Take-home PEARL: if a patient p/w new tachycardia and bilateral lower extremity edema but has a FLAT JVP, then s/he is unlikely to have new heart failure! Consider alternate etiologies for the edema, like anasarca from hypoalbuminemia or IVC occlusion/external compression, and appropriate cardiac compensation.
More advanced echo PEARL: if you are worried about high output heart failure, look at LVOT VTI (LV outflow tract velocity time integral) on echo report – expect it to be HIGH! VTI is a doppler method of calculating LV stroke volume.
High output heart failure
- common causes to remember: anemia, hyperthyroidism, liver disease, beriberi (severe thiamine deficiency), systemic AVM/fistulas, pregnancy
- a word on AVMs/fistulas since this was considered for this patient: can be congenital or acquired – blood from high pressure arteries is shunted into veins (bypasses capillaries), leading to decreased SVR and increased venous return à leads to increased HR and stroke volume.
- Physical exam: tachycardia (usually mild), bounding pulse with quick upstroke, wide pulse pressure, hyperdynamic PMI. Also can see subungual capillary pulsations (Quincke’s pulse), carotid bruits. None of these are specific (eg you can see them in aortic regurg, patent ductus arteriosus)
- See this most commonly with aflutter at fast rates (eg 2:1) or atrial tachycardia
- Rare to see with sinus tach or SVT because these are often reversible
- Can happy quickly (days to weeks)!
- Treatment: consider beta blocker
- Prognosis: most patients will have significant recovery/normalization of LVEF!
A few other pearls from the case
- BNP is often NORMAL in constrictive cardiomyopathy! It is often ELEVATED in restrictive cardiomyopathy
- Another TTE pearl: if LVESVI (LV end-systolic volume index) is LOW, it means that the LV is contracting and squeezing out a lot. In these cases, also look at the LV mass index! If the mass index is HIGH, think of hypertrophic cardiomyopathy. If it’s LOW, that points towards poor intravascular volume