0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
Chronic Heart Failure 319■Chronic non-productive cough
■Reduced exercise capacity
■Generalized weakness and fatigue
■Nocturia, oliguria
■Confusion, poor memory, insomnia, anxiety, headache, delirium
■Nausea, abdominal discomfort, anorexia, right upper quadrant pain
■Consistent with underlying or inciting pathophysiology
■General: distressed, dyspnea, pallor, diaphoresis, cachexia, jaundice
(acute hepatic congestion)
■Vital signs: tachycardia (usually), hypotension or hypertension, nar-
row pulse pressure, tachypnea, diaphoresis, low grade fever.
■Respiratory: rales, pleural effusion, Cheyne-Stokes respiration pat-
tern
■CV: jugular venous distension, hepatojugular reflux, pulsus alter-
nans (indicates severe LV dysfunction), cardiomegaly, LV heave, RV
lift, loud P2, S3, S4, systolic murmur (functional MR/TR)
■Abd: hepatomegaly, ascites
■Extrem: peripheral edema, cool/ poorly perfusedtests
■Basic Blood Tests
➣Usually normal, except for other comorbidities
➣Electrolytes: Hyponatremia (dilutional), secondary hyperal-
dosteronism, Hypokalemia (diuretic use), hypophosphatemia,
hypomagnesemia (diuretics, alcohol)
➣BUN/creatinine: Prerenal azotemia
➣BNP (B-type natriuretic peptide) or nt-pro-BNP: suggestive
of elevated cardiac filling pressures or ventricular wall stress;
usually only used for acute exacerbations; may be elevated
in right-sided heart failure (i.e., cor pulmonale, pulmonary
embolus)
➣Cardiac enzymes: elevated troponins or CK-MB (myocardial
injury)
➣Liver function tests: AST, ALT, LDH, direct and indirect bilirubin
elevated in congestive hepatopathy
➣TSH: hypo- or hyperthyroidism
■Basic Urine Tests
➣Proteinuria, high specific gravity, acellular casts
■Specific Diagnostic Tests
➣Chest X-ray: cardiomegaly (size and shape can assist with
dx); pulmonary vascular redistribution, interstitial pulmonary