Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr Warrick Bishop and welcome to my videocast and podcast channel and of course welcome to the Healthy Heart Network. Today I'm looking forward to talking about the diagnosis and investigation of cardiac failure. Well, whenever we talk about conditions in medicine, we always start with history and examination. You may have already figured so far, from some of the information that's been shared, that when we consider cardiac failure, one of the main symptoms is that of shortness of breath. Of course, shortness of breath can come on rapidly, we would call that acute, or it can come on gradually, we would call that chronic. we can quantify the degree of shortness of breath. I've already touched on the New York Heart Association classification which talks about levels 1, 2, 3 and 4. 4 being shortness of breath with minimal exertion, almost at rest or almost no capacity before shortness of breath develops. Level 1 being almost negligible shortness of breath at extremes of exercise, it's noted. And then 2 and 3 sitting in between that. The other thing that we want to know about shortness of breath is, is it related to position? We know that if patients with cardiac failure lay down, that there can be shifts of fluid within the body. which means more fluid moves back towards the lungs. Obviously, when you stand up, fluid drains away from the lungs. If you lay down flat, that fluid can make its way back to the lungs. And if there is excess fluid in the system, it can accumulate in the lungs and lead to shortness of breath on laying down. That shortness of breath in the supine position we call orthopnea. They're medical words. You don't need to know those, but we certainly... want to understand if that's one of the features that a patient has. One of the other symptoms that patients will sometimes report is shortness of breath that wakes them up in the middle of the night. This is a little bit like orthopnea, but it takes a couple of hours for that fluid to redistribute. and then wake the person who's been asleep for several hours while that fluid redistributes, accumulates in the lungs and wakes them up from their sleep. Characteristically, these people wake up in the early hours of the morning or late hours of the night, short of breath, gasping, stand up, throw open a window to get cool, clean, reinvigorating air, and the symptoms settle down. They have air hunger. We call that intermittent. Nighttime, shortness of breath. We call that paroxysmal, being intermittent. Nocturnal, meaning nighttime. Dyspnea, the word we use for shortness of breath. Paroxysmal, nocturnal, dyspnea. We write it in the notes as PND because we know what we're talking about and we of course ask about that in the context. of heart failure. The other thing that we want to ask about in terms of cardiac failure in history is a history of swelling. Patients will of course notice if their legs are swollen up by like balloons because that might be their presenting problem, the issue that they actually go to their doctor with saying that their legs are swollen to a terrible degree. But questioning around more subtle swelling is also really important. Things like are there significant sock marks where the patient notices that over a period of time their socks are making an indentation into their ankles. This can be really important and can be a really useful bit of examination for the patient to show you if it's present. Shorts, breath and swelling are the two main symptoms that patients will present with but of course in the history we need to know all sorts of other things. Right back to issues from childhood. Was there a childhood murmur? Was there childhood surgery? Were there conditions or fevers or infections such as rheumatic fever that may have impacted that person at a young age? Is there a family history of heart problems? All these other things. Has there been a heart attack in the past? What's the history of blood pressure been? Of course, there's so much background that we also need to get. We can't forget that in trying to get to the bottom of cardiac failure. When we examine the patient, we also are looking for clues as to how their heart and how their body is responding to cardiac failure. Is that person short of breath at rest? Were they short of breath walking into the consulting room? Were they short of breath getting undressed or bending over? What's their pulse rate like? Is it going fast? Is it thready? Is it thumping? Is it irregularly irregular like the condition that we see called atrial fibrillation which can be associated with heart failure? So we're thinking all the time, how are they breathing? How is their pulse? We check blood pressure as well. Trying to ascertain, is the blood pressure very high? Could this be a driver of someone going into cardiac failure? Is the blood pressure very low? Showing that the heart's weak and the blood vessels in the body are dilated. So that the pressures are low, maybe because the heart's not working, maybe because there's peripheral dilatation of all the blood vessels. One of the things that we particularly look at in cardiac failure, and this, if you've had cardiac failure, it may have happened to you and you may have wondered what was going on, is that doctors will look at your neck. And you might think that's a bit of an odd thing to do, but it's a really, really important thing to do. And what we're looking at is the wave, the venous wave of the jugular vein. Now that sounds pretty complicated when you say it, but let me put it another way. If we think about the heart with the veins running back into it, the inferior vena cava and the superior vena cava, then if we imagine the superior vena cava runs back up and is connected to the jugular vein, which is running from the brain into the heart. So that superior vena cava connects directly to the right atrium, therefore fluid in the right atrium is connected to fluid in the superior vena cava connected to fluid in the jugular vein. So in fact the jugular vein is almost like a dipstick telling us what the fluid pressures are like in the right atrium. In cardiac failure the pressures in the right atrium can increase and so the wave form of the jugular wave, the dipstick to the heart can be visible in patients sitting upright, which it normally isn't when a heart is healthy and a patient is well. So we look really closely to see where that fluid level is in what we call the jugular venous pulse. It's an important bit of information. It's something we learn all the way through medical school and we continue to apply it. when we examine patients all the time then we go on and we listen to the heart we're listening for the normal heartbeats of course but we're also listening for clues which might be about one of the valves not working properly a blowing murmur or a rumbling murmur a decrescendo or a crescendo murmur murmurs that get softer murmurs that get louder and softer there's a whole lot of stuff that we try and listen to to ascertain if the valves are working properly or not and if there's a clue as to if they're not working how bad might that be interestingly we can also listen for extra sounds related to how the blood falls or fills the ventricle these extra heart sounds also give us a clue as to what may be going on within the heart and how the heart has responded to that. After we've listened to the heart, we listen to the lungs and in cardiac failure we're specifically listening for evidence of fluid accumulation within the lungs. This is a noise that characteristically we hear at the back, at the bottom part of where the lungs would be, we call that the lung bases. And as a person breathes in, there are fine crackly sounds that we call crepitations. Those fine crackly sounds can represent fluid within the tissues of the lungs. And they're a sign that can come and go depending on appropriate therapy. They can give us an idea of severity and they can match up with the patient's clinical situation. So really important for us to understand. the significance and document the extent of those noises in the lungs. We'll often then examine the abdomen and if heart failure has been a problem for some time, particularly right heart failure where there's congestion in the right side, then back congestion, which may have given rise to swelling in the legs, can also give rise to swelling of the organs of the abdomen. And so sometimes the liver can be enlarged and we would want to know that. that can occasionally be fluid accumulated in the tummy and fluid in the tummy may make that person appear distended. Fluid may also be present in the legs as we've already talked about and we look for that swelling. We often call it pitting edema and we'll press our thumb into the shin bone and try and see if we can form a divot where fluid is displaced, clearly showing that there's waterlogged tissue there. As part of a fairly standard assessment for someone presenting shortness of breath who we suspect cardiac failure, apart from the history and the examination we've done, we'll often grab a 12-lead ECG. This is a very common test for us to do. The 12-lit ECG gives us lots of information pertaining to the heart. How fast is the heart going? Is it rapid? Is it under strain? Is its rhythm normal or has it gone out of rhythm? This is important as well. When we look at the QRS complex, the spiky bits on the ECG, these can give us some clues as well. If these are exaggerated, if these are large, they can tell us that the heart is under some strain or load. These characteristics can tell us that the heart has thickened up to try and accommodate with extra strain that it's under. Or these changes can also point to the heart dilating to try and accommodate problems within the heart that it needs to compensate for. So, we also have the opportunity in a fairly standard examination to get a chest x-ray, and this will show us the size of the heart, but it may also show us very fine features, which we call curly B-lines, which you don't need to remember, but these are the features. the little lines that we see within the lungs that correspond to the crepitations or noises we hear if someone's got cardiac failure. Lastly, as part of a routine assessment, we would do some bloods. We'd check normal biochemistry and make sure their electrolytes are okay, the sodium potassium balance are okay, that the kidneys are not failing. That's really important. We'd want to make sure that there's no evidence of infection, which could also be driving a process. We want to check liver function is okay, so if there is any congestion in the liver, has it suffered at all or not. We'd also want to check for anemia and make sure that there's plenty of blood in the system so that the heart's not trying to make up for an anemia, which might be from another cause. We'd want to make sure that all the standard bloods, including things like thyroid function and iron, are all within normal limits. obvious reversible driver to the symptoms that the patient is presented with. I've pretty well covered history, I've certainly covered examination and I've touched on some of the most basic beginning tests that we do when we suspect someone with cardiac failure. I'm going to wrap it up there. There are some specific tests we do for cardiac failure, which I'm going to talk about in more detail in another session. I hope this has given you a little bit of information to think about. I hope you understand cardiac failure just a little bit more. As always, if you have any queries or questions, please drop me a note and let us know. Until next time, of course, I wish you the very best health. Take care and bye for now. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
