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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
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• Injury to heart muscle, such as:
• Myocardial infarction
• Myocarditis
• Arrhythmia
• Toxic exposures
• Chagas’ disease
C. V. Pollack, Jr. and V. G. Riese
Presentation
Typical/“Classic”
• Most patients with acute heart failure present with shortness of breath.
• Dyspnea on exertion and orthopnea are common.
• Chest pain and palpitations are not uncommon.
• Patients with right-sided failure only will complain of dependent edema,
weight gain, and swelling of the abdomen.
Atypical
• Patients may present only with weight gain or nocturia.
• Chest pain or palpitations without dyspnea would be unusual.
Primary Differential Considerations
• Patients who present with signs and symptoms of heart failure should also be
evaluated for these potential diagnoses:
• Acute coronary syndrome
• Pulmonary embolism
• COPD exacerbation
• Pneumonia
History andPhysical Exam
• In the history, focus on symptoms of uid overload and pump failure, such as:
• Dyspnea (specically asking about dyspnea at rest vs only with exertion,
and about nocturnal dyspnea/orthopnea)
32 Heart Failure
• Peripheral edema and ascites (socks leaving indentations, having to loosen
belt)
• Nocturia and insomnia
• Fatigue
• Generalized weakness
• Abdominal pain (which may result from hepatic congestion)
• On physical examination, there are a number of ndings associated with heart
failure that should be sought:
• Pulmonary rales
http://www.easyauscultation.com/rales
Rales. [Rales Lung Sounds; Easy Auscultation; www.easyauscultation.com;
copyright 2015, MedEdu LLC]
• Peripheral edema
• Hepatomegaly
• Orthopnea
• Third heart sound (S3 gallop)
https://www.youtube.com/watch?v=xbLMC0kPQ-E
Audio of the third heart sound.
• Fourth heart sound
479
https://www.youtube.com/watch?v=r-HqK7NRL8I
Audio of the fourth heart sound with animated diagram.
• Neck vein distention
Findings that Conrm Diagnosis
• More than two or three of the signs and symptoms are strongly suggestive of
heart failure. Conrmation of the diagnosis (and important prognostic information) is obtained by echocardiography.
480
C. V. Pollack, Jr. and V. G. Riese
M-mode echocardiogram (left) and parasternal long-axis view from a patient with
marked alcohol consumption and heart failure. The echocardiographic pattern is
that of dilated cardiomyopathy with reduced contraction. [Nihoyannopoulos
P.Cardiomyopathies. In: Nihoyannopoulos P, Kisslo J, editors. Echocardiography
[Internet]. London: Springer London; 2009 [cited 2015 Jun 4]. p.399–434. Available
from: http://link.springer.com/10.1007/978-1-84882-293-1_20] Caption from
original
Two‐dimensional M‐mode echocardiogram of a dog with congestive heart failure
induced by rapid pacing. Note the generalized cardiac dilatation and decreased left
32 Heart Failure
ventricular shortening fraction. LA—left atrium; LV—left ventricle; RA—right
atrium; RV—right ventricle. [Gwathmey J, Abelmann W.Chapter 11. In: Lee RT,
Braunwald E, editors. Atlas of Cardiac Imaging, 1e. Philadelphia: Current Medicine;
1998. 248 p. ISBN: 0-443-07567-0] Caption from original
481
Factors that Suggest Diagnosis
• More than two of the signs and symptoms listed above are suggestive and
warrant specic evaluation
Factors that Exclude Diagnosis
• A normal echocardiogram and a normal brain-type natriuretic peptide (BNP
level) exclude heart failure. It may not be possible to exclude the diagnosis
fully on clinical grounds alone.
Ancillary Studies
Laboratory
• Baseline CBC (to exclude anemia) and renal function should be evaluated
• Urine should be checked for protein, blood, and glucose
• Serum electrolytes (especially potassium) should be checked
• A BNP level should be checked
Electrocardiography
• Electrocardiogram should be obtained to evaluate rhythm and to look for left
ventricular hypertrophy or Q-waves. There are no pathognomonic ndings for
heart failure on ECG.
482
C. V. Pollack, Jr. and V. G. Riese
A 12-lead electrocardiogram demonstrating left ventricular hypertrophy with a
“strain” pattern. [Fleisher L.Chapter 3. In: Miller RD, Lichtor JL, editors. Atlas of
Anesthesia: Preoperative Preparation and Intraoperative Monitoring, Volume 3, 1e.
Philadelphia: Current Medicine; 1997. 251 p. ISBN: 0-443-07902-1] Caption
adapted from original
Imaging
• Chest x-ray should be obtained to look for cardiac enlargement, pleural effusion, signs of pulmonary edema, COPD, or pneumonia.
Cardiomegaly on chest X-ray. [YÕldÕrÕm SV, Durmaz C, Pourbagher MA, Erkan
AN. A case of achondroplasia with severe pulmonary hypertension due to
32 Heart Failure
483
obstructive sleep apnea. European Archives of Oto-Rhino-Laryngology. 2006
Aug;263(8):775–7.] Caption from original
Hydrostatic pulmonary edema in a patient with congestive heart failure. Two successsive axial computed tomography slices (a and b) demonstrate a nodular thickening of the interlobular septa reecting the enlarged pulmonary veins (blue arrows)
with bilateral pleural effusion. Note the peribronchial cufng on (b; orange arrow).
The chest radiograph equivalent (c) and the focused view on the left upper lobe (d)
show a loss of denition of vascular markings throughout both lungs associated
484
C. V. Pollack, Jr. and V. G. Riese
with Kerley lines (yellow arrows), reminiscent of interstitial edema. Note the
enlargement of the cardiac silhouette. By viewing average coronal slabs (c–f) of
decreasing slice thickness, Kerley A lines seen on (f) corresponding to septal thickening are perfectly understood. [Ilsen B, Gosselin R, Delrue L, Duyck P, de Mey J,
Beigelman-Aubry C.Interstitial Lung Disease. In: Coche EE, Ghaye B, de Mey J,
Duyck P, editors. Comparative Interpretation of CT and Standard Radiography of
the Chest [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 2011 [cited
2015 Jun 4]. p.195–220. Available from:
http://link.springer.com/10.1007/978-3-
540-79942-9_8] Caption from original
• Echocardiography is helpful in diagnosing, staging, and following heart
failure.
M-mode echocardiogram (left) and parasternal long-axis view from a patient with
marked alcohol consumption and heart failure. The echocardiographic pattern is
that of dilated cardiomyopathy with reduced contraction. [Nihoyannopoulos
P.Cardiomyopathies. In: Nihoyannopoulos P, Kisslo J, editors. Echocardiography
[Internet]. London: Springer London; 2009 [cited 2015 Jun 4]. p.399–434. Available
from:
http://link.springer.com/10.1007/978-1-84882-293-1_20] Caption from
original
32 Heart Failure
485
Two‐dimensional M‐mode echocardiogram of a dog with congestive heart failure
induced by rapid pacing. Note the generalized cardiac dilatation and decreased left
ventricular shortening fraction. LA—left atrium; LV—left ventricle; RA—right
atrium; RV—right ventricle. [Gwathmey J, Abelmann W.Chapter 11. In: Lee RT,
Braunwald E, editors. Atlas of Cardiac Imaging, 1e. Philadelphia: Current Medicine;
1998. 248 p. ISBN: 0-443-07567-0] Caption from original
Other Studies
• None indicated in initial evaluation.
Special Populations
Age
• With rare exception, heart failure is a disease of older patients, with the incidence increasing with increasing age.
486
C. V. Pollack, Jr. and V. G. Riese
Co-morbidities
• Co-morbidities may include:
• Hypertension
• Renal disease
• Cardio- and cerebrovascular disease
• Drug and alcohol abuse
Pitfalls inDiagnosis
Critical Steps Not toMiss
• Recognition of acute heart failure that may precipitate circulatory collapse or
severe pulmonary
Mimics
• Potential mimics include:
• Pneumonia
• COPD
• Acute coronary syndrome
• Pulmonary embolism
Time-Dependent Interventions
• Provide ventilatory and circulatory support as needed.
• Noninvasive ventilation should be attempted before intubation and mechanical ventilation unless the patient is already in ventilatory failure.
• Initiation of diuresis.
Overall Principles ofTreatment
• Relief of uid overload and improvement in ventilatory and circulatory status
are paramount.
• Diuresis with attention to electrolyte levels will improve symptoms.
32 Heart Failure
• ACE inhibitors and beta-blockers will improve long-term management.
• Diet and exercise counseling will help patients manage their symptoms
better.
487
Treatment algorithm of patients with chronic heart failure. [Marín-García
J.Treatment of Chronic Heart Failure. Heart Failure [Internet]. Totowa, NJ: Humana
Press; 2010 [cited 2015 Jun 4]. p. 379–92. Available from: http://link.springer.
com/10.1007/978-1-60761-147-9_20] Caption from original