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Fig. 19.6 Vegetation on the posterior of the mitral valve
(red arrow)
Fig. 19.7 Severe mitral regurgitation due to destruction
of the valve leaet by vegetation
vention is to remove all damaged and infected tissue by debridement and restore valve integrity. If
salvageable, valve repair is always preferred over
replacement to avoid placement of prosthetic
material into an infected space. This is especially
important with right- sided endocarditis associated with IV drug users (IVDU) as repair is associated with better late survival and longer freedom
from recurrent IE [13]. If the valve is unrepair-
A. Stephens et al.
Fig. 19.8 Aortic valve endocarditis complicated by
annular abscess. Vegetation in the ascending aorta (red
arrow) in communication with leaet and hypodense
abscess formation in the aortic annulus (yellow arrow).
Management requires urgent surgical intervention
able, infection is unable to be effectively
debrided, or an abscess is present, valve replacement is warranted. Valve selection is challenging
in IE with the decision between bioprosthetic and
mechanical valve being critical. Prosthetic valves
are at risk for reinfection if active infection persists. However, in the setting of IE secondary to
IVDU, medical compliance is questionable and
mechanical valve placement is not advised. Refer
to Chap. 16 on aortic stenosis for further discussion on valve selection. Homograft or freestyle
aortic valves are utilized when the endocarditis
involves an aortic root abscess and root extraction is warranted. In patients with relapsing prosthetic valve endocarditis after a full course
antibiotic therapy, the prosthetic valve is presumed to be the source and should be removed
[10].
The timing of valve surgery is not well dened
and is a highly individualized decision that is best
made by an experienced multidisciplinary team
[14]. The timing of surgery, criteria for potentially delaying surgery, and predictors of surgical
mortality and poor outcomes need to be better
dened. However, intervention is recommended
during the initial hospitalization and prior to the
completion of the recommended course of antibiotics when the below listed indications for early
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Table 19.7 Indications for early intervention valve surgery for the treatment of IE
• Patients who present with valve dysfunction resulting
in symptoms of HF
• Patients with left-sided IE caused by S. aureus, a
fungal organism, or another highly resistant organism
• Patients with IE complicated by heart block, annular
or aortic abscess, or destructive penetrating lesions
• Patients with IE and evidence of persistent infection as
manifested by persistent bacteremia or fevers lasting
>5days after initiation of antimicrobial therapy
• For patients with IE and an implanted cardiac
electronic device, complete removal of the pacemaker,
or debrillator system is indicated
• Patients with prosthetic valve endocarditis and
relapsing infection (dened as bacteremia recurrence
after antibiotic course completion and negative blood
culture results)
• Patients with IE present with recurrent emboli and
persistent vegetations despite appropriate antibiotic
therapy
Adapted from the American College of Cardiology/
American Heart Association 2020 Guideline for the
Management of Valvular Heart Disease
surgery are present (see Table19.7). In this population, early intervention has shown improved
outcomes and decreased mortality [10].
Heart failure caused by valvular regurgitation
or obstruction is the most common indication for
surgery. Outcomes for IE have historically been
dire without surgery once the patient has developed refractory pulmonary edema or cardiogenic
shock secondary to their IE [12]. Emergent surgery for heart failure unresponsive to medical
management is crucial, and swift surgery is also
recommended even if temporary stabilization of
the patient with heart failure secondary to IE can
be achieved.
Uncontrolled or complex infection is the
second- most common indication for surgery.
Abscesses and paravalvular extension of infection often cannot be cured with antibiotic therapy
alone. Mortality rate is signicantly reduced
when early surgery is undertaken in these patients
[15].
The third-most common indication for surgery is to prevent recurrent emboli from the vegetation, a devastating complication that affects
25–50% of patients [12]. Embolism is more
likely when vegetations are large (>10 mm in
length), highly mobile, and located on the mitral
valve [12]. Emboli most often involve major arterial beds, including the brain, lungs, coronary
arteries, spleen, bowel, and extremities. Up to
65% of embolic events involve the CNS, and
>90% of CNS emboli lodge in the distribution of
the middle cerebral artery [16]. The rate of
embolic events decreases dramatically during
and after the rst 2–3weeks of successful antibiotic therapy [16]. In patients with IE and evidence of CVA, regardless of the indications for
anticoagulation, it is reasonable to temporarily
discontinue anticoagulation [15]. This is because
anticoagulation therapy may increase the risk of
an embolic infarct becoming hemorrhagic. Even
in most patients with prosthetic valves who experience a CNS embolic event, all anticoagulation
therapy should be held for at least 2weeks. This
time should allow for thrombus organization and
help to prevent acute hemorrhagic conversion of
embolic lesions [16]. Most guidelines do agree
on delaying valve surgery for at least 4weeks in
patients with large embolic CNS lesions or intracranial hemorrhage [14]. Other reasonable reasons to delay early surgery are very high operative
risk or major neurologic impairment [17].
Indications for surgery in right-sided native
valve endocarditis differ and include very large
vegetations (>20mm in diameter), recurrent septic pulmonary emboli, highly resistant organisms, or persistent bacteremia. HF is not a
common indication for early surgery in rightsided NVE since severe TR is better tolerated
than left-sided regurgitation [17].
Early surgery can also be indicated for certain
pathogens (examples including Pseudomonas
aeruginosa, Brucella, fungi, enterococci, and S.
aureus) as these pathogens can be extremely dif-
cult to cure with medical therapy alone and are
also prone to abscess or stula formation and
other cardiac tissue destruction [15].
In patients with an implanted cardiac electronic device, the entire system, including the
generator and leads, should be removed even if
there is no sign of infection along the device.
This is because blood stream infections can cause
a biolm of infection to coat (seed) the leads,
thus making the infection impossible to irradicate
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A. Stephens et al.
with medical therapy alone. Removal can be performed at the time of infected valve surgery or at
a specialized center where laser lead extractions
are performed, for those not undergoing surgical
valve management.
Surgical risk stratication can be quantied
utilizing the Society for Thoracic Surgeon (STS)
risk calculator for mitral or aortic endocarditis,
but not currently for tricuspid endocarditis. Refer
to Chap. 4 for surgical management of coronary
artery disease and discussion on risk assessment.
In all cases, decisions on intervention should be
multifactorial and include discussions with the
multidiscipline teams involved with the patient’s
care.
The risk calculator is available on the STS
website:
https://riskcalc.sts.org/stswebriskcalc/
calculate
Surgical risk is exceptionally high in patients
with active IE; however, in many cases, the
patient will not improve without surgical intervention. The average mortality risk for patients
undergoing surgery for IE with associated HF is
21%, however, mortality risk for patients with
medical therapy alone is 45% [10].
Outpatient Management
andFollow-Up Evaluation
(Table19.8)
Although novel diagnostic and therapeutic strategies have emerged, the 1-year mortality has not
improved and remains at >30%, which is worse
than many cancers [12]. While on antimicrobial
therapy, patients should be monitored for toxicity. Weekly lab monitoring (including a complete
blood count and complete metabolic panel)
should be performed [18]. Historically, the entire
course of antibiotics has been intravenous (typically with a peripherally inserted central catheter
placed to allow home IV antibiotic administration). However, recent data have shown that transitioning certain patients to oral antibiotics, after
at least 10 days of IV antibiotics, was noninferior. This transition to an oral step-down regimen may be a possible course, with direction
Table 19.8 Patient care during and after completion of
antimicrobial treatment
Initiate before or at completion of therapy
• Obtain transthoracic echocardiogram to establish
new baseline
• Drug rehabilitation referral for patients who use
illicit injection drugs
• Educate regarding signs of endocarditis, need for
antibiotic prophylaxis for certain dental/surgical/
invasive procedures
• Thorough dental evaluation and treatment if not
performed earlier in evaluation
• Prompt removal of intravenous catheter at
completion of antimicrobial therapy
Short-term follow-up
• Obtain at least three sets of blood culture
specimens from separate sites for any febrile illness
and before initiation of antibiotic therapy
• Physical examination for evidence of congestive
heart failure
• Evaluate for toxicity resulting from antimicrobial
therapy
Long-term follow-up
• Obtain at least three sets of blood cultures from
separate sites for any febrile illness and before
initiation of antibiotic therapy
• Evaluation of valvular and ventricular function
(echocardiography)
• Scrupulous oral hygiene and frequent dental
professional ofce visits
Adapted from Mann etal. Braunwald’s Heart Disease. A
Textbook of Cardiovascular Medicine, Tenth Edition.
Elsevier
from an infectious disease specialist, in certain
patients who are clinically stable with reassuring
TEE results [15].
At the completion of antibiotic therapy, a
transthoracic echocardiogram should be performed to serve as a new baseline reference for
valve appearance, severity of valvular regurgitation, and quantication of left ventricular function [17].
Ongoing monitoring is recommended after
hospital discharge, mainly for recurrent infection
(either relapse or reinfection) and progressive
valve dysfunction [12]. Patients should be
informed that they remain at risk of recurrent IE,
estimated to occur at a rate of 1–3% per year. At
regular medical checkups, patients should be questioned about symptoms of heart failure, and a thorough physical exam should be performed [16].
19 Infective Endocarditis
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193
Patients should be made aware that relapses
can occur and that new onset of fever, chills,
or other evidence of systemic infection mandates immediate evaluation, including a thorough history and physical exam and three sets
of blood cultures [16]. Prescribing empirical
antibiotic therapy should be avoided for undefined febrile illness until after blood cultures
have been obtained (unless the patient’s clinical condition warrants urgent empirical therapy) [16].
Measures to prevent IE recurrence, including
good oral hygiene and consideration of antibiotic
prophylaxis at the time of dental and other invasive procedures, are important [12]. Oral health
and hygiene is now considered more important
than antibiotic prophylaxis to reduce the risk of
recurrent IE. For ongoing long-term follow up,
daily dental hygiene should be stressed, with
serial evaluations by a dentist who is ideally
familiar with this patient population. Patients
should be counseled to discuss with their team
the role of antibiotic prophylaxis prior to specic
types of procedures, including certain types of
dental procedures [17]. The ACC and AHA do
recommend ongoing use of antibiotic prophylaxis for patients undergoing certain procedures
who are the highest risk of IE.Patients deemed
high risk include those with a history of IE [12].
SBE prophylaxis is recommended for dental
procedures only for patients with cardiac conditions at highest risk of adverse outcomes
from endocarditis including prosthetic cardiac
valve, previous endocarditis, congenital heart
disease with unrepaired cyanotic lesions
(including palliative shunts and conduits), completely repaired CHD with prosthetic material
or device during the rst 6months after placement, repaired CHD with residual defects at the
site or adjacent to the site of prosthetic patch or
device, and/or cardiac transplant patients with
cardiac valvular disease. Prophylaxis is no longer recommended for gastrointestinal or genitourinary procedures. The antibiotics used for
prophylaxis are listed below (Table 19.9) and
are taken 30–60min before the procedure start.
The guidelines are listed on the American Heart
Association website: https://www.heart.org/en/
Table 19.9 SBE prophylaxis antibiotic regimens
Adult
Situation Medication
Oral Amoxicillin 2gm
Unable to take oral
meds
Allergic to PCN or
AMP-oral
Allergic to PCN or
AMP-unable to take
oral meds
Amoxicillin
Ampicillin
Cefazolin/
ceftriaxone
Cephalexin
Azithromycin/
clarithromycin
Doxycycline
Cephazolin/
ceftriaxone
dosing
2gm IM/
IV
2gm IM/
IV
1gm IM/
IV
2gm
500mg
100mg
1gm IM/
IV
health- topics/infective- endocarditis which also
has printable cards for patients. It is critical to
educate high-risk patients regarding the potential symptoms of endocarditis as the associated
morbidity and mortality are high. Note: guidelines recently changed to no longer include
clindamycin for prophylaxis due to potential
for severe adverse drug reactions.
Clinical Pearls
• It is critically important for high-risk patients
to know the signs and symptoms of IE.
• Fever and new or worsening murmur are the
most common ndings of IE.
• Gram positive bacteria are the most common
“bug” identied in native IE.
• The diagnosis is made using the Duke Criteria.
• Annular and aortic abscesses have an increased
risk of heart block and death.
• Valve repair is always preferred over replacement to avoid placement of prosthetic
material.
• Right-sided endocarditis is often associated
with IV drug use.
• The most common indication for surgery in
left-sided lesions is heart failure.
• Embolic risk is high with large, mobile, MV
vegetations.
• If a pacemaker/debrillator is present, it is
assumed to be infected with any blood stream
infection and removal will need to be
considered.
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A. Stephens et al.
References
1. Mann, etal. Braunwald’s Heart Disease. A textbook
of cardiovascular medicine. 10th ed. Elsevier.
2. Otto CM, et al. ACC/AHA guideline for the management of valvular heart disease. Circulation.
2020;2021(143):e72–e227.
3. Nataloni M, et al. Prosthetic valve endocarditis. J
Cardiovasc Med. 11:869–83.
4. Wang A, etal. Management considerations in infective
endocarditis: a review. JAMA. 2018;320(1):72–83.
5. Chambers, etal. Native-valve infective endocarditis.
N Engl J Med. 2020;383:567–76.
6. Baddour LM, et al. Infective endocarditis in adults:
diagnosis, antimicrobial therapy, and management of
complications. Circulation. 2015;132:1435–86.
7. Murdoch DR. Clinical presentation, etiology, and
outcome of infective endocarditis in the 21st century. Arch Intern Med. 2009;169(5):463. https://doi.
org/10.1001/archinternmed.2008.603.
8. Cahill TJ, et al. Infective endocarditis. Lancet.
2016;387:882–93.
9. UpToDate: overview of management of infective
endocarditis in adults.
10. Otto CM, Nishimura RA, Bonow RO, Carabello BA,
Erwin JP III, Gentile F. 2020 ACC/AHA guideline for
the management of patients with valvular heart disease: a report of the American College of Cardiology/
American Heart Association Joint Committee on
Clinical Practice Guidelines. J Am Coll Cardiol.
2021;77(4):e25–197.
11. UpToDate: antimicrobial therapy of left-sided native
valve endocarditis.
12. The Society of Thoracic Surgeons; 2022. Available
from: https://www.sts.org/resources/riskcalculator.
13. Shmueli H, Thomas F, Flint N, Setia G, Janjic A,
Siegel RJ. Right-sided infective endocarditis 2020:
challenges and updates in diagnosis and treatment. J
Am Heart Assoc. 2020;9(15).
14. Bonow RO, O’Gara PT, Adams DH, Badhwar V,
Bavaria JE, Elmariah S, et al. 2019 AATS/ACC/
SCAI/STS expert consensus systems of care document: operator and institutional recommendations
and requirements for transcatheter mitral valve intervention. J Am Coll Cardiol. 2020;76(1):96–117.
15. Lawton JS, Tamis-Holland JE, Bangalore S,
Bates ER, Beckie TM, Mischoff JM, et al. 2021
ACC/AHA/SCAI Guideline for Coronary artery
Revascularization, A report of the American College
of Cardiology/American Heart Association Joint
Committee on Clinical Practice Guidelines. J Am
Coll Cardiol. 2022;79(2):e21–e129.
16. Chung J, Shum-Tim D.The current indications and
options for aortic valve surgery. J Surg. 2014;2(1):6.
17. Fedak PWM, McCarthy PM, Bonow RO.Evolving
concepts and technologies in mitral valve repair.
Circulation. 2008;117(7):963–74.
18. Watts TMF, Brescia AA, Murray SL, Burn DA,
Wisniewski A, Romano MA. Degenerative mitral
valve repair restores life expectancy. Ann Thorac
Surg. 2020;109(3):494–801.
19. UpToDate: clinical Manifestations and evaluation of adults with suspected left-sided native valve
endocarditis.
Part V
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Cardiomyopathies/Congestive Heart
Failure
JosephMishkin
Heart failure is a syndrome characterized by shortness of breath and fatigue
and is often associated with evidence of uid retention. This syndrome can
occur due to a multitude of cardiac insults that lead to either impaired contraction or relaxation of the myocardium [1]. In some instances, the primary
etiology can be due to pathology involving the pericardium as described in
Chap. 23. Understanding the instigating cause of heart failure can be important in directing appropriate treatment, i.e., identifying ischemic heart disease
and providing appropriate revascularization [2]. The classication of heart
failure based on ejection fraction is important as most clinical trials with positive results have enrolled patients with systolic dysfunction. Fortunately, in
recent years, new drug therapies have been identied to improve outcomes in
those with heart failure and preserved ejection fraction [3–6]. Furthermore,
advances in the treatment of cardiac amyloidosis have given optimism when
targeted therapies previously did not exist [7]. In many cases, the pathophysiological cascade of neurohormonal activation and cytokine upregulation is
similar regardless of the etiology of heart failure. Therefore, the pharmacological interventions to treat heart failure follow a common pathway regardless of the etiology of the heart failure syndrome [8–11].
The following chapters will dene some of the most common causes of
systolic and diastolic heart failure and provide the rationale for guideline
directed medical therapy. Given the expected rise in incidence of heart failure
in the USA and beyond, a solid foundation in identifying and treating this
syndrome is important for a variety of cardiovascular and internal medicine
specialties. Later sections will provide the basis for managing the more fulminant form of heart failure—cardiogenic shock.
Joseph Mishkin
Heart Failure and Transplant Services, Atrium Health/Sanger Heart and
Vascular Institute, Charlotte, NC, USA
joseph.mishkin@atriumhealth.org
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Cardiomyopathies/Congestive Heart Failure
References
1. Braunwald E.Heart failure. JACC Heart Fail. 2013;1(1):1–20.
2. Truby L, Rogers J.Advanced heart failure: epidemiology, diagnosis, and
therapeutic approaches. J Am Coll Cardiol HF. 2020;8:523–36.
3. Bhatt AS, Abraham WT, Lindenfeld J, etal. Treatment of HF in an era of
multiple therapies: statement from the HF collaboratory. J Am Coll
Cardiol HF. 2021;9(1):1–12.
4. Fonarow GC, Stough WG, Abraham WT, et al. Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry. J Am
Coll Cardiol. 2007;50:768.
5. Anker SD, Butler J, Filippatos G, etal. Empagliozin in heart failure
with a preserved ejection fraction. N Engl J Med. 2021;385:1451–61.
6. Pitt B, Pfeffer MA, Assmann SF, etal. Spironolactone for heart failure
with preserved ejection fraction. N Engl J Med. 2014;370:1383–92.
7. Ruberg FL, Grogan M, Hanna M, Kelly JW, Maurer MS. transthyretin
amyloid cardiomyopathy: JACC state-of-the-art review. J Am Coll
Cardiol. 2019;73:2872–91.
8. Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart
Failure (MERIT-HF). Effect of metoprolol CR/XL in chronic heart failure. Lancet. 1999;353:2001.
9. Packer M, Fowler MB, Roecker EB, etal. Effect of carvedilol on the
morbidity of patients with severe chronic heart failure: results of the
carvedilol prospective randomized cumulative survival (COPERNICUS)
study. Circulation. 2002;106:2194.
10. Zannad F, McMurray JJ, Krum H, etal. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364:11.
11. Desai AS, McMurray JJ, Packer M, etal. Effect of the angiotensin-receptor-neprilysin inhibitor LCZ696 compared with enalapril on mode of
death in heart failure patients. Eur Heart J. 2015;36:1990.
Heart Failure withReduced
https://t.me/medicina_free
Ejection Fraction (HFrEF)
LaurenEyadiel andBridgetRasmussen
20
Introduction
Heart failure is a complex systemic syndrome
where inadequate blood supply due to heart dysfunction is unable to meet the metabolic demands
of the tissues [1]. This clinical syndrome consists
of symptoms of congestion and/or inadequate
cardiac perfusion. Congestive symptoms include
shortness of breath, lower extremity edema,
abdominal bloating, orthopnea, and/or paroxysmal nocturnal dyspnea (PND). Symptoms of
inadequate cardiac perfusion include mental status changes, cardiac cachexia, renal dysfunction,
and fatigue due to decreased end organ perfusion.
The clinical syndrome is combined with elevated
natriuretic peptides and objective evidence of
congestion and/or echocardiographic ndings of
structural changes to the heart including reduction in ejection fraction. Heart failure with
reduced ejection fraction (HFrEF) is dened as
patients with the clinical syndrome of heart failure with a left ventricular ejection fraction of less
than 40% [2, 3]. This will be the focus of this
chapter. Heart failure with preserved ejection
fraction will be covered in Chap. 21.
L. Eyadiel · B. Rasmussen (*)
Advanced Heart Failure, Heart Transplant, and
Mechanical Circulatory Support, Cardiology, Atrium
Health Wake Forest Baptist,
Winston Salem, NC, USA
e-mail: lesykes@wakehealth.edu;
brasmuss@wakehealth.edu
Anatomy andPhysiology
Heart failure is a complex neurohormonal process that is not completely understood. Simply
put, there is an inciting event that results in damage to the homeostasis of the metabolic system
resulting in activation of multiple compensatory
mechanisms. These compensatory mechanisms
involve the adrenergic nervous system, renin
angiotensin aldosterone system (RAAS), and
cytokine system. This process is initially protective, but sustained activation of these compensatory mechanisms results in adverse remodeling
of the left ventricle with associated dilation and
increase in left ventricular volume and mass [4,
5]. Cardiomyocyte loss leads to the inability of
heart muscle to contract properly and reduces
cardiac output. A reduction in cardiac output
causes activation of the sympathetic nervous system and norepinephrine release, promoting
peripheral vasoconstriction, increased heart failure, and increased myocardial contractility.
Activation of RAAS leads to water and sodium
retention, increasing circulating volume and preload. The Frank-Starling mechanism states that
cardiac ber length increases contractile strength
[6] (see Chap. 2). Thus, the increased preload
causes increased myocardial contractility. If this
process persists, detrimental ventricular remodeling develops. Figure20.1 summarizes this process. A basic understanding of the
pathophysiology of HFrEF is required as
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
R. Musialowski, K. Allshouse (eds.), Cardiovascular Manual for the Advanced Practice Provider,
https://doi.org/10.1007/978-3-031-35819-7_20
197
198
Congestion
LC
mW
Adequate Perfusion
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Fig. 20.1 Neurohormonal inuences in HFrEF. (Adapted
from Harrison’s Principles of Internal Medicine)
guideline- directed medical therapies (GDMT)
target these compensatory mechanisms. There
are multiple etiologies of heart failure including
both ischemic and nonischemic disease which
are further discussed in the pathology section of
this chapter.
Physical Exam
Careful clinical examination of patients with
heart failure is essential. Broadly speaking, heart
failure physical exam components can fall into
two categories: volume status and perfusion status. Combining these assessments provides a
clinical prole [7] that can drive decisions in
management (Fig.20.2).
Volume Status
Jugular vein distention, indicating an elevated
jugular vein pressure (JVP), is common in
patients who have increased congestion. JVP is
used to estimate right atrial pressure. Waveform
or pulsation is examined, typically at 45°, on
both sides of the neck, which can be calculated
by measuring elevation and calculating horizontal distance from the sternal angle in centimeters
(cm) then estimating distance to the right atrium
by adding 5cm. Inspiratory increase in JVP is a
L. Eyadiel and B. Rasmussen
A B
Dry-war
Dry-cold Wet-cold
Fig. 20.2 Hemodynamic prole of heart failure patients
[8]
et-warm
poor prognostic indicator [9]. Pressing on the
abdomen should cause transient JVP elevation
that can help differentiate the waveform from
carotid pulsation. This change in abdominal
pressure, termed hepatojugular reux (HJR), is
pathologic if a sustained elevation is noted over
10 seconds of abdominal pressure, suggesting
elevated right-sided lling pressure [9].
Likewise, the presence of orthopnea—dyspnea
when lying back or supine—is indicative of elevated left ventricular lling pressures and pulmonary capillary wedge pressure (PCWP).
Respiratory exam may be notable for crackles or
diminished breath sounds indicative of pleural
effusions, but the presence or absence of this is
nonspecic. Cardiac auscultation may be notable for S3 gallop sound, a brief third heart sound
in early diastole indicating increased ow rates
or increased ventricular dilation. This is best
heard over the apex when the patient is in a left
lateral position (see Chap. 1). Pulsus alternans,
alternating weak and strong pulse pressure, is an
indicator of left ventricular resistance and leftsided dysfunction and may suggest decompensation. While lower extremity edema is
frequently present, it is not specic for heart
failure etiology. Dry oral mucosa and poor skin
turgor without an obvious cause are a sign of
intravascular volume depletion (Fig.20.3).
Perfusion Status
Although a careful review of systems is vital to
determining cardiac output or perfusion status,
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Fig. 20.3 How to measure JVP. (https://www.renalfel-
low.org/2011/01/02/jugular- venous- pressuredistention)
perfusion can be assessed by clinical exam as
well. A narrow pulse pressure (systolic minus
diastolic pressure) or low proportional pulse
pressure (pulse pressure divided by systolic
pressure) is a marker of low cardiac output.
Cool or tepid extremities are suggestive of low
cardiac output, but sensitivity is low. Prolonged
or sluggish capillary rell time (greater than
2 seconds), if present, is a marker of poor
perfusion.
Review ofSystems
Like physical examination, a thorough review of
systems can be instructive. Pertinent positive
review of system ndings connoting elevated
volume status includes weight changes; new
cough, especially when lying supine; orthopnea;
paroxysmal nocturnal dyspnea (may be expressed
as change in sleep habit); early satiety; abdominal bloating; and lower extremity edema.
Findings that suggest poor cardiac perfusion
include fatigue or malaise, decreased appetite,
cold intolerance, confusion, decreased urination,
and dizziness/lightheadedness. Early decompensated heart failure is often misdiagnosed as a
respiratory ailment.
Clinical Classications
There are two main tools to classify heart failure. The ACC/AHA stages of Heart Failure
emphasize the development and progression of
disease, and the New York Heart Association
(NYHA) classes focus on exercise capacity,
physical examination, and the symptomatic status of the HF disease (Table20.1).
199
Table 20.1 Classication of heart failure
ACCF/AHA stages of 6FNYHA functional
classication
Stage A: At high risk
for HF but without
structural heart disease
or symptoms of HF
Stage B: Structural
heart disease but
without signs of
symptoms of HF
Stage C: Structural
heart disease with prior
or current symptoms of
HF
Stage D: Refractory HF
requiring specialized
interventions
I: No limitation of physical
activity.
II: Slight limitation of
physical activity.
Comfortable at rest, but
ordinary activity results in
symptoms of HF
III: Marked limitation of
physical activity.
Comfortable at rest, but less
than ordinary activity causes
symptoms of HF
IV: Unable to carry on any
physical activity without
symptoms of HF, or
symptoms of HF at rest
Imaging
Imaging is utilized in heart failure to conrm the
diagnosis, provide information regarding the etiology, monitor for treatment response, and to assist
in prognostication. Depending on the type of
imaging, information is given regarding the cardiac chamber size, architecture, global, and
regional left ventricular function. Choosing the
most appropriate imaging modality can be challenging and requires careful attention to patientspecic factors based on history, physical
examination, and laboratory testing. Table 20.2
provides a comprehensive overview of the imaging modalities used for evaluation of patients with
heart failure. The most common imaging modalities will be discussed in further detail below. Of
note, routine repeat measurement of left ventricular function is not indicated in the absence of a
clinical status change or treatment intervention.
Echocardiography
Two-dimensional echocardiography is considered the most useful, versatile, and cost-effective diagnostic method for patients with heart
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