Heart Failure Clinical Features & Diagnosis PDF

Heart Failure: Clinical & Diagnostic Findings VETM 5291 Cardiovascular, Respiratory and Hemolymph Systems II Mandy Coleman, DVM, DACVIM (Cardiology) [email protected] Clinical Manifestations of Heart Failure Heart failure "Forward" (outpu...

Heart Failure: Clinical & Diagnostic Findings VETM 5291 Cardiovascular, Respiratory and Hemolymph Systems II Mandy Coleman, DVM, DACVIM (Cardiology) [email protected] Clinical Manifestations of Heart Failure Heart failure "Forward" (output) failure "Backward" (congestive) failure Right-sided (systemic) Left-sided (pulmonary) congestion congestion  Clinical Manifestations of Heart Failure Consequences of inadequate output Consequences of congestion “Forward” failure “Backward” failure ▪ Generalized weakness, depressed mentation ▪ Abnormal fluid accumulation (important!): ▪ ↓ exercise tolerance (esp. performance animals) ▪ If left-sided: interstitial pulmonary edema ▪ Syncope (fainting) ▪ If right-sided: pleural and/or abdominal effusions (free fluid), peripheral tissue ▪ Hypotension, hypothermia edema ▪ Lactic acidosis, azotemia, oliguria due to ▪ In cats, left-sided CHF can cause pulmonary inadequate tissue perfusion edema, pleural effusion, or both Most patients have a combination of these Clinical Manifestations of Heart Failure Heart failure "Forward" (output) failure "Backward" (congestive) failure Right-sided (systemic) Left-sided (pulmonary) congestion congestion  Congestive (“backward”) heart failure (CHF) If RIGHT-sided… If LEFT-sided… ▪ Usually: abnormal cardiac exam (e.g., ▪ Usually: abnormal cardiac exam (e.g., murmur, gallop, arrhythmia) murmur, gallop, arrhythmia) ▪ Tachycardia (exception: hypothermic cats) ▪ Tachycardia (exception: hypothermic cats) left atrium right atrium Why do patients with CHF almost always have sinus tachycardia?  Congestive (“backward”) heart failure (CHF) If RIGHT-sided… ▪ Visual evidence of high right-sided filling pressures: ▪ Jugular venous distension/pulsation ▪ Hepatojugular reflux (dogs) ▪ Signs of abnormal fluid accumulation: ▪ Abdominal distension from liver enlargement and/or ascites (free fluid) right ▪ Decreased/absent lung sounds from atrium pleural effusion ▪ Dependent peripheral edema (rare in dogs and cats; common in horses and cattle) Congestive (“backward”) heart failure (CHF) If LEFT-sided… ▪ Respiratory signs due to pulmonary edema: ▪ Dyspnea, tachypnea, orthopnea ▪ Cough (exception: cats with CHF do NOT cough ) ▪ Expectoration of frothy fluid or frothy left blood-tinged fluid in nostrils (esp. horses) atrium ▪ Fine inspiratory pulmonary “crackles” ▪ Cats only: may have decreased/absent lung sounds due to pleural effusion  Clinical diagnosis of CHF ▪ To confirm CHF diagnosis, must establish: ▪ Patient has heart disease sufficiently severe to cause clinical signs noted (imaging) ▪ Clinical signs directly relate to patient’s heart disease (vs. some other condition) Clinical diagnosis of CHF: Tools for assessment of CV system (beyond the PE) Echocardiography (cardiac ultrasound) ▪ Assessment of heart size/function + “sidedness” of disease if present ▪ Assessment of pleural and pericardial spaces ▪ Is edema/effusion likely cardiogenic (is there atrial enlargement)? Thoracic radiographs ▪ “Big picture” of cardiac silhouette size ▪ Assessment of heart, lungs, great vessels, pleural space ▪ Is there evidence of fluid accumulation (congestion)? Electrocardiography (ECG, EKG) ▪ Assessment of heart rhythm and rate ▪ Supportive if arrhythmia/tachycardia present Circulating cardiac biomarkers (NT-proBNP) ▪ Ancillary: are respiratory signs likely cardiogenic?  Normal thorax Clinical diagnosis of CHF Thoracic radiographs are most useful tool to establish whether respiratory signs are likely due to heart failure! Left-sided CHF ▪ Left-sided heart enlargement pattern L-CHF ▪ ± pulmonary vein enlargement ▪ Pulmonary infiltrates ▪ Unstructured interstitial/alveolar pattern ▪ Perihilar/caudodorsal distribution (exception: cats; can be anywhere!) ▪ ± pleural effusion (cats) R-CHF Right-sided CHF ▪ Right-sided heart enlargement pattern (careful!) ▪ Enlargement of the caudal vena cava ▪ Pleural and/or abdominal effusion (ascites) Thoracic radiographs from a dog with left-sided CHF 10-year-old MC Australian shepherd with Normal thoracic radiograph (dog) dyspnea and heart murmur Left-sided heart enlargement pattern Thoracic radiographs from a dog with left-sided CHF 10-year-old MC Australian shepherd with Normal thoracic radiograph (dog) dyspnea and heart murmur Left-sided heart enlargement pattern Thoracic radiographs from a dog with left-sided CHF 10-year-old MC Australian shepherd with Normal thoracic radiograph (dog) dyspnea and heart murmur Diffuse unstructured interstitial-to-patchy alveolar pulmonary pattern, worst in perihilar and caudodorsal lung fields  Normal pulmonary pattern soft tissue air Crisp (distinct) vascular margins V = pulmonary vessel B = bronchus/alveoli (airways)  (moderate) Perivascular Vascular margins obscured interstitial fluid Enlarged pulmonary veins V = pulmonary vessel B = bronchus/alveoli (airways)  (severe) Interstitial fluid Vascular margins obscured V = pulmonary vessel B = bronchus/alveoli (airways)  Alveolar pulmonary pattern Interstitial fluid Vascular margins obliterated spilling into alveoli Air bronchograms V = pulmonary vessel B = bronchus/alveoli (airways) Thoracic radiographs from a dog with left-sided CHF 10-year-old MC Australian shepherd with dyspnea and heart murmur  T4 R Vertebral Heart Score - 11.4 (1400 increased CHF likelihood NT-proBNP > 270* (cutoff for feline SNAP Best when other test results are ambiguous test) supportive of CHF in dyspneic cat Most powerful as a test of rule-out! If echo (by specialist) is available, NT-proBNP test NOT necessary