Diagnosis of Heart failure, symptoms,signs and investigations

Here we are going to discuss How to diagnose a case of Chronic Heart Failure .
To do so , we must learn the clinical picture (symptoms and signs ) of the disease and the recommended investigations .
Diagnosis of Heart failure

A. Clinical picture of  Chronic Left Sided Heart Failure

1. Symptoms due to decreased cardiac output  (Forward failure):

  • Dizziness
  • Easy fatigue, muscle weakness.
  • Oliguria, cold extremities.

2. Symptoms due to P.V.C (Backward failure)

  • Dyspnea
  • Orthopnea.
  • Cough and expectoration. PND

3. Signs of Left Sided Heart Failure

  • Tachycardia except in digitalized patient.
  • Signs due to decreased cardiac output ( Low pulse volume, decreased Systolic blood pressure, Cold extremities and peripheral cyanosis )
  • Signs of PVC (bilateral fine basal crepitations) .
  • Plsus altemans.
  • Gllop on the apex (3rd heart sound+ tachycardia= ventricular gallop) .
  • Murmur of MI. (MI may be a cause of heart failure or a result due to left ventricular dilatation).

The term congestive heart failure is best restricted to cases where right heart failure results from pre-existing left heart failure.

B.  Clinical picture of  Right Sided Heart Failure

 1. Symptoms due to decreased cardiac output  (Forward failure):

- Dyspnea , Easy fatigue and Oliguria ( as mentioned above )

2.  Symptoms due to SVC  (Backward failure) :

  • Swelling of both lower limbs.
  • Pain in the right hypochondrium.
  • Dyspepsia.

3. Signs of  Right Sided Heart Failure

  • Tachycardia.
  • Congested neck veins 
  • Enlarged tender liver.
  • Lower limb edema .
  • Pulsus alternans.
  • Gallop on the tricuspid area (3rd heart sound + tachycardia)
  • Murmurs of TI (Functional) due to dilated right ventricle .

Investigations  (diagnosis of heart failure is mainly clinical)

1. X-ray: Cardiomegally (dilated heart), Left sided failure (PVC) .
2. ECG:
  • It records electrical activity of the heart & not the mechanics (No specific findings for heart failure).
  • It detects chamber enlargement, tachycardia or ischaemia. 
3. Echo:
  • Measures COP, this reflects ventricular function .
  • Measurement of ejection fraction .
4. Cardiac scan.
5. Other investigations: e.g.: serum creatinine. blood urea, serum Na and K, Hb and liver enzymes, bilirubin .

Complications of heart failure

  • Uremia (Prerenal failure) .
  • Hypokalemia (diuretics and ++  aldosterone).
  • Hyponatremia (diuretics). 
  • Impaired liver function (-- COP + SVC).
  • Thromboembolism.
  • Arrhythmias.
  • Cardiac cachexia.

What is meant by Cardiac cachexia ?

Chronic heart failure is sometimes associated with marked weight loss caused by a combination of anorexia and impaired absorption due to gastrointestinal congestion, poor tissue perfusion due to decreased COP and skeletal muscle atrophy due to immobility. Also increased circulating levels of tumour necrosis factor have been found in patients with cardiac cachexia.  

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