Management of Heart Failure

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History and Physical Examination For Diagnosis

Symptoms and signs can be divided into four broad categories: those associated with easy fatigue, volume overload, adrenergic stimulation, and cardiac remodeling.


Easy Fatigue

Although decreased cardiac output may be the primary cause of fatigue and weakness in HF, these nonspecific symptoms may be worsened by peripheral factors such as abnormal autoregulation of blood flow to the extremities and muscle deconditioning. Related to fatigue is dyspnea on exertion ("What level of activity causes you to become short of breath?").

Volume Overload.

Dyspnea can also be a symptom of volume overload particularly when it presents with sudden onset such as in the setting of uncontrolled hypertension or an acute myocardial infarction. For ambulatory patients being evaluated for HF the physician should inquire about orthopnea ("How many pillows do you sleep on? Has this changed? Do you sleep sitting up?), paroxysmal nocturnal dyspnea ("Do you wake up short of breath?" or "Do you have a cough during the night?").
Peripheral edema is a nonspecific yet common sign in HF. A corresponding symptom of weight gain may often be elicited from patients. The edema is typically bilateral and
symmetric in the dependent portions of the body.For ambulatory patients the edema worsens as the day progresses and resolves after a night’s rest.
Systemic venous hypertension is suggested by an internal jugular venous pressure level higher than 4 cm above the sternal angle when the patient is examined sitting at a 45-degree angle. In advanced cases, venous pressure is so high that peripheral veins on the dorsum of the hand are dilated and fail to collapse when elevated above the shoulder.

Moist crackles, when present, are a consequence of transudation of fluid into the alveoli and are usually heard in both lung bases. Pleural effusion collecting in the bases may lead to dullness on percussion. If the bronchial mucosa are congested, then bronchospasm and associated high-pitched wheezes also may be present.

The presence of an S3 gallop occurs with rapid ventricular diastolic filling. It is a low-pitched sound that is best heard with the bell of the stethoscope over the apical impulse. Abdominojugular reflux is another useful clinical tool for assessing systemic venous congestion. While the neck veins are observed, the right upper quadrant of the abdomen is compressed continuously for 20 to 30 seconds. The patient is instructed to breath normally. This maneuver increases venous return to the heart. In HF patients, the jugular veins expand during and immediately after compression because of the inability of the heart to respond to the increased venous supply.

Hepatomegaly may be caused by congestion of the liver. If this occurs acutely the liver may be tender to palpation. With advanced HF, the liver is still enlarged but typically nontender.

Adrengeric Stimulation.

Tachycardia is a clinical sign present in many patients with HF and reflects increased adrenergic activity. Other symptoms related to increased adrenergic activity are pallor and cool extremities and cyanosis of the digits (peripheral vasoconstriction).

Cardiac Remodeling.

Cardiomegaly is also a nonspecific yet common sign in HF patients. A normal apical impulse is located in the fourth or fifth intercostal space and is a brief tap. It is only palpable in about 50% of HF patients. If the apical impulse involves more than one intercostal space, cardiomegaly is present. Precordial percussion is more sensitive but less specific than the apical impulse for detecting abnormal LV size. A percussion dullness distance greater than 10.5 cm in the fifth intercostal space has a sensitivity of 91% and a specificity of 30% for increased LV size. Although the false positive-rate for cardiac percussion is high, a negative result (less than 10.5 cm) is useful for ruling out cardiomegaly (few false negatives).

Clinical criteria can be used to aid in the diagnosis of HF. Two commonly used criteria are the Framingham HF Criteria and the Boston HF Score (Table 1) . Using these clinical criteria standardizes the approach to making a diagnosis of HF, and they are commonly used in clinical trials. These criteria, however, do have limitations for clinicians. Not all the parameters are readily available to the primary care physician.
The criteria may not identify individuals with LV dysfunction who have mild or intermittent symptoms.

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physiology 

what is the explanation for orthopnoea in CCF

srk001 

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retheesh 

very informative article !!!

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