First and foremost, congestive heart failure is a symptom. You wouldn’t say, “Oh I’ve got a patient; I diagnosed him with fever,” because I’m going to say, “Well, what’s causing the fever?” You really wouldn’t say someone has anemia, because I’m going to say, “Well, what’s causing the anemia?” Anemia is a symptom.
You need to think that same way with CHF, because if someone has CHF, it’s a symptom of a problem. Is it a cardiomyopathy? Is it an ischemic problem, is it ischemic cardiomyopathy? Is it systolic dysfunction from an old MI? Is it valvular? Is it sarcoid? Is it hypertrophic obstructive cardiomyopathy? With CHF, I always want to know what’s causing it. You may not know exactly but you better back it up with at least their ejection fraction.
A good clinician will tell me, “CHF with an ejection fraction of 30% from an echo done six months ago.” Don’t just call me and say, “Hey John, I’m admitting a patient with CHF,” when you don’t know their ejection fraction and you haven’t looked for it. A high-end provider’s going to either going to tell me their ejection fraction or tell me they looked for it and they couldn’t find it.
Now what are the major symptoms of CHF?
What are the two roads that lead into the heart? Your superior and inferior vena cava. If the right heart has failed, it’s going to back up traffic. If you back traffic up the superior vena cava, you definitely get distended neck veins any maybe hepatojugular reflux. If you back up fluid down the inferior vena cava, three things happen: hepatic engorgement or hepatojugular reflux, ascites and edema.
The first road coming to your heart is the superior vena cava. The second road is your inferior vena cava.
What are the cardio findings of CHF? Well, the big ones, especially on your boards, are going to be an S3, because an S3 represents a dilated ventricle. On your boards, they don’t give you audio, but they’ll tell you what you hear.
They can also have mitral regurgitation murmur and know that with your lungs you’ll have rales or crackles. They’ll have lung symptoms. I call it lung symptoms as well as redistribution symptoms. What are redistribution symptoms? Understand this, guys. This is very important to understand for medicine and your boards. Fluid lives in one of three compartments: a cell, a blood vessel, or shifting back and forth. You either have intercellular, intervascular or interstitial.
Now, that fluid moves based on two pressure readings. One is called hydrostatic pressure reading, based on water pressure, your ejection fraction and gravity. If you’ve got a bad ejection fraction, 30%, guess what? That’s 30% whether you’re upright or supine. Body position is irrelevant but gravity is relevant.
When you’re walking around, there’s gravity to keep water away from your heart. When you lay down at night, you no longer have gravity. Therefore, the fluid in your legs goes intervascular and you get redistribution symptoms. You get sick at night; you get paroxysmal nocturnal dyspnea, orthopnea, and if your blood volume goes up at night, you want to pee more. That’s why patients want to sleep on more pillows.
The second pressure gradient is on CaCh, based on protein. If your body protein is low or if you’re peeing out protein, you are going to get puffy. It’s an osmotic edema. If you have that, you have to thicken up the blood. How do you thicken up the blood? It’s either with ivy protein, which we really don’t do, albumin or a colloid.
Here’s my pearl for the boards: anybody who pees out protein gets puffy – it just goes together. The two big ones are nephrotic syndrome and preeclampsia. When we teach people to practice for their boards, we give you all sort of hacks, but you have to silo things. What am I saying? Anybody who pees out protein has proteinuria; they’re going to get puffy – it just goes with the gig.
Our whole goal is to help you maximize your mind. Get involved with an immersion environment; think about coming to one of our conferences. Malcolm Gladwell said, “We’ve come to confuse information with understanding.” I think too many physician assistants and nurse practitioners come to conferences because they want information. I don’t think you want information. You’re overwhelmed with information. Instead, you want to understand the information so you can apply it or you can use it to take your boards.