Congestive heart failure echocardiography

Resident Survival Guide

Congestive Heart Failure Microchapters
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Overview
Historical Perspective
Classification
Pathophysiology Systolic Dysfunction Diastolic Dysfunction HFpEF HFrEF
Causes
Differentiating Congestive heart failure from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Clinical Assessment
History and Symptoms
Physical Examination
Laboratory Findings
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Echocardiography
Exercise Stress Test
Myocardial Viability Studies
Cardiac Catheterization
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Invasive Hemodynamic Monitoring
Medical Therapy:
Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
Exercise Training
Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Echocardiography is commonly used to diagnose and monitor the progress of heart failure. This modality uses ultrasound to determine the stroke volume (SV, the amount of blood in the heart that exits the ventricles with each beat), the end-diastolic volume (EDV, the total amount of blood at the end of diastole), and the SV divided by the EDV, a value known as the ejection fraction (EF). In pediatrics, the shortening fraction is the preferred measure of systolic function.

Abnormalities Detected / Evaluated on Echocardiography in Congestive Heart Failure

The most useful diagnostic test in the evaluation of patients with or at risk for HF (eg, postacute MI) is a comprehensive 2-dimensional echocardiogram; coupled with Doppler flow studies, the transthoracic echocardiogram can identify abnormalities of myocardium, heart valves, and pericardium. Echocardiography can reveal subclinical HF and predict risk of subsequent events.</ref>

LVEF is reduced, LV structure is abnormal, and other structural abnormalities are present that could account for the clinical presentation. This information should be

Echocardiography can be used in the following ways:

• To evaluate left ventricular function and ejection fraction to distinguish systolic dysfunction with a low ejection fraction (<40%) from diastolic dysfunction with a preserved ejection fraction.
• LV structural abnormalities
• To assess for the presence of regional wall motion abnormalities that would suggest an ischemic basis for the heart failure
• Detection and quantification of mitral regurgitation
• Detection and quantification oof aortic stenosis
• Measurement of pulmonary artery pressure
• Pericardial diseases such as cardiac tamponade can be rapidly diagnosed by echocardiography.
• Echocardiography may also aid in deciding what treatments will help the patient, such as medication, insertion of an implantable cardioverter-defibrillator or cardiac resynchronization therapy.

Echocardiographic findings must be quantified, including numerical estimates of EF measurement, ventricular dimensions, wall thickness, calculations of ventricular volumes, and evaluation of chamber geometry and regional wall motion.

Documentation of LVEF is an HF quality-of-care performance measure.</ref>

Right ventricular size and function as well as atrial size and dimensions should also be measured.

All valves should be evaluated for anatomic and flow abnormalities.

Many of these abnormalities are prognostically important and can be present without manifest HF.</ref>

Serial echocardiographic evaluations are useful because evidence of cardiac reverse remodeling can provide important information in patients who have had a change in clinical status.

2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT)

Echocardiography in Patients Presenting With Heart Failure (DO NOT EDIT)

Class I

"1. Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with heart failure to assess left ventricular ejection fraction, left ventricular size, wall thickness, and valve function. Radionuclide ventriculography can be performed to assess left ventricular ejection fraction and volumes. (Level of Evidence: C) "

Serial Clinical Assessment (Echocardiography) of Patients Presenting With Heart Failure (DO NOT EDIT)

Class IIa

"1. Repeat measurement of ejection fraction and the severity of structural remodeling can provide useful information in patients with heart failure who have had a change in clinical status or who have experienced or recovered from a clinical event or received treatment that might have had a significant effect on cardiac function. (Level of Evidence: C) "

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation

References

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