Heart Failure

HEART FAILURE

Rationale

Congestive heart failure (CHF) is one of the most common cardiac problems encountered in clinical practice. Identification and correction of treatable underlying causes, control of precipitating factors and judicious use of multi-drug regimens for individuals with CHF are important issues for third-year medical students.

Prerequisites

Knowledge of the structure and function of the heart and lungs

Knowledge of the epidemiology of heart disease

Knowledge of the pathogenesis and pathophysiology of cardiovascular disease

Knowledge of the pharmacology of cardiovascular drugs and the interaction of multiple drugs given simultaneously

Ability to perform a cardiovascular risk assessment and understand issues related to primary and secondary prevention of cardiovascular disease

Knowledge

Students should be able to define and describe:

types of processes and most common disease entities that cause CHF:

ischemic

valvular

hypertrophic

infiltrative

inflammatory

staging system for heart failure:

Stage A: high risk for CHF but no structural heart disease is present

Stage B: structural heart disease is present but never any symptoms

Stage C: past or current symptoms associated with structural heart disease

Stage D: end-stage disease with requirements for specialized treatment

types of processes that cause systolic vs. diastolic dysfunction

symptoms and signs of left-sided vs. right-sided heart failure

compensatory mechanisms of heart failure including cardiac remodeling and activation of endogenous neurohormonal systems

factors leading to symptomatic exacerbation of CHF including:

ischemia

arrhythmias

hypoxemia

anemia

fever

hypertension

thyroid disorders

non-adherence with medications and/or dietary restrictions

use of nonsteroidal anti-inflammatory drugs and other drugs that may worsen CHF

importance of age, gender and ethnicity on the prevalence and prognosis of HF

physiological basis and/or scientific evidence supporting each type of treatment, intervention or procedure commonly used in the management of patients who present with heart failure

role of critical pathways or practice guidelines in delivering high-quality, cost-effective care for patients presenting with new or recurrent heart failure

Skills

Students should demonstrate specific skills, including:

History-Taking Skills: Students should be able to obtain, document, and present an appropriately complete medical history that:

differentiates between various etiologies of heart failure (answers the question: Why is the patient in heart failure?)

identifies clinical factors responsible for symptomatic exacerbation (answers the question: Why is the patient worse now?)

Specifically, the medical history of a patient with heart failure should contain information about:

exercise intolerance

fatigue

dyspnea on exertion

fluid retention

peripheral edema

dyspnea

changes in sleep pattern

orthopnea

paroxysmal nocturnal dyspnea (PND)

nocturia

Students should be able to use the medical history as a tool to assess the functional capacity of patients with CHF:

walking distance

New York Heart classification

Physical Exam Skills: Students should be able to perform a focused physical exam to help establish the diagnosis of CHF and estimate its severity. The initial physical exam of a patient with CHF should include:

measurement of vital signs including weight and respiratory rate/pattern

accurate measurement of arterial blood pressure and recognition of the typical blood pressure findings that occur in patients with aortic stenosis and aortic insufficiency

assessment of the neck veins for jugular venous distention and, when necessary, evaluation for abdominal jugular reflux

assessment of the extremities to ascertain for skin conditions, including:

color

temperature and the presence of edema

cyanosis, clubbing

assessment of the lungs for:

crackles

rhonchi

decreased breath sounds

inspection and palpation of the anterior chest to identify right- and left-sided heaves, lifts and thrills

auscultation of the heart to determine:

rhythm

intensity of heart sounds

splitting of S2 and the presence of rubs

gallops (S3, S4, summation)

extra heart sounds (e.g., clicks)

auscultation of the heart to detect the presence of heart murmurs. When a heart murmur is present, students should be able to:

identify timing;

systolic vs. diastolic

holosystolic vs. ejection

describe pitch, location and pattern of radiation

assessment of the abdomen to determine the presence of:

hepatomegaly

ascites

abnormal pulsations

bruits

Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis and recognize specific history and physical exam findings that help support or refute a clinical diagnosis of heart failure.

Students should be able to distinguish between the various underlying etiologies of CHF including disease processes that primarily affect:

pericardium (constrictive pericarditis, pericardial tamponade)

endocardium

valvular (congenital, acquired)

endocarditis

myocardium

hypertension

coronary artery disease – ischemic cardiomyopathy

hypertrophic cardiomyopathy

dilated cardiomyopathy

Laboratory Interpretation: Students should be able to interpret specific diagnostic tests and procedures that are commonly ordered to evaluate patients who present with heart failure. Test interpretation should take into account:

pre-test and post-test likelihood of disease

performance characteristics of individual tests:

sensitivity

specificity

positive and negative predictive value

likelihood ratios

Students should be able to define the indications for, and independently interpret the results of the following diagnostic tests and procedures:

12-lead electrocardiogram

chest x-ray

b-type natriuretic hormone level

Students should be able to define the indications for, and interpret (with consultation) the results of the following diagnostic tests and procedures.

echocardiography:

treadmill exercise testing (for functional capacity)

radionuclide ventriculogram (multiple gated acquisition scan [MUGA])

cardiac MRI

coronary angiography

Communication Skills: Students should be able to:

communicate the diagnosis, prognosis and treatment plan to patients and their families

educate patients about cardiovascular risk factors

address palliative care and end-of-life issues with patients who have intractable symptoms associated with end-stage heart failure

Management Skills: Students should be able to:

develop a timely and appropriate evaluation and treatment plan for patients with heart failure due to systolic dysfunction. Specifically students should be able to identify the indications, contraindications, mechanisms of action, adverse reactions, significant interactions, and relative costs of the following treatments/interventions.

Non-pharmacological management

sodium and fluid restriction

physical activity

Pharmacological management (recommended for routine use)

diuretics

angiotensin converting enzyme inhibitors or ARBs and/or both

ß-blockers

aldosterone antagonists

spironolactone

eplerenone

digoxin

Interventions considered for use in selected patients

hydralazine and isosorbide dinitrate

angiotensin converting enzyme inhibitors or ARBs and/or both

calcium channel blockers

anti-arrhythmic agents

anticoagulants/anti-thrombotic agents

Other modalities

coronary revascularization

synchronized biventricular pacing

develop a timely and appropriate evaluation and treatment plan for patients with heart failure due to diastolic dysfunction including:

control of physiologic factors

blood pressure

heart rate

reduction in central blood volume by judicious use of diuretics

alleviation of myocardial ischemia

use of calcium channel blockers

use of beta-blockers

describe use of other agents and/or interventions that may be useful in treating patients with refractory, end-stage heart failure:

intravenous vasodilators

intravenous positive inotropic agents

infustion of b-type natriuretic peptide (nesiritide)

ventricular assist devices

heart transplantation

demonstrate how critical pathways or practice guidelines in ambulatory or hospitalized patients with CHF can be used to guide diagnostic test ordering and medical decision making

determine when to consult a cardiologist in the management of patients with heart failure

Attitudes and Professional Behaviors

Students should be able to:

recognize the importance of early detection and treatment of risk factors that may lead to the development of heart failure.

recognize the importance of lifestyle limitations caused by heart failure and counsel patients appropriately.

recognize the significant morbidity and mortality associated with a diagnosis of heart failure and, when appropriate, provide palliative care for patients with refractory symptoms associated with end-stage disease.

Resources

Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: a report of the America College of Cardiology/American Heart Association Task Force on Practice Guidelines

Clerkship Seminar, “Congestive Heart Failure”, S. Frank, MD

Clerkship Seminar, “Chest Radiograph Interpretation,” K. Kraudel, MD

Internal Medicine Clerkship Guide, Paauw, et al, Mosby 2003, pp 208-214 and 113-119

Jessup, M., and Brozena, S. “Heart Failure”, NEJM, 2003;348:2007-18.

"Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure?", Charlie S. Wang, MD, J. Mark FitzGerald, MB, DM, Michael Schulzer, MD, PhD, Edwin Mak, Najib T. Ayas, MD, MPH, JAMA. 2005;294:1944-1956

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