SIU School of Medicine

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Department of Internal Medicine

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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