Cardiac Causes of Shortness of Breath - PowerPoint Presentation

Slide1

Cardiac Causes of Shortness of Breath

Akash Srinivasanas14317@ic.ac.uk

Slide2

Shortness of Breath

Heart Failure

Cardiomyopathy

Constrictive pericarditis

Myocarditis

Slide3

Shortness of Breath

Poor removal of CO2

Poor delivery of oxygen

Slide4

Shortness of Breath

1. Not enough oxygen reaching the lungs

Breathing issues

E.g. asthma, COPD, anaphylaxis

Slide5

Shortness of Breath

2. Not enough oxygen getting into the blood

V/Q mismatch

E.g. pulmonary embolism, pulmonary oedema, pulmonary fibrosis

Slide6

Shortness of Breath

3. Not enough oxygen reaching the rest of the body

Heart issues

(or anaemia, shock etc.)

Slide7

Shortness of Breath

Heart Failure

Cardiomyopathy

Constrictive pericarditis

Myocarditis

Slide8

SBA 1

JB is a 34-year-old male, with a history of infective endocarditis, complaining that he’s tired all the time and struggles to run as far as he used to. He also says that his ankles and face feel more swollen than before. On examination, he has a raised JVP, breathing rate and heart rate. You also hear a pansystolic murmur on auscultation. What is the most likely diagnosis?

A. Left heart failure secondary to mitral regurgitation B. Left heart failure secondary to cocaine abuse C. Right heart failure secondary to tricuspid regurgitation

D. Myocardial infarction

E. High output heart failure

Menti: 15 04 90 5

Slide9

Definition:

The failure of the heart to maintain the cardiac output (CO) required to meet the body’s

demands

Not enough oxygen reaches the rest of the body

Heart Failure

Slide10

HF: Classification

Slide11

HF: Classification

Left Heart Failure

(LHF)

Right Heart Failure

(RHF)

LHF + RHF =

Congestive Heart Failure

(CHF)

Slide12

HF: Classification

Low Output State: Heart fails to pump in response to normal exertion -> low CO

High Output State: CO is normal but higher metabolic needs e.g. pregnancy, anaemia, hyperthyroidism

Slide13

Chronic Left HF: Aetiology

ValvularAortic stenosisAortic regurgitation

Mitral regurgitationMuscular

Ischaemia (IHD)

Cardiomyopathy

Myocarditis

Arrhythmias (AF)

SystemicHypertensionAmyloidosisDrugs (e.g. cocaine, chemo)

Slide14

Chronic Right HF: Aetiology

LungsPulmonary hypertension (cor pulmonale)

Pulmonary embolismChronic lung disease e.g. interstitial lung disease, cystic fibrosis

Valvular

Tricuspid regurgitation

Pulmonary valve disease

LHF -> CHF

Slide15

Chronic High Output HF: Aetiology

Conditions that require a higher CO = strain on the heart NAP MEALSNutritional (B1/thiamine deficiency)

Anaemia

P

regnancy

M

alignancyEndocrine

AV malformationsLiver cirrhosisSepsis

Slide16

HF: Signs and Symptoms

What happens if fluid is congested backwards?

Slide17

LHF: Symptoms

Respiratory ProblemsDyspnoea: Paroxysmal nocturnal dyspnoea (PND)

Exertional dyspnoea

Orthopnoea

Nocturnal cough

(+/- pink frothy sputum)

Fatigue

OSCE TIPS:1) Assess SOB: “How far are you able to walk before getting breathless? How many flights of stairs?”2) Assess orthopnoea: “Have you noticed anything making the SOB worse? What about lying down, standing up?” 3) Assess PND: ”Do you ever wake up at night gasping for air? How many pillows do you sleep with at night? Has this changed recently?”

Slide18

LHF: Signs

Heart

Lungs

↑HR, ↑RR

Irregularly irregular heartbeat

Pulsus alternans

Displaced apex beat

S3 Gallop rhythmS4 in severe HFMurmur (AS, MR, AR)Fine end-inspiratory crackles at lung bases (pulmonary oedema)Wheeze (cardiac asthma)

Slide19

RHF: Signs and Symptoms

SymptomsFatigueReduced exercise tolerance

AnorexiaNausea

Nocturia

Signs

Face

: face swelling

Neck: ↑ JVPHeart/Chest: TR murmur, ↑ HR, ↑ RRAbdomen: ascites, hepatomegalyOther: ankle and sacral pitting oedema

Slide20

HF: Summary of Signs and Symptoms

Slide21

SBA 1

JB is a 34-year-old male, with a history of infective endocarditis, complaining that he’s tired all the time and struggles to run as far as he used to. He also says that his

ankles and face feel more swollen

than before.

On examination, he has a

raised JVP

, breathing rate and heart rate. You also hear a pansystolic murmur on auscultation. What is the most likely diagnosis?

A. Left heart failure secondary to mitral regurgitation B. Left heart failure secondary to cocaine abuse C. Right heart failure secondary to tricuspid regurgitation D. Myocardial infarction E. High output heart failure

Slide22

SBA 1

A. Left heart failure secondary to mitral regurgitation No breathlessness symptoms – LHF unlikely B. Left heart failure secondary to cocaine abuse No breathlessness symptoms – LHF unlikely

C. Right heart failure secondary to tricuspid regurgitation

Signs of RHF, pansystolic murmur, infective endocarditis

D. Myocardial infarction This would present more acutely with crushing chest pain

E. High output heart failure No mentioned condition like anaemia or hyperthyroidism

Slide23

HF: Investigations

Slide24

HF: Investigations

↓

BNP

↑BNP

HF unlikely

TTE

BNP is SENSITIVE but

NOT SPECIFIC

Slide25

HF: Investigations

Transthoracic echocardiogram (TTE) coupled with doppler = DIAGNOSTICVisualise the structure and function of the heart -> may show the cause of HF

Can calculate ejection fraction (EF): % of the blood present in the LV that gets pumped during systole – normal = 50-70%

EF < 40%:

HF with reduced ejection fraction (

HFrEF

) – previously called

systolic HFIndicates inability of the ventricle to contract normallyEF >50%: HF with preserved ejection fraction (HFpEF) – previously called diastolic HFIndicates inability of the ventricle to relax and fill normally

Slide26

HF: Investigations

Chest X-Ray Alveolar oedema

B-lines (

Kerley

)

C

ardiomegaly

Dilated upper lobe vessels + Diverted upper lobe Effusion (Transudative pleural effusion)

Slide27

HF: Diagnosis

Clinical diagnosis can be made using the Framingham Criteria 2+ majors OR 1 major and 2 minors

Major:

Paroxysmal nocturnal dyspnoea

Bibasal crepitations

S3 gallop

Cardiomegaly

Increased central venous PressureWeight lossNeck vein distensionAcute pulmonary oedemaHepatojugular reflux Minor- bilateral ankle oedema- dyspnoea on ordinary exertion- tachycardia

- decrease in vital capacity by 1/3

- nocturnal cough

- hepatomegaly

- pleural effusion

Slide28

HF: Management

For Chronic HF:

Slide29

HF: Management

ACE inhibitors: give to all patients with LV dysfunctionEnalapril, perindopril, ramipril (all end in –pril)Can switch to ARB if not tolerable (cough)

Beta-blockers: reduce O2 demand on the heartBisoprolol, carvedilol

Diuretics: use if evidence of fluid retention

Loop diuretics e.g. furosemide

Aldosterone antagonists e.g. spironolactone

Hydralazine + nitrates – considered in Afro-Caribbean patients Digoxin – positive inotrope, improves symptoms

but not mortality Cardiac resynchronization therapy – aims to improve timings of contraction of atria and ventricles

Slide30

HF: Management

DMONSDiureticsMorphine

OxygenNitratesS

it-up

For Acute HF:

MEDICAL EMERGENCY - ABC

Slide31

HF: Complications and Prognosis

Complications:Respiratory failureRenal failure - due to hypoperfusion

Acute exacerbations

Death

Prognosis:

Very poor, worse than most malignancies

50% of severe HF patients die within 2 years

Acute HF in-hospital mortality = 2-20%

Slide32

SBA 2

After measuring BNP levels and performing echocardiography on JB, a diagnosis of heart failure is confirmed. You perform a chest X-ray as well. What would you expect to see on the CXR? A. Reduced cardio-thoracic ratio B. Lower lobe diversion

C. Sharp costophrenic angles D. Kerley C lines E. Alveolar oedema

Menti: 15 04 90 5

Slide33

SBA 2

After measuring BNP levels and performing echocardiography on JB, a diagnosis of heart failure is confirmed. You perform a chest X-ray as well. What would you expect to see on the CXR?

A. Reduced cardio-thoracic ratio B. Lower lobe diversion C. Sharp costophrenic angles D. Kerley C lines

E. Alveolar oedema

Slide34

SBA 2

A. Reduced cardio-thoracic ratio Cardiomegaly so cardio-thoracic ratio is increased B. Lower lobe diversion

Upper lobe diversion

C. Sharp costophrenic angles

Pleural effusion results in blunt costophrenic angles

D. Kerley C lines

Kerley B lines E. Alveolar oedema Left heart failure causes pulmonary oedema

Slide35

Shortness of Breath

Heart Failure

Cardiomyopathy

Constrictive pericarditis

Myocarditis

Slide36

Definition:

A group of diseases in which the myocardium

becomes structurally and functionally abnormal

In the absence of coronary artery disease, valvular disease and congenital heart disease

It can affect young people

Cardiomyopathy

Slide37

Cardiomyopathy: Types

Slide38

Cardiomyopathy: General Presentation

HistorySymptoms of HF:SOB on exertion

FaintingFatigue

Sudden death often 1

st

presentation

Family history

ExaminationSigns of HF:Respiratory cracklesMurmursS3, S4

Investigations

No single diagnostic test for all types

ECHO

Can also do bloods, BNP, CXR, ECG, cardiac catheterisation, stress test

OSCE TIP:

Ask if there is a family history of sudden, unexplained cardiac death at a young age e.g. under 50.

Slide39

Dilated Cardiomyopathy

Pathophysiology Ventricles enlarge and become dilated. Walls thin and weaken -> can’t contract effectively. Think of the Law of Laplace: increased radius leads to reduced ventricular pressure

Risk Factors

Alcohol

, post-viral, haemochromatosis, genetic

Presentation

Signs and symptoms of HF

Displaced apex beat

, TR/MR murmur, S3

Investigations

Globular heart on CXR, dilated ventricle on Echo

Slide40

Hypertrophic Cardiomyopathy

PathophysiologyH for Hench – muscle thickens inwards.

Increased stiffness of the muscle affects pumping.Thickened muscle disrupts electrical conduction and causes arrythmia.

Hypertrophic Obstructive Cardiomyopathy (HOCM) = thickened ventricle obstructs the outflow of blood.

50% is familial (autosomal dominant)

Slide41

Hypertrophic Cardiomyopathy: Presentation

Symptoms

Usually asymptomatic

Sudden cardiac death is often the 1

st presentation Angina, dyspnoea on exertion, palpitations, syncope Signs Ejection systolic murmur Jerky carotid pulse Double apex beat but NOT DISPLACED S4

Investigations

ECG: Q waves, left axis deviation, signs of left ventricular hypertrophy

Echo: ventricular hypertrophy (asymmetrical septal hypertrophy

Amir Sam’s Tip:

LVH by voltage criteria:

Deep S in V1/2

Tall R in V5/6

S in V1 + R in V5 or V6

≥ 7 large squares

Slide42

Restrictive Cardiomyopathy

PathophysiologyR for Rigid – ventricles become abnormally rigid and lose flexibility.Impaired ventricular filling during diastole.

Reduced preload -> reduced blood flow + backing up of blood.

Causes

Sarcoidosis, amyloidosis, haemochromatosis (the infiltrative ”osis” diseases)

Familial

IdiopathicRarer than dilated or hypertrophic cardiomyopathy

Symptoms

Asymptomatic or HF symptoms

Signs

RHF signs: raised JVP, S3, ascites and oedema, hepatomegaly

Kussmaul’s sign = paradoxical rise in JVP during inspiration

Slide43

Other Cardiomyopathies

Arrhythmogenic Right Ventricular CardiomyopathyProgressive fatty and fibrous replacement of the ventricular myocardiumInherited (autosomal dominant)

Takotsubo Cardiomyopathy

Sudden temporary weakening of heart muscle after a

significant stressor

”Broken heart syndrome”

Slide44

Shortness of Breath

Heart Failure

Cardiomyopathy

Constrictive pericarditis

Myocarditis

Slide45

Constrictive Pericarditis

Definition

Chronic inflammation of the pericardium (outer sac) with thickening and scarring

Causes

Idiopathic

Infectious (TB, bacterial, viral)

Acute pericarditis

Cardiac surgery and radiation

Signs and Symptoms

Similar to restrictive cardiomyopathy

RHF presentation (raised JVP, oedema)

Kussmaul’s sign

Investigations

CXR: pericardial calcification

Echo: increased pericardial thickness – differentiate from restrictive cardiomyopathy

Cardiac CT/MRI

Slide46

Shortness of Breath

Heart Failure

Cardiomyopathy

Constrictive pericarditis

Myocarditis

Slide47

Myocarditis

Definition

Inflammation of the myocardium

Inflammatory cardiomyopathy

Causes

Infectious

Drugs - cocaine

Metals

Radiation

Coxsackie B virus is the most common cause of myocarditis in Europe

Signs and Symptoms

Flu-like prodrome

Chest pain (worse when lying down)

SOB

Palpitations

Investigations

ECG: non-specific ST and T wave changes

Cardiac biomarkers: CK and troponin

Endomyocardial biopsy:

diagnostic but not routinely performed

Slide48

Shortness of Breath

Heart Failure

Cardiomyopathy

Constrictive pericarditis

Myocarditis

Slide49

SBA 3

Aston was a 33-year-old male who suddenly collapsed on stage. Although the doctors attempted “love CPR”, the patient died, and the post-mortem revealed a hypertrophic heart. What was the most likely cause of death? A. Obstructed flow of blood from the heart B. Arrhythmia

C. Reduced pumping of blood due to stiff myocardium D. Stroke E. Sub-arachnoid haemorrhage

Menti: 15 04 90 5

Slide50

SBA 3

Aston was a 33-year-old male who suddenly collapsed on stage. Although the doctors attempted “love CPR”, the patient died, and the post-mortem revealed a

hypertrophic heart. What was the most likely cause of death?

A. Obstructed flow of blood from the heart

B. Arrhythmia C. Reduced pumping of blood due to stiff myocardium D. Stroke E. Sub-arachnoid haemorrhage

Slide51

SBA 3

A. Obstructed flow of blood from the heart Likely to experience warning symptoms beforehand B. Arrhythmia

Most likely cause of death from HCM, hypertrophic muscle affects electrical circuits

C. Reduced pumping of blood due to stiff myocardium

Likely to experience warning symptoms beforehand

D. Stroke Heart issue rather than brain issue, ventricular arrhythmia (not AF)

E. Sub-arachnoid haemorrhage Heart issue rather than brain issue

Slide52

SBA 4

Oritsé presents with breathlessness and he says that he experienced a fever recently. His CK and troponin are elevated, so a presumptive diagnosis of myocarditis is made. What other signs or symptoms would be consistent with this diagnosis?

A. Kussmaul’s sign B. Ankle oedema C. Ascites D. Jaundice E. Chest pain

Menti: 15 04 90 5

Slide53

SBA 4

Oritsé presents with breathlessness and he says that he experienced a fever recently. His

CK and troponin are elevated, so a presumptive diagnosis of myocarditis is made.

What other signs or symptoms would

be most

consistent with this diagnosis?

A. Kussmaul’s sign B. Ankle oedema C. Ascites D. Jaundice

E. Chest pain

Slide54

SBA 4

A. Kussmaul’s sign B. Ankle oedema C. Ascites D. Jaundice

All of these are subacute/chronic signs of heart failure, restrictive cardiomyopathy, constrictive pericarditis etc. E. Chest pain

Only option which fits with the acute picture of myocarditis

Slide55

Scan here

Before the final question…

Slide56

SBA 5

Marvin presents with a 4-month history of increasing breathlessness and ankle swelling. On examination, he has ascites and Kussmaul’s sign is elicited. What would be the most useful diagnostic investigation? A. Echocardiography B. ECG

C. Endomyocardial biopsy D. Abdominal X-ray E. CK

Menti: 15 04 90 5

Slide57

SBA 5

Marvin presents with a 4-month history of increasing breathlessness and ankle swelling. On examination, he has ascites

and Kussmaul’s sign is elicited. What would be the

most useful diagnostic investigation

?

A. Echocardiography B. ECG C. Endomyocardial biopsy D. Abdominal X-ray E. CK

Slide58

SBA 5

A. Echocardiography Allows differentiation between restrictive cardiomyopathy and constrictive pericarditis

B. ECG Non-specific signs – not the most useful

C. Endomyocardial biopsy

Pericardial biopsy might be useful – but highly invasive

D. Abdominal X-ray Chest X-ray would be useful to look for pericardial calcifications, but these are not specific to constrictive pericarditis E. CK May be mildly elevated in both constrictive pericarditis and restrictive cardiomyopathy – not that helpful

Slide59

Any Questions?

Email me any questions: as14317@ic.ac.uk Please fill in the feedback

:)

Scan here