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Diagnosis of Congestive Heart Failure

Congestive Heart Failure Diagnosis: Book Excerpts

Diagnosis of Congestive Heart Failure: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Congestive Heart Failure:

Diagnostic Tests for Congestive Heart Failure: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Congestive Heart Failure.


CARDIOMEGALY: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a murmur? Cardiomegaly with cardiac murmurs suggests valvular disease, but it also suggests congestive heart failure and advanced myocardiopathies. One should also be sure that the murmur is not a pericardial friction rub.
  2. Is there fever? Fever with cardiomegaly should suggest rheumatic heart disease and bacterial endocarditis. However, it may also suggest an acute myocarditis or acute pericarditis.
  3. Is there chest pain? Cardiomegaly with chest pain would certainly suggest a myocardial infarction, but it also may suggest an acute pericarditis.
  4. Is there hepatomegaly? Cardiomegaly and hepatomegaly suggest congestive heart failure. Hepatomegaly also may suggest one of the systemic diseases that causes a myocardiopathy such as amyloidosis.
  5. Is there edema? The presence of peripheral edema would suggest congestive heart failure, and if it is nonpitting, it would suggest myxedema.
  6. Is there hypertension? Cardiomegaly with hypertension would suggest that the cardiomegaly is due to left ventricular enlargement from the chronic hypertension.
  7. Is there cyanosis? Cardiomegaly with cyanosis, particularly if there is an associated murmur, suggests congenital heart disease of the cyanotic type.

DIAGNOSTIC WORKUP

A CBC, sedimentation rate, ANA, chemistry panel, VDRL test, thyroid profile, EKG, and chest x-ray should be done on all patients. An echocardiogram will be helpful in diagnosing valvular disease, myocardiopathies, congestive heart failure, and pericardial effusion. If congestive heart failure is suspected, venous pressure and circulation time can be measured, and one should do pulmonary function studies. If there is fever, then one would want to do a streptozyme test, ASO titer, and serial blood cultures. If there is hypertension, a hypertensive workup may be indicated . Patients with cyanosis need a workup for congenital heart disease, which will probably include cardiac catheterization and angiocardiography.

Most prudent physicians will refer the patient with cardiomegaly to a cardiologist before pursuing this extensive diagnostic workup.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Cardiomegaly: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Congestive heart failure
  • Ischemic heart disease
  • Hypertension (with left ventricular hypertrophy)
  • Valvular disease (primarily MR, AS, AR)
  • Hypertrophic cardiomyopathy
  • Congenital heart disorders (e.g., ASD, VSD, PDA, coarctation of the aorta, Ebstein's anomaly, tetralogy of Fallot)
  • Idiopathic cardiomyopathy
  • Alcoholic cardiomyopathy
    • Lung disease (leading to right-sided enlargement)
      –Pulmonary embolus
      –COPD
      –Cor pulmonale
      –Primary pulmonary hypertension
    • Subacute bacterial endocarditis
    • Myocarditis
    • Renal failure (risk of pericardial effusion)
    • Anemia
    • Scleroderma
    • Systemic lupus erythematosus
    • Sickle cell disease
    • Marfan's syndrome
    • Pregnancy
    • Drugs (numerous drugs are cardiotoxic)
    • Postradiation
    • Normal, “athletic” heart
    • Mediastinal mass
    • Kyphoscoliosis
    • Rheumatoid arthritis
    • Less common etiologies include infiltrative diseases (e.g., amyloidosis, hemochromatosis, atrial myxoma, endocardial fibroelastosis, Fabry's disease, Hurler's syndrome, Pompe's disease), epicardial fat pad, carcinoid, acromegaly, hyper- or hypoparathyroidism, and severe cases of hypocalcemia, hypomagnesemia, and/or hypophosphatemia

    Workup and Diagnosis

    • Complete history and physical exam
      –Associated symptoms may include fatigue, dyspnea at rest and/or on exertion, palpitations, dizziness, or syncope
      –Note use of alcohol or recreational drugs
      –Family history of heart disease or sudden death
  • Chest X-ray and ECG
  • Echocardiogram is indicated in all patients to evaluate for valvular disease, chamber size, wall motion abnormalities, and ventricular function
  • Stress testing if coronary artery disease is suspected
  • Cardiac catheterization may be indicated to evaluate for coronary artery disease and valvular disease
  • Laboratory studies may include CBC, ESR, electrolytes, BUN/creatinine, glucose, TSH, calcium, magnesium, and phosphorus
  • Blood cultures are indicated in some cases
  • Consider ANA, rheumatoid factor, and screening for pheochromocytoma (i.e., urinary metanephrines and VMA) and hemochromatosis (i.e., iron studies) in selected patients

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Paroxysmal Nocturnal Dyspnea: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • CHF is the most common cause
    –Etiologies include uncontrolled HTN, pulmonary embolus, endocarditis, hyperthyroidism, pericardial disease, endocardial disease (e.g., valvular stenosis, insufficiency, rupture, endocarditis), and myocardial disease (e.g., MI, ischemia, arrhythmias)
  • Mitral stenosis
    –Almost always secondary to rheumatic heart disease (after 15–40 years)
    –Advanced cases result in pulmonary hypertension and right heart failure
    –Dyspnea is the most significant symptom
    –Classic triad: Diastolic rumble, opening snap, and loud first heart sound
  • Aortic regurgitation
    –Most commonly due to rheumatic fever
  • Cardiomyopathies
    –Abnormal myocardium, resulting in impaired cardiac output and CHF
  • Aortic stenosis
    –Due to senile valve degeneration, rheumatic disease, or congenital
    –Associated with angina, syncope, and CHF
  • Congenital heart disease
    –May see failure to thrive, progressive CHF symptoms, cyanosis, and/or murmur
    • “Cardiac asthma”
      –Bronchospasm secondary to pulmonary congestion and interstitial edema that compresses small airways
      –Standing decreases lung congestion
    • Anxiety
    • Severe COPD and emphysema
    • Asthma
    • Obstructive sleep apnea
    • Obesity/hypoventilation
    • Tropical pulmonary eosinophilia (filariasis)

    Workup and Diagnosis

    • Complete history and physical exam with special attention to cardiac and respiratory systems
    • Initial laboratory studies may include CBC, pulse oximetry, electrolytes, BUN/creatinine, glucose, and calcium
    • Chest X-ray to evaluate for effusion and heart size
    • Echocardiogram may be used to evaluate valves, chamber size, and ventricular function
    • ECG
    • Consider cardiology consult
    • Cardiac catheterization may be indicated for valvular disease, cardiomyopathies, and congenital heart disease

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Heart Failure: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Increased afterload

  • Most common in the neonate due to left-sided obstructive lesions, which present acutely
  • Aortic coarctation is most common
    –Increased pulse/BP in right arm
    –Decreased pulse/BP in lower extremities
  • Critical aortic stenosis
    –Poor pulses, loud murmur
    • Hypoplastic left heart syndrome, aortic arch interruption

    Left-to-right shunt lesions
  • Normal cardiac muscle funtion but overcirculation of lungs due to a congenital connection between the right and left side of the heart and low PVR
    • Usually presents at 1–2 months of age
      –PVR drops and systemic resistance becomes higher than PV
      –Blood shunts from left to right (systemic circulation to pulmonary circulation)
      –Pulmonary overcirculation and poor systemic output (poor peripheral perfusion, low urine output)
  • Ventricular septal defect (most common)
  • Atrioventricular septal defect (AV canal, endocardial cushion defect), associated with Down syndrome
  • Patent ductus arteriosus
    • Atrial septal defect (usually asymptomatic)

    Intrinsic myocardial disease
  • More common cause of heart failure in older children and adolescents
    • Myocarditis
      –Acute inflammation and dysfunction of cardiac muscle, usually postviral
      –1/3 remain stable, 1/3 return to normal cardiac function, and 1/3 deteriorate
    • Cardiomyopathy
      –Dilated most common, but also hypertrophic and restrictive
      –Multiple genetic and metabolic causes, often positive family history, some represent old, “burned-out” myocarditis
  • Myocardial infarction (rare)
    –Kawasaki disease
    –Congenital coronary abnormalities (anomalous left coronary artery)

Workup and Diagnosis

  • Neonate
    –Consider left-sided obstructive lesions in any neonate with poor or differential pulses/perfusion
    –Often have respiratory distress, hepatomegaly, and metabolic acidosis
    –Critically ill requiring supplemental O2 and ventilatory support; transfer to tertiary care ICU
  • Infants/children
    –History: Activity tolerance, poor feeding, diaphoresis, respiratory symptoms (wheezing or frequent infections due to pulmonary overcirculation), weight gain (poor due to increased metabolic demands or excess due to activity intolerance and edema), dyspnea on exertion for older patients
    –Physical exam: Vital signs (tachypnea, tachycardia), perfusion/pulses, edema (especially of face/eyes for infants), increased work of breathing/retractions, hepatomegaly, increased jugular venous distension
  • Chest X-ray often reveals nonspecific cardiomegaly and pulmonary venous congestion
  • ECG: Evaluate for ventricular hypertrophy (left-to-right shunt lesions, hypertrophic cardiomyopathy); low QRS voltage (myocarditis, dilated cardiomyopathy)
  • Echocardiography and/or cardiac catheterization to further define anatomy and function
  • Serum electrolytes, BUN/creatinine, and LFTs (including total protein and albumin) to further define current metabolic state before therapy

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

CARDIOMEGALY: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis of cardiomegaly can be further developed be a good history and the association of other symptoms and signs. Is there a history of hypertension, alcoholism, rheumatic fever or other systemic disease? Has the patient experienced shortness of breath, angina, fever, joint pains, and so forth? Are there findings of pedal edema, hepatomegaly, or jugular venous distention (CHF)? Are there hypertension and proteinuria (renal disease or essential hypertension)? Is there a significant heart murmur (congenital heart disease, rheumatic heart disease)?

The diagnostic workup will include a CBC, urinalysis, chemistry panel, sedimentation rate, a chest x-ray, and ECG. At this point, it is wise to consult a cardiologist. Echocardiography will be helpful in diagnosing valvular heart disease, myocardiopathy, and pericardial effusion. If CHF is suspected, a venous pressure and circulation time as will as spirometry will support the diagnosis. Echocardiography can diagnose congestive heart failure by determining the left ventricular ejection fraction (LVEF). If there is unexplained fever, an ASO titer or streptozyme test should be ordered to rule out rheumatic fever and perhaps serial blood cultures need to be done to exclude subacute bacterial endocarditis. If there is hypertension the patient may need a hypertensive workup (see page 299).

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Paroxysmal nocturnal dyspnea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin by exploring the patient’s complaint of dyspnea. Does he have dyspneic attacks only at night or at other times as well, such as after exertion or while sitting down? If so, what type of activity triggers the attack? Does he experience coughing, wheezing, fatigue, or weakness during an attack? Find out if he has a history of lower extremity edema or jugular vein distention. Ask if he sleeps with his head elevated and, if so, on how many pillows or if he sleeps in a reclining chair. Obtain a cardiopulmonary history. Does the patient or a family member have a history of a myocardial infarction, coronary artery disease, or hypertension or of chronic bronchitis, emphysema, or asthma? Has the patient had cardiac surgery?

Next perform a physical examination. Begin by taking the patient’s vital signs and forming an overall impression of his appearance. Is he noticeably cyanotic or edematous? Auscultate the lungs for crackles and wheezing and the heart for gallops and arrhythmias.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pulse pressure, narrowed: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

After you detect a narrowed pulse pressure, check for other signs of heart failure, such as hypotension, tachycardia, dyspnea, jugular vein distention, pulmonary crackles, and decreased urine output. Also check for changes in skin temperature or color, the strength of peripheral pulses, and the patient’s level of consciousness (LOC). Auscultate the heart for murmurs. Ask about a history of chest pain, dizziness, or syncope.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Paroxysmal nocturnal dyspnea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin by exploring the patient’s complaint of dyspnea. Does he have dyspneic attacks only at night or at other times as well, such as after exertion or while sitting down? If so, what type of activity triggers the attack? Does he experience coughing, wheezing, fatigue, or weakness during an attack? Find out if he has a history of lower extremity edema or jugular vein distention. Ask if he sleeps with his head elevated and, if so, on how many pillows or if he sleeps in a reclining chair. Obtain a cardiopulmonary history. Does the patient or a family member have a history of a myocardial infarction, coronary artery disease, or hypertension, or of chronic bronchitis, emphysema, or asthma? Has the patient had cardiac surgery?

Next perform a physical examination. Begin by taking the patient’s vital signs and forming an overall impression of his appearance. Is he noticeably cyanotic or edematous? Auscultate the lungs for crackles and wheezing and the heart for gallops and arrhythmias.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pulse pressure, narrowed: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

After you detect a narrowed pulse pressure, check for other signs of heart failure, such as hypotension, tachycardia, dyspnea, jugular vein distention, pulmonary crackles, and decreased urine output. Check for changes in skin temperature or color, strength of peripheral pulses, and level of consciousness (LOC). Auscultate the heart for murmurs. Ask about a history of chest pain, dizziness, or syncope.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cardiomegaly: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Presenting symptoms. As congestive heart failure (CHF) and cardiomegaly represent the final common path for many patients with these common conditions, the typical symptoms are exertional dyspnea, syncope, fatigue, and angina. Many patients are asymptomatic at the time of diagnosis and sudden death can be the presenting event (2) (Chapter 7.5).

 B. Etiology. The most common conditions that result in cardiomegaly include hypertension, coronary artery disease, rheumatic and degenerative valvular heart disease, anemia, alcoholism, endocrinopathies, and infectious and inflammatory conditions.

C. Family history. Premature atherosclerosis and ischemic cardiomyopathy can be caused by familial dyslipidemia. A family history of early CHF may indicate familial dilated cardiomyopathy and premature sudden death may indicate familial hypertrophic obstructive cardiomyopathy.

Physical examination

The typical signs of CHF are usually noted on examination. A decreased arterial pulse with narrowed pulse pressure is common. Cyanosis is rare. Significant cardiac enlargement should be evident on physical examination. Examples of these finding include the following:

A. Lung sounds. Rales or pleural effusion with dullness to percussion and decreased breath sounds may be indicative of left ventricular failure.

 B. Heart sounds. Gallops, soft heart sounds, and regurgitant heart murmurs are nonspecific findings of advanced CHF. Alterations in S1 or S2, specific murmurs, (e.g., a Valsalva-enhanced systolic murmur in hypertrophic obstructive cardiomyopathy), and muffled sounds with pericardial effusion, all indicate specific underlying pathology.

 C. Cardiac pulsations or point of maximal impulse (PMI). Visible pulsations seen lateral to the midclavicular line signify cardiac enlargement unless is found a thoracic deformity or congenital absence of the pericardium.

 D. Apical beat or PMI. The apical beat, or PMI, which is typically palpable in only 40% of cases, is highly dependent on body habitus. Use the flat of the hand to palpate the PMI. Time the pulsations using the carotid pulse or auscultated heart sounds. The left lateral decubitus position increases the palpability of both normal and pathologic apical beats.

A PMI within or superior to the fifth intercostal space is normal. Left ventricular enlargement displaces the PMI laterally and downward. A PMI lateral to the midclavicular line or more than 10 cm lateral to the midsternal line is a sensitive but nonspecific indicator of left ventricular enlargement. An apical impulse of more than 3 cm diameter is an accurate sign of left ventricular enlargement.

With moderate or severe left ventricular hypertrophy, the outward systolic thrust persists throughout ejection, often lasting up to the second heart sound. In patients with volume overload or sympathetic stimulation, the left ventricular impulse is brisker and larger than normal but is hypokinetic in patients with reduced stroke volume (e.g., acute myocardial infarction or dilated cardiomyopathy). Large left ventricular aneurysms are palpable above and medial to the apex beat. Thoracic deformities—particularly scoliosis and pectus excavatum—can laterally displace a normal heart.

 E. Percussion. In the absence of an apical beat, as in patients with pericardial effusion or with dilated cardiomyopathy and a markedly displaced, hypokinetic apical beat, the left border of the heart can be outlined by means of percussion. Percussed dullness in the left fifth intercostal space more than 10.5 cm from the midsternal line is sensitive and specific for cardiomegaly (3).

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Congestive Heart Failure: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Common presenting symptoms. Does the patient have orthopnea, paroxysmal nocturnal dyspnea, or dyspnea on exertion? How much exertion triggers dyspnea? These are relatively specific symptoms for CHF. Less specific symptoms include swelling of the legs, increasing weight, and generalized fatigue. Older patients with CHF may not have dyspnea on exertion because of a sedentary baseline status; they often present with atypical symptoms such as dry cough, daytime oliguria with nocturia, and confusion (3).

B. Past medical history. Are conditions present that can cause CHF (Table 7.2)? If so, are they well-controlled with lifestyle changes, medications, or both? Uncontrolled hypertension, myocardial ischemia, and medication noncompliance frequently trigger CHF.

 C. Psychosocial history. Is there current or previous heavy alcohol use, tobacco use, or stimulant drug use? Is the patient consuming too much dietary sodium (> 2 g/d)? Are symptoms hindering the patient’s ability to perform daily activities? Is the patient depressed? How is the family coping? Poor understanding of lifestyle factors, depression, and limited family resources can lead to noncompliance and frequent CHF exacerbations.

Physical examination

A. Focused physical examination. In general, the physical examination is more sensitive in detecting acute CHF than it is in detecting chronic CHF. Evaluate the following:

1. Vital signs. Note the blood pressure; hypertension with acute CHF suggests diastolic dysfunction (4). Obtain pulse, respiratory rate, and pulse oximetry to detect hypoxia.

2. Neck. Look for jugular venous distension, one of the more reliable physical examination indicators of CHF (4).

3. Lungs. Rales are commonly heard, but wheezing (“cardiac asthma”) can also appear.

4. Heart. Palpate the apical impulse. If laterally displaced, diffuse, and especially of sustained duration, CHF caused by reduced left ventricular (LV) systolic function is likely (4). Listen for murmurs, gallops, and rubs. An S3 gallop is generally suggestive of CHF (4), whereas an S4 gallop may be a nonpathologic, age-related finding in elderly patients (3).

5. Abdomen. Assess for hepatosplenomegaly and try to elicit abdominojugular reflux.

 6. Extremities. Look for leg edema (pitting in acute CHF, brawny in chronic CHF).

 B. Additional physical examination. Further examination is appropriate if the history suggests specific causes for CHF: funduscopic examination to search for hypertensive retinopathy; thyroid palpation and auscultation; palpation of peripheral pulses; and carotid palpation and auscultation for evidence of stenosis, a marker of coronary atherosclerosis.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Cardiomegaly/Congestive Heart Failure: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Congestive heart failure

❑ Hypertensive left ventricular hypertrophy

❑ Anterior myocardial ischemia

❑ Athlete’s heart

❑ Mitral regurgitation

❑ Aortic stenosis

❑ High output

❑ Hypertrophic obstructive cardiomyopathy

❑ Pulmonary hypertension

❑ Cor pulmonale

❑ Dilated cardiomyopathy

❑ Endocarditis

❑ Pericardial effusion

❑ Left ventricular aneurysm

❑ Mitral stenosis

❑ Amyloidosis

Diagnostic Approach

The Framingham criteria for congestive heart failure are a good reference point. Major criteria include paroxysmal nocturnal dyspnea, rales, cardiomegaly, acute pulmonary edema, third heart sound, jugular pressure greater than 16 cm, and positive abdominojugular reflex. Minor criteria include edema, night cough, dyspnea on exertion, hepatomegaly, pleural effusion, and pulse rate slower than 120. Functional limitation is most often classified using the New York Heart Association (NYHA) system: Class I—symptoms of heart failure only at levels of exertion that would limit normal individuals; Class II—symptoms of heart failure with ordinary exertion; Class III—symptoms of heart failure with less than ordinary exertion; Class IV—symptoms of heart failure at rest.

History is key in CHF. Findings due to excess fluid accumulation include dyspnea, edema, hepatic congestion, and ascites. Findings due to reduced cardiac output include weakness and fatigue, more pronounced with exertion. Acute and subacute CHF produce primarily shortness of breath with exertion or at rest. Other common symptoms include orthopnea, paroxysmal nocturnal dyspnea, and right upper quadrant discomfort due to hepatic congestion in right heart failure.

Decreased cardiac output is counterbalanced by increased sympathetic activity, manifest as sinus tachycardia, diaphoresis, and peripheral vasoconstriction (cool and cyanotic extremities due to decreased perfusion and increased oxygen extraction). A prominent dicrotic notch may be felt in severe left ventricular dysfunction, as the compensitory increase in total peripheral resistence and corresponding reduced aortic compliance accentuate the aortic valve closure. Pulsus alternans (alternating strong and weak pulse beats) is uncommon but pathognomonic of advanced heart failure. Volume overload is manifest as pulmonary congestion (rales), peripheral edema, and elevated jugular venous pressure. The medulla controls the respiratory rate based on pCO 2. The length of the Cheyne-Stokes cycle is proportional to the circulatory delay from the alveoli to the arterioles (r = 0.80).

Systolic heart failure is marked by decreased cardiac output, with manifestations such as weakness, fatigue, and decreased exercise tolerance. Mitral regurgitation, especially when acute, augments early diastolic inflow and may produce an S3 with normal systolic function. Diastolic heart failure is associated with reduced ventricular compliance and increased filling pressures with manifestations of dyspnea and rales.

Findings suggesting left ventricular hypertrophy include a sustained forceful apical thrust, a double apical impulse, an apical impulse larger than 3 cm, and a fourth heart sound on auscultation. Left ventricular enlargement will cause the apical impulse (PMI) to be displaced downward and to the left. Right ventricular hypertrophy will cause a sustained right parasternal lift. It is seen with pulmonary hypertension, pulmonic stenosis, and volume overload with tricuspid regurgitation or atrial septal defect. Right ventricular failure is recognized by edema, jugular venous distension, and abdominojugular reflex.

Key findings on physical examination:

Rales  Increased interstitial fluid/pressure causes alveoli to pop open. Pulmonary venous capacitance increases in chronic heart failure, and rales may be absent.

Third heart sound (S3)  Ventricular vibration occurs during rapid inflow of blood in early diastole when the long-axis expansion limit is reached, due to reduced LV compliance or increased filling pressure. S3 is a low-pitched sound over the apex, and yield is doubled in the 45 degree left lateral decubitus position. JVD and S3 are independent on multivariate analysis.

JVD  The IJ is a right atrial manometer. High JVD (present .45 deg) has a LR 4.1 that CVP is .10 cm. Low JVD (present ,30 deg) has a LR 3.4 that CVP is ,5 cm.

Abdominojugular reflux  Apply abdominal pressure for 10 sec. A positive AJR is a 4 cm or greater drop in JVP after release, due to decreased RV compliance or increased LVEDP.

Edema  With renin-angiotensin-aldosterone activation, pulmonary and peripheral fluid accumulates. After the extracellular fluid is in excess of about five liters, symmetric, dependent, and pitting peripheral edema develops.

Valsava response  The normal response is for BP to rise .15 mm Hg during valsalva, but to fall before 10 seconds passes. When valsalva is released, the BP rises again .15 mm over the resting threshold. In CHF, an abnormal response can consist of absent phase 4 overshoot or a square wave in phase 2.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Heart failure: Diagnosis
(Handbook of Diseases)

The following tests are used to diagnose heart failure:

❑ Electrocardiography reflects heart strain, enlargement, and ischemia. It may also reveal atrial enlargement, tachycardia, and extrasystole.

❑ Chest X-ray shows increased pulmonary vascular markings, interstitial edema, pleural effusion, and cardiomegaly.

❑ Pulmonary artery monitoring typically demonstrates elevated pulmonary artery and pulmonary artery wedge pressures, elevated left ventricular end-diastolic pressure in left-sided heart failure, and elevated right atrial pressure or central venous pressure in right-sided heart failure.

❑ Echocardiography demonstrates left ventricular dysfunction with a reduced ejection fraction.

❑ Brain natriuretic peptide (BNP) assay detects abnormal hormone levels produced by failing ventricles.

❑ Cardiopulmonary exercise testing determines oxygen consumption and severity of heart failure.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Pulse pressure, narrowed: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient about specific cardiac symptoms, such as chest pain, dizziness, or syncope. Obtain his past medical history, and assess his risk factors for heart disease.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Paroxysmal nocturnal dyspnea: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Begin by exploring the patient's complaint of dyspnea. Does he have dyspneic attacks only at night or at other times as well, such as after exertion or while sitting down? If so, what type of activity triggers the attack? Does he experience coughing, wheezing, fatigue, or weakness during an attack? Find out if he has a history of lower extremity edema or jugular vein distention. Ask if he sleeps with his head elevated and, if so, on how many pillows or if he sleeps in a reclining chair. Obtain a cardiopulmonary history. Does the patient or a family member have a history of a myocardial infarction, coronary artery disease, or hypertension or of chronic bronchitis, emphysema, or asthma? Has the patient had cardiac surgery?

Next perform a physical examination. Begin by taking the patient's vital signs and forming an overall impression of his appearance. Is he noticeably cyanotic or edematous? Auscultate the lungs for crackles and wheezing and the heart for gallops and arrhythmias.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Pulse pressure, narrowed: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

After you detect a narrowed pulse pressure, check for other signs of heart failure, such as hypotension, tachycardia, dyspnea, jugular vein distention, pulmonary crackles, and decreased urine output. Also check for changes in skin temperature or color, the strength of peripheral pulses, and the patient's level of consciousness (LOC). Auscultate the heart for murmurs. Ask about a history of chest pain, dizziness, or syncope. Obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

CARDIOMEGALY: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The diagnosis of cardiomegaly can be further developed by a good history and the association of other symptoms and signs. Is there a history of hypertension, alcoholism, rheumatic fever, or other systemic disease? Has the patient experienced shortness of breath, angina, fever, joint pains, and so forth? Are there findings of pedal edema, hepatomegaly, or jugular venous distention (CHF)? Are there hypertension and proteinuria (renal disease or essential hypertension)? Is there a significant heart murmur (congenital heart disease, rheumatic heart disease)? The diagnostic workup will include a CBC, urinalysis, chemistry panel, sedimentation rate, chest x-ray, and ECG. At this point, it is wise to consult a cardiologist. Echocardiography will be helpful in diagnosing valvular heart disease, myocardiopathy, and pericardial effusion. If CHF is suspected, a venous pressure and circulation time as well as spirometry will support the diagnosis. Echocardiography can diagnose CHF by determining the left ventricular ejection fraction (LVEF). If there is unexplained fever, an antistreptolysin O (ASO) titer or streptozyme test should be ordered to rule out rheumatic fever, and perhaps serial blood cultures should be done to exclude subacute bacterial endocarditis. If there is hypertension, the patient may need a hypertensive workup .

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007


 » Next page: Signs of Congestive Heart Failure

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