The document discusses diagnostic procedures for congestive heart failure, including clinical exams, echocardiography, blood tests, cardiac imaging like angiography and MRI, and hemodynamic monitoring. Key diagnostic tests are clinical exams, echocardiography to assess heart structure and function, blood tests like BNP to support diagnosis, and additional cardiac imaging tests like angiography to evaluate underlying heart conditions. Hemodynamic monitoring provides cardiac functional parameters but has limited clinical use due to its invasiveness.

1. Medical Science Tanzania Cardiology Lectures
Congestive Heart Failure
2. Diagnostic procedures
Prof. Hennersdorf SES
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2. Procedures
• Clinical pathways
• Echocardiography
• Biochemistry
• Hemodynamics
• Imaging: Angiography, MRI
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3. Procedures
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4. General signs and symptoms
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5. Definition of Heart Failure CHF
 New York Heart Association (NYHA)
 I  no visible signs and symptoms
 II  signs and symptoms at high level exercise
 III  signs and symptoms at low level exercise
 IV  no physical exercise possible, bed rest
necessary
Mostly used functional definition of CHF throughout the world!
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6. NYHA
NYHA II NYHA III NYHA IV
NYHA I without clinical signs and symptoms
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7. Physical examination: general
• Dyspnea (rest, exercise), Orthopnea
• Weight gain, swelling of the legs
• Nocturia
• Tachycardia (Palpitation)
• Fatigue
• Sweating
• Nausea, vomiting, cough
• Anorexia
• Cachexia (cardiac)
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8. Pulmonary edema/orthopnea
Pulmonary edema
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9. Swelling by fluid retention
Pulmonary edema
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10. Swelling by fluid retention
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11. Physical examination: acute vs. chronic
• acute
– Severe symptoms
– No weight gain due to rapid onset
– Tachycardia
• Chronic
– Less severe symptoms (NYHA classes)
– Weight gain
– Nausea, vomiting, cough
– Anorexia
– Cachexia
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12. Physical examination: special
• Palpation
– Precordial heave
– Cardiac apex localization (outside the midclavicular
line)
• Auscultation
– 3rd, 4th heart sound
– Mitral systolic murmur
– pulmonary rales
• Prominent jugular vein (positive pulse; TI)
• Hepatojugular reflux
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13. Physical examination: heart sounds
S4 S1 S2 OS S3
Sound
ECG
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14. Physical examination: heart sounds
S1 S2 S3
midsystolic murmur Sound
ECG
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15. Physical examination:
functional tests
 6-min walk: Pt. is forced to walk as he likes walking,
standing, running etc. The achieved distance is
documented
and should reach
>350 (female) - 400 (male) m
weak but reproducible relation to peak O2-
consumption
 Ergometry: objective measurement of workload, but
also used for rehabilitation in special cases or
postoperatively (HTX): sitting or supine, treadmill
preferred
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16. Physical examination:
Exercise device ergometry equipment
ECG Cart
Emergency Kit
(necessary)
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17. Procedures
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18. Echocardiography
 Underlying disease
 Cardiomyopathy
 Valve disease
 CHD (Stress Echo)
 Pathophysiology: LV filling patterns
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19. Left heart failure: US LVDD*
*left ventricle diast.
Diameter, norm
<50<mm
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20. Left heart failure: US TMF*
A B
C A normal transmitral filling
B early diastolic dysfunction
C progredient diastolic
Dysfunction
*Transmitral flow
DT deceleration time
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21. Left heart failure: US MI
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22. Left heart failure: US TR*
Eval.
systolic PA pressure *Tricuspid
regurgitation
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23. Procedures
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24. Chest XRay CXR
normal finding
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25. Chest XR CXR
Pulmonary edema
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26. Chest XR CXR
Pulmonary edema Pulmonary edema
before therapy after successful therapy
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27. Angiography indications
 Underlying disease (CHD) with therapeutic
consequences (PCI, CABG)
 Intervention (cardiogenic shock)
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28. Left heart failure, hemo + angio
Angio
+
hemodynamics
Left ventricle shape, size and function Pumping, blood delivery, work
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29. Left heart failure:
right heart hemodynamics
SWAN GANZ Catheter PA Pressure monitoring
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30. Left heart failure, hemodynamics
Measurements:
Cardiac output
Ventricular filling pressures,
Vascular resistances
Work load
Work capacity
Limited clinical value, limited use to invasive cases (Cathlab,OP),
potentially harmful!
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31. HF parameter by heart catheterization
Some hemodynamic values
Cardiac output/index norm 2-2.5 l(min/m 2)
Stroke work norm 21 mjoule
enddiastolic pressure norm 12 mm Hg
Vascular bed resistances (norm)
TPR 1200 dyn*sec*cm-5
PVR 70 dyn*sec*cm-5
Clinical use limited to ICU control
during vasoactive therapy
e.g. of cardogenic shock
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32. CHF parameter by angiography*
Ejection fraction EF
EDV**
EF = --------------- x 100 (%)
EDV**-ESV***
Norm = 70%
Strongest predictors
Reduced = <40%
Low= <20% of survival and prognosis
*today fairly achieved by echocardiography
**Enddiastolic volume/area
*** endsystolic volume/area
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33. Angiography diagnose: LV shape
Systole
Regional scar Diastole
EF < 20%
red lines
Diastole show normal
contraction
Regional scar
Systole
Anterior wall infarction
Dilated cardiomyopathy
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34. Angiography diagnose: LV shape
Regional scar
Diastole
Regional scar
Systole
EF 70%
normal infarction
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35. CHF and MRI
• Dimensions
• Contractility, Viability
• Valve function
MRI crossectional
sequence of dilated LV
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36. Procedures
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37. Biochemistry
 Red, white BC
 Blood sedimentation rate
 Electrolytes
 Urinalysis, Kreatinine
 Enzymes (GOT, GPT, LDH, CK, CKMB, Troponine)
 CRP (Inflammation)
 Epinephrine/Norepinephrine levels scientific
 Peptide (BNP/ANP) levels  mostly scientific, but probably
prognostic
Value: diagnostic, prognostic, therapy control
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38. Biochemistry: BNP/NT-proBNP
 BNP= brain natriuretic peptide
(delivered in myocardial atrial tissue
during atrial stress)
regulating hormone in order to reduce atrial stress
 Inactive precursor of BNP = NT-proBNP
 Blood test after 10 min valid
 Mostly valid to exclude CHF under clinical conditions
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39. CHF Diagnose: stepwise procedure
1st step: clinical approach, additional ECG, CXR
2nd step: echocardiography
3rd step: blood tests (BNP)
4th step: exclude CHD (card-CT, Cathlab)
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40. The End
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