Fig. 22.1
Pulmonary capillary wedge pressure (PCWP) measurements are reported in relation to the clinical presence (+) or absence (−) of jugular venous distension (JVD) and the presence of a positive (+) or negative (−) abdominojugular test (AJT). Purple circles = patients without elevated jugular venous pressure and a negative abdominojugular test; Yellow circles = patients without elevated jugular venous pressure but with a positive abdominojugular test; blue circles = patients with evidence of both elevated jugular venous pressure at rest in addition to a positive abdominojugular test (Used with permission from Butman [6])
In the setting of heart failure, it is important to differentiate between heart failure with either preserved or reduced systolic function (also referred to as diastolic and systolic heart failure).
Diastolic heart failure is characterized by a LVEF above 50 %, elevated left atrial pressures, elevated left end diastolic pressure, impaired left ventricular relaxation, and decreased compliance [12].
The combination of diastolic blood pressure ≥105 mmHg and the absence of JVD has high specificity and 100 % positive predictive value in identifying diastolic heart failure at the bedside [11].
Prognostic Implications of the Auscultation Features
The 1 year life expectancy of advanced heart failure patients is only 62 % [13].
The prognosis is similar for heart failure with preserved and reduced ejection fraction. The 5 year mortality rate is 65 % for patients with preserved ejection fraction and 68 % for patients with a reduced ejection fraction [14].
Each 10 % reduction in ejection fraction is associated with a 39 % increase in the risk of mortality in patients with an ejection fraction below 45 % [15].
The presence of clinical variables such as a previous acute MI, anterior acute MI, congestion on chest x-ray, and creatine kinase >1000 were predictive of a stepwise decrease in LVEF and an increase in the proportion of patients with a reduced LVEF [16].
The presence of an S3 gallop is indicative of excess morbidity and mortality (42 % increase in hospitalization and 15 % increase in death) [17]. The presence of elevated JVP is also associated with similar increased risks.
There is a 35 % increase in relative risk of death for each 100 pg/ml increase in BNP from baseline [18].
Each 1 g/dL reduction in hemoglobin has been associated with a 20 % adjusted increase in risk of death [19, 20].
Persistently elevated levels of high sensitivity troponin T are associated with a twofold increase in mortality risk [21].
The cumulative 1 and 2 year survival rates of patients with a VO2 above 14 ml/kg/min) are 94 % and 84 % which is equivalent to post cardiac transplant survival rates [22].
Statement on Management
Medication management and timing of specialized interventions should follow the 2009 ACCF/AHA Heart Failure Guidelines.
Stage A recommendations include treatment of hypertension and lipid disorders, smoking cessation, control of metabolic syndrome, regular exercise, discouragement of alcohol and illicit drug use, and drug therapy using an ACEI or ARB in appropriate patients.
Stage B recommendations include all of Stage A guidelines in addition to treatment with a beta blocker in appropriate patients and the placement of implantable defibrillators in selected patients.
Stage C recommendations include all Stage A and B measures in addition to dietary salt restriction, treatment of fluid retention with diuretics, and adjunct aldosterone antagonists, digitalis, and hydralazine or nitrate in selected patients. Biventricular pacing and implantable defibrillators should also be considered in selected patients.
Stage D therapy goals include recommendations for Stage A, B, and C in addition to heart transplantation, chronic inotropes, permanent mechanical support, experimental surgery or drugs, and supportive end of life care.
In patient post-MI, 35 % can be reliably predicted to have and ejection fraction less than or equal to 40 %, with anterior MIs having the highest incidence of reduced LVEF [1].
In patients with CAD, a normal electrocardiography and the absence of cardiomegaly establishes an extremely high likelihood of normal EF.
In patients previously diagnosed with CHF, assessment of LVEF, S3 gallop, BNP, hemoglobin, troponin, and VO2 can help predict survival outcomes.
Clinical Summary of the Case
This patient with a history of prior myocardial infarction presents with symptoms and signs of congestive heart failure. In the setting of left ventricular systolic dysfunction, the presence of elevated JVP, even in the setting of a clear chest exam, indicates high intracardiac filling pressures. The narrow pulse pressure, (27 mmHg [119/92 mmHg], or 23 % suggests that cardiac index is abnormally low. Prognosis is reduced in the setting of poor hemodynamics in chronic systolic dysfunction, therefore tailored management of congestive heart failure with diuresis, afterload reduction, and further assessment of cardiac performance is warranted.
References
< div class='tao-gold-member'>
Only gold members can continue reading. Log In or Register to continue
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
