary venous pressures above 25 mm Hg
 Bilateral pleural effusions occur, the right side is more commonly affected if they are unilateral
Davies MK, Gibbs CR, Lip GY. ABC of heart failure: investigation. BMJ: British Medical Journal. 2000 Jan 29;320(7230):297.
Chest X-ray Examination
Pulmonary congestion in heart failure
Tachycardia mediated cardiomyopathy
 Recommended in patients with suspected, acute decompensated, or new-onset HF
 Useful tool to identify pulmonary venous congestion or edema in HF

12.  Provides an objective assessment of cardiac structure and function
 A quantitative measurement can be obtained from calculation of the LVEF
 Regional abnormalities can also be quantified into a wall motion index
 These abnormalities - Hypokinetic (reduced systolic contraction), akinetic
(no systolic contraction) and dyskinetic (abnormalities of direction or timi
ng of contraction, or both), refer to universally recognized segments of
the left ventricle
 Also show other abnormalities, including valvar disease, left ventricular
aneurysm, intra cardiac thrombus, and pericardial disease
 Assistance with decisions about embolic risk
Who should have an echocardiogram?
 Almost all patients with symptoms or signs of HF
 Symptoms of breathlessness in association with signs of a murmur
 Dyspnea associated with atrial fibrillation
 Patients at “high risk” for left ventricular dysfunction—for example, those
with anterior myocardial infarction, poorly controlled hypertension, or
arrhythmias
Echocardiography
Davies MK, Gibbs CR, Lip GY. ABC of heart failure: investigation. BMJ: British Medical Journal. 2000 Jan 29;320(7230):297.

13. ECHOCARDIOGRAPHY
Transthoracic
echocardiography
Transesophageal
echocardiography
Stress
echocardiography
Preferred choice to assess both LV and
right ventricular systolic and diastolic f
unction
Important modality in certain clinical scenarios (patie
nts with congenital heart disease, valve disease,
suspected aortic dissection or suspected endocarditis
, and to rule out intracavitary thrombic in patients
with AF who need cardioversion)
• Help assess inducible ischemia, exerci
se capacity and /or myocardium viability
• In the assessment of valve morpholog
y for possible intervention
Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., ... & Van Der Meer, P. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chroni
c heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European heart journal, 37(27), 2129-2200.
Echocardiography..

14. Echocardiography: Advantages and Disadvantages
Modality Advantages Disadvantages
Tissue Doppler imaging
• Very high frame rates resulting in excellent temporal resolution
• Good for assessment of longitudinal velocities
• Extremely angle independent
• Not suitable for assessment of deformation in the circumfe
rential and radial directions as well as rotation
Two-dimensional speckle-tracking
echocardiography
Relatively angle independent, permits comprehensive assessm
ent of myocardial deformation
• Depends on gray-scale image quality
• Tracking suboptimal at too low or too high frame rates (opti
mal frame rate 50–80/s). Affected by through plane motion
• Quality of tracking is better in proximal than in distal speckl
es
• Inability to permit simultaneous assessment of deformatio
ns in all directions Vendor dependence
Three-dimensional speckle- tracking
echocardiography
• Permits simultaneous assessment of myocardial deformati
on in all directions
• Obviates the problem of through-plane motion. More number o
f speckles in the pyramidal volume sample enhance tracking
quality
• Depends on gray-scale image quality
• Limited spatiotemporal resolution
• Technically demanding; relative complexity of offline i
mage processing Vendor dependence
Different Modalities of Echocardiographic Deformation Imaging
Omar, A. M. S., Bansal, M., & Sengupta, P. P. (2016). Advances in echocardiographic imaging in heart failure with reduced and preserved ejection fraction. Circulation rese
arch, 119(2), 357-374.

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17. Echocardiographic Modalities:
Evaluation and Risk Stratification of HF Patients
Omar, A. M. S., Bansal, M., & Sengupta, P. P. (2016). Advances in echocardiographic imaging in heart failure with reduced and preserved ejection fraction. Circulation rese
arch, 119(2), 357-374.
Phenotyping and prognostic
assessment
Role in the evaluation of HF patients
Additional markers of
prognosis
LV mass
LV volumes
and EF 3D LV volumes
and EF
LV myocardial
deformation
Intracardiac flow
mapping
LV dys-synchrony
Functional MR
LA volume
LV diastolic function and
filling pressures
Pulmonary artery
Systolic pressure
LV wall thickness and volumes

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19. BIOMARKERS
19

20.  To rule out HF
 To assess short - term prognosis (admission BNP)
 To estimate long - term prognosis (discharge BNP)
 For guided (tailored) HF therapy
• As per European Society of Cardiology guidelines, for clinical purposes in India, a BNP value of >500 pg/mL or a NT-pro-BNP value of 1000 pg
/mL strongly suggests the possibility of HF
• Of the array of biomarkers available for the diagnosis of HF, BNP and NT-pro-BNP are the ones that are extensively used clinically
When pharmacotherapy for HF involves an ARNI, NT-pro-BNP and not BNP, should be the preferred biomarker; because ARNI
acts by increasing BNP levels. Lower NT-pro-BNP levels indicates better prognosis.
Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., ... & Van Der Meer, P. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chroni
c heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European heart journal, 37(27), 2129-2200.
Role of BNP and NT-pro-BNP in HF
Biomarkers

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24.  Tissue damage
 Reduced blood flow in the heart muscle to help determine whether heart artery blockages are the cause of the chest pain (angina)
 Problems in the aorta such as a tear, aneurysm (bulge), or narrowing
 Diseases of the pericardium (outer lining of the heart muscle) such as constrictive pericarditis
 Heart valve disorders, such as regurgitation
 Congenital heart problems and the success of surgical repair
Magnetic resonance imaging (MRI) helps in diagnosing:
• Angiography - in patients with recurrent ischemic chest pain associated with HF and in those with evidence of severe reversible ischemia or
hibernating myocardium
• Cardiac catheterization with myocardial biopsy - Valuable in more difficult cases where there is diagnostic (In restrictive and infiltrating
cardiomyopathies [amyloid heart disease, sarcoidosis], myocarditis, and pericardial disease)
• Left ventricular angiography show global or segmental impairment of function and assess end diastolic pressures
Angiography, Cardiac Catheterization, and Myocardial Biopsy
• The assessment of the global left and right ventricular function
• substantial reproducibility and the low intra-observer and inter-observer variability
• assessment of ejection fraction, systolic filling rate, diastolic emptying rate, and wall motion abnormalities
• Ideal for the serial reassessment of ejection fraction, but expose the patient to radiation.
Radionuclide ventriculography
Other Diagnostic Tests that can Aid Diagnosis of HF

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29. JACC Cardiovasc Imaging 2008;1:652 29

30. Coming to case.
 ECG – Evolved Inferolateral wall STEMI
 ECHO – severe MR, Moderate LV dysfunction
 NT proBNP – 1970pg/ml
 CXR – Cardiomegaly, pulmonary edema
 FBS – 220 mg/dl
 Serum creatinine – 1.7 – 1.1mg/dl
 Planned for CAG
 After CAG further management
30

31. Key takeaways
The burden of heart failure is in epidemic proportions, but effective treatments that improve quality of life and survival are available.
Accurate and timely diagnosis is crucial to ensure patients receive appropriate treatment and avoid hospital admissions. However, diagnosing
heart failure can be difficult as symptoms and signs commonly overlap with other conditions.
A chest X-ray can be useful to identify evidence of heart failure or other lung pathology; however, a normal result does not rule out a
diagnosis of heart failure.
An electrocardiogram (ECG) is often abnormal in patients with heart failure, although up to 10% of patients may have a normal ECG.
Natriuretic peptides are a useful biomarker for heart failure & a negative result can rule out the diagnosis. This can be helpful in determining
who should be referred for echocardiogram

33. Thank You !