As a Cardiology fellow, we get a lot of consults for systolic heart failure. Here is my approach/work-up for this consult (Part 3). *Not to use as medical advice, just tips, and always discuss with your fellow/attending* -thread ?- #MedTwitter #MedEd #Cardiotwitter #IMG

Presentation: - Dyspnea: earliest and most common - Orthopnea: more with advanced disease (90% sensitive and specific), can develop PND and Cheyne-Stokes - Fatigue/exercise intolerance - Anorexia, abdominal pain, bloating with advanced right-sided heart failure

Physical Examination: - Well-compensated: no symptoms - Volume overloaded: weight gain, elevated JVP, +Hepatojugular reflex (>4 cm) - Pedal edema (can be non-specific if venous insufficiency, nephrotic syndrome, hepatic dysfunction, use of Ca2+ blocker, or TZD)

Diagnostic Evaluation: - Hyponatremia: worse prognosis - Hypokalemia: with diuretics - Hyperkalemia: Over K repletion, RAAS antagonists, K-sparing diuretics, or concomitant RTA - Elevated LFT, BUN/Cr - Anemia: 40% patients, increased mortality & functional impairment

Diagnostic Evaluation: - BNP and NT-proBNP released with ventricular dilation or wall stress. Elevated levels with increasing age, anemia, renal dysfunction - Normal BNP < 100 pg/mL (can be lower than expected in obese patients); high negative predictive value

EKG: - Can see previous MI, chamber enlargement, hypertrophy, conduction disease, and SVT or ventricular arrhythmias - Amyloidosis: low voltage and pseudo-infarction pattern in anterior leads - ARVC: Epsilon waves/localized prolongation in right precordial leads

Imaging: - Holter Monitor: Can be used to identify occult arrhythmia - CXR: Bilateral pleural effusions, Kerley B lines, pulmonary edema - TTE: Useful for regional wall motion abnormalities for ischemic CMO

Imaging: - MRI: myocardial viability assessment, used in LV non-compaction, cardiac sarcoidosis, amyloidosis. Can be limited by devices. - RHC: Can determine CO/CI with thermodilution or Fick's, PCWP, RA pressure (important predictor of volume status and right heart function)

Part 4 coming soon regarding the medical management for systolic heart failure! I hope this helps and let me know what you think ?