S2: Ch1 Cv 1-5

Front 1

142. Sx of left-sided CHF (15)?

Back 1

a. Dyspnea- 2º to pulmonary congestion/edema.
b. Orthopnea
c. Paroxysmal Nocturnal Dyspnea (PND)
d. Nocturnal cough (non-productive)
e. Confusion and memory impairment
f. Diaphoresis and cool extremities at rest.

Front 2

143. Orthopnea?

Back 2

a. Dyspnea while recumbent; relieved by elevation of head w/pillows.

Front 3

144. Paroxysmal Nocturnal Dyspnea (PND)?

Back 3

a. Awakening after 1-2 hours of sleep due to acute shortness of breath (SOB).

Front 4

145. Nocturnal cough in L. sided CHF- when is it worse?

Back 4

a. Worse in recumbent position (same pathophys as orthopnea).

Front 5

146. Why can people develop confusion and memory impairment w/L. sided CHF?

Back 5

a. Inadequate brain perfusion.

Front 6

147. Signs of left-sided heart failure?

Back 6

a. Displaced PMI (usually to the left) due to cardiomegaly
b. Pathologic S3 (ventricular gallop)
c. S4
d. Crackled/rales at lung base
e. Dullness to percussion and decreased tactile fremitus of lower lung fields caused by pleural effusion.
f. Increased intensity of pulmonic component of second heart sound.

Front 7

148. Pathologic S3?

Back 7

a. Rapid filling phase “into” a noncompliant left ventricular chamber.
b. May be normal finding in children; in adults, usually associated w/CHF.
c. May be difficult to hear, but is among the most specific signs of CHF.
d. Heard best at apex w/bell of stethoscope!
e. The sequence in the cardiac cycle for S3: S3 follows S2 (Ken-tuck-y)

Front 8

149. NYHA (NY Heart Association Classification)
150. NYHA class I CHF?

Back 8

a. Sx occur only w/vigorous activities, such as playing a sport.
b. Pts are nearly asymptomatic.

Front 9

151. NYHA class II CHF?

Back 9

a. Sx occur w/prolonged or moderate exertion, such as climbing a flight of stairs or carrying heavy packages.
b. Slight limitation of activities.

Front 10

152. NYHA class III CHF?

Back 10

a. Sx occur w/usual activities of daily living, such as walking across the room or getting dressed.
b. Markedly limited.

Front 11

153. NYHA class IV CHF?

Back 11

a. Sx occur at rest. Incapacitating.

Front 12

154. Tests to order for a new pt w/CHF (5)?

Back 12

1. CXR (pulmonary edema, cardiomegaly, rule out COPD)
2. ECG
3. ACP X3
4. CBC (anaemia)
5. Echocardiogram (estimate EF, rule out pericardial effusion).

Front 13

155. High-output Heart Failure?

Back 13

a. In high-output HF, an increase in CO is needed for the requirement of peripheral tissues for oxygen.

Front 14

156. Causes of high-output heart failure?

Back 14

1. Chronic anaemia
2. Pregnancy
3. Hyperthyroidism
4. AV fistulas
5. Wet beriberi (caused by thiamine [B1] deficiency)
6. Paget’s disease of bone
7. Mitral regurg
8. Aortic insufficiency
b. The conditions listed above rarely cause HF by themselves. However, if these conditions develop in the presence of underlying heart disease, heart failure can result quickly.

Front 15

157. Symptoms/signs of Right-sided heart failure?

Back 15

a. Peripheral pitting edema-pedal edema lacks specificity as an isolated finding. In the elderly, it is more likely to be secondary to venous insufficiency.
b. Nocturia- due to increased venous return w/elevation of legs.
c. JVD
d. Hepatomegaly/hepatojugular reflex.
e. Ascites
f. Right ventricular heave.

Front 16

158. Tx of mild CHF (Class I and II)?

Back 16

a. Mild restriction of sodium intake (no-added-salt diet of <4 g sodium) and physical activity.
b. Start a loop diuretic if volume overload or pulmonary congestion is present.
c. Use an ACE inhibitor as a first-line agent.

Front 17

159. Tx of mild to moderate CHF (NYHA Class II and III)?

Back 17

a. Start a diuretic (loop diuretic) and an ACE inhibitor
b. Add a β-blocker if moderate disease (class II and II) is present and the response to standard treatment is suboptimal.

Front 18

160. Tx of moderate to severe CHF (NY HA Class II and IV)?

Back 18

a. Add digoxin (to loop diuretic and ACE inhibitor).
b. Note: digoxin may be added at any time for the relief of sx in pts w/systolic dysfunction. (It does not improve mortality).
c. In pts w/class IV sx who are still symptomatic despite the above, adding spironolactone can be helpful.

Front 19

161. 6 tests for dx of CHF?

Back 19

1. CXR
2. Echocardiogram
3. ECG
4. Radionucleotide
5. Cardiac catheterization
6. Stress testing

Front 20

162. What do you see on a CXR for CHF?

Back 20

a. Cardiomegaly
b. Kerley B lines-short horizontal lines near periphery of the lung near the costophrenic angles. Indicate pulmonary congestion secondary to dilatation of pulmonary lymphatic vessels.
c. Prominent interstitial markings.
d. Pleural effusion.

Front 21

Initial test of choice for CHF?!?!?

Back 21

ECHO

Front 22

163. Echo for CHF-findings?

Back 22

a. Initial test of choice- should be performed whenever CHF is suspected based on hx, examination, or CXR.
b. Useful in determining whether systolic or diastolic dysfunction predominates, and determines whether the cause of CHF is due to a pericardial, myocardial, or valvular process.
c. Estimates EF (very important): pts w/systolic dysfunction (EF < 40%) should be distinguished from pts w/preserved L. ventricular function (EF > 40%).
d. Shows chamber dilation and/or hypertrophy.

Front 23

164. ECG for CHF?

Back 23

a. Usually non-specific but can be useful for detecting chamber enlargement and presence of ischaemic heart disease or prior MI.

Front 24

165. Radionuclide ventriculography using technetium-99m for CHF dx?

Back 24

a. RBCs tagged w/radioisotope are imaged during exercise/rest.
b. Provides precise measurement of left and right ventricular EF (and can assess wall motion abnormalities in ischaemic heart disease).
c. Can be useful when an echo is technically suboptimal (e.g., severe pulmonary disease), or when more precise assessment of left ventricular function is desired.

Front 25

166. Cardiac cath for CHF?

Back 25

a. Can provide valuable quantitative information regarding diastolic and systolic dysfunction, and can clarify the cause of CHF if non-invasive test results are equivocal.
b. Consider coronary angiography to exclude CAD as an underlying cause of CHF.

Front 26

167. Stress testing for CHF?

Back 26

a. Identifies ischaemia and/or infarction.
b. Quantitate level of conditioning.
c. Can differentiate cardiac vs. pulmonary etiology of dyspnea.
d. Assesses dynamic responses of HR, heart rhythm, and BP.