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C HAP TE R 24 / Heart Failure and Cardiogenic Shock 567

Pulmonary crackles are first noted over the lung bases, and as the
PAWP increases, they progress toward the apices. Table 24-6 ■ CLINICAL INDICATORS AND PHYSICAL
Stage 3 occurs when the PAWP rises to 25 to 28 mm Hg, caus- FINDINGS OF LEFT AND RIGHT VENTRICULAR FAILURE
ing rapid movement of fluid out of the intravascular and intersti- Left Ventricular Failure Right Ventricular Failure
tial spaces into the alveoli. As the edema progresses, the alveoli no
longer remain open because of the large fluid accumulation. At this Subjective Findings
point, the alveolar–capillary membrane is disrupted, fluid invades Breathlessness Lower extremity heaviness
the large airways, and the patient describes or exhibits frothy, pink- Cough Abdominal distention
tinged sputum. Acute pulmonary edema is a catastrophic indicator Fatigue and weakness Gastric distress
Memory loss and confusion
Anorexia, nausea
of HF. These pulmonary congestion stages are broad categories. Diaphoresis
The correlation between a patient’s PCWP and clinical symptoms Palpitations
is highly variable and most likely dependent upon the duration of Anorexia
illness and individual compensatory mechanisms. Insomnia
Objective Findings
Right-Sided HF Weight gain Weight gain
Tachycardia
Neck vein pulsations and distention
Right-sided HF, associated with increased systemic venous pres- Increased jugular venous pressure
Decreased S 1
sure, gives rise to the clinical signs of jugular venous distension, S 3 and S 4 gallops (increased central venous pressure)
hepatomegaly, dependent peripheral edema, and ascites. 22 De- Crackles (rales) Edema
pendent ascending peripheral edema is a manifestation in which Pleural effusion Hepatomegaly
Diaphoresis
Positive hepatojugular reflux
edema begins in the lower legs and ascends to the thighs, geni- Pulsus alternans Ascites
talia, and abdominal wall. Patients may notice their shoes fitting Increased pulmonary artery wedge
tightly or marks left on the feet from their shoes or socks. pressure
Weight gain is what most patients recognize; consistent self- Decreased cardiac index
weighing in the morning helps to detect subtle changes in fluid Increased systemic vascular resistance
status. An adult may retain 10 to 15 lb (4 to 7 L) of fluid before
edema occurs.
Congestive hepatomegaly characterized by a large, tender, pul- Obtaining a description of a patient’s exercise capacity and ability
sating liver, and ascites also occurs. Liver engorgement is caused to perform activities of daily living may be useful in assessing their
by venous engorgement, whereas ascites results from transudation degree of limitation. Patients who describe symptoms of presyn-
of fluid from the capillaries into the abdominal cavity. Gastroin- cope or syncope should be evaluated for arrhythmias, because atrial
testinal symptoms such as nausea and anorexia may be a direct fibrillation and ventricular arrhythmias are commonly found in
consequence of the increased intra-abdominal pressure. this patient population. Sudden death is responsible for up to 40%
Another finding related to fluid retention is diuresis at rest. to 50% of fatal events in HF. 43 In patients with decompensation
When at rest, the body’s metabolic requirements are decreased, of existing HF, dietary or medication noncompliance, or exacer-
and cardiac function improves. This decreases systemic venous bating mediations (like NSAIDs) should be investigated.
pressure, allowing edema fluid to be mobilized and excreted. Re-
cumbency also increases renal blood flow and GFR, also increas- Physical Examination
ing diuresis. Table 24-6 lists the various subjective and objective A major goal in assessing the patient with HF is to determine the
indicators for LV and right ventricular (RV) failure.
type and severity of the underlying disease causing HF and the
extent of the HF syndrome. Physical examination of the patient
Diagnosis and Clinical Manifestations with HF focuses on the cardiovascular and pulmonary systems, as
well as relevant aspects of the integumentary and gastrointestinal
The predominant symptoms of HF are breathlessness or dyspnea systems (See Chapter 10.)
and fatigue. Orthopnea and paroxysmal nocturnal dyspnea occur
in the more advanced stages of HF. For more detail, refer to “Part Cardiovascular Assessment. Determination of the rate,
III/Assessment of Heart Disease.” rhythm, and character of the pulse is important in patients with
HF. The pulse rate is usually elevated in response to a low cardiac
History output. Pulsus alternans (alternating pulse) is characterized by an
A careful history is important to ascertain possible causes of HF altering strong and weak pulse with a normal rate and interval.
and identify patients at increased risk for HF. The history should Pulsus alternans is associated with altered functioning of the LV
include past medical history and a thorough review of systems. causing variance in LV preload. An irregular pulse is usually indica-
Table 24-7 lists the vital elements in a thorough history, including tive of an arrhythmia. Increased heart size is common in patients
a history of CAD, hypertension, valvular heart disease, congenital with HF. This cardiac enlargement is detected by precordial palpa-
heart defects, or diabetes. Other endocrine abnormalities include a tion, with the apical impulse displaced laterally to the left and
history of thyroid disease or a family history of cardiomyopathy or downward. In patients with HF, there maybe a third heart sound
CAD should be explored. Ascertain if the patient is using possible (S 3 ) that is associated with a reduced EF and impaired diastolic
toxic agents, such as alcohol or cocaine, or has been exposed to ra- function as determined by the peak filling rate. 44 A fourth heart
diation or chemotherapy. Patients with a history of central sleep sound (S 4 ) may occur, although it is not in itself a sign of failure but
apnea may also have impaired autonomic control and increased rather a reflection of decreased ventricular compliance associated
cardiac arrhythmias. 42 Precipitating factors for HF should be as- with ischemic heart disease, high blood pressure, or hypertrophy.
sessed, such as anemia, infection, or pulmonary embolism. When the heart rate is rapid, these two diastolic sounds may merge