CONGESTIVE HEART FAILURE and ACUTE PULMONARY EDEMA

1
CONGESTIVE HEART FAILURE and ACUTE PULMONARY EDEMA

• Dr. Richard Lee
• University Of Alberta

2
OUTLINE

• I. Etiology
• II. Precipitating factors
• III. Pathophysiology
• IV. Clinical signs and symptoms
• V. Treatment

3
ETIOLOGY
4
RIGHT VENTRICULAR FAILURE etiology

• LEFT VENTRICULAR FAILURE
• PULMONARY ARTERY HYPERTENSION
• MITRAL/TRICUSPID VALVE DISEASE

5
RVF etiology (cont.)

• RESTRICTIVE/INFILTRATIVE CARDIOMYOPATHY
• MYOCARDITIS
• viral, idiopathic
• CONGENITAL HEART DISEASE

6
LEFT VENTRICULAR FAILURE etiology

• WITH DECREASED CARDIAC OUTPUT
• HYPERTENSION
• CORONARY ARTERY DISEASE
• AORTIC/MITRAL VALVE DISEASE
• DILATED CARDIOMYOPATHY

7
LEFT VENTRICULARFAILURE etiology

• WITH NORMAL CARDIAC OUTPUT
• DIASTOLIC DYSFUNCTION
• FIBROSIS
• Ischaemia, Infarct, Infiltrative
• MYOCYTE HYPERTROHY
• Chronic HTN, Valvular disease

8
LVF etiology (cont.)

• WITH INCREASED CARDIAC OUTPUT
• ANEMIA
• PREGNANCY
• HYPERTHYROIDISM

9
LVF (high output) etiology (cont.)

• SEPTIC SHOCK
• ARTERIOVENOUS FISTULA
• PAGETS DISEASE

10
PRECIPITATING FACTORS

• CARDIAC ARRHYTHMIA
• ISCHAEMIA/INFARCT
• NONCOMPLIANCE TO MEDICATIONS

11
PRECIPITATING FACTORS(cont.)

• INCREASED SODIUM INTAKE
• NEGATIVE INOTROPES
• PHYSICAL OVER-EXERTION

12
PATHOPHYSIOLOGYSystolic CHF

• INITIAL INSULT
• DECREASED CARDIAC OUTPUT

13
Pathophysiology (cont.)

• RESULT
• SELECTIVE ARTERIOLAR CONSTRICTION
• ACTIVATION OF RENIN-ANGIOTENSIN-ALDOSTERONE
  SYSTEM
• INCREASED SODIUM RETENTION AND AFTERLOAD

14
Pathophysiology (cont.)

• INITIAL INSULT
• INCREASED LEFT ATRIAL PRESSURE

15
Pathophysiology (cont.)

• RESULTS
• INCREASED PULMONARY CAPILLARY PRESSURES
• PULMONARY FLUID TRANSUDATION
• INCREASED PAP, DECREASED COMPLIANCE, BRONCHOSPASM

16
Pathophysiology (cont.)

• INITIAL INSULT
• INCREASED RIGHT VENTRICULAR VOLUME AND PRESSURE

17
Pathophysiology (cont.)

• RESULT
• INCREASED SYSTEMIC CAPILLARY PRESSURES
• TRANSUDATION OF SERUM INTO TISSUES

18
PATHOPHYSIOLOGYDiastolic CHF

• INITIAL INSULT
• NORMAL VENTRICULAR CONTRACTILITY
• REDUCED VENTRICULAR COMPLIANCE

19
Pathophysiology (cont.)

• RESULT
• RAISED VENTRICULAR PRESSURES
• PULMONARY HYPERTENSION

20
COMPENSATORY MECHANISMS

• INCREASED LV FILLING PRESSURES (PRELOAD)
• CARDIAC HYPERTROPHY
• INCREASED SYMPATHETIC TONE

21
CLINICAL SIGNS AND SYMPTOMS

• RVF
• DEPENDENT EDEMA
• HEPATO-JUGULAR REFLUX
• JUGULAR VENOUS DISTENTION

22
Signs and symptomsRVF (cont.)

• TENDER, ENLARGED LIVER
• PULSATILE LIVER
• NOCTURIA
• PLEURAL EFFUSION
• Usually right side

23
Signs and symptomsRVF (cont.)

• The only useful signs to clinically diagnose RVF
  is a raised jugular venous pressure and a
  positive X-ray.
• Badgett, R. et al. Can the Clinical Examination
  Diagnose Left-Sided Heart Failure in Adults?,
  JAMA, Jun 4, 97, Vol277, No. 21.

24
CLINICAL SIGNS AND SYMPTOMS

• LVF
• EXERTIONAL DYSPNEA
• PAROXYSMAL NOCTURNAL DYSPNEA
• ORTHOPNEA

25
Signs and symptomsLVF (cont.)

• DRY COUGH
• PINK FROTHY SPUTUM
• RALES/ CREPITATIONS
• PLEURAL EFFUSION
• Usually right side

26
Signs and symptomsLVF (cont.)

• S3, S4
• PULSUS ALTERNANS
• CHEYNE-STOKES RESPIRATIONS
• DISPLACED APICAL IMPULSE

27
Signs and symptomsLVF (cont.)

• The only useful signs to clinically diagnose LVF
  is a delayed apical impulse and a positive X-ray.
• Badgett, R. et al. Can the Clinical Examination
  Diagnose Left-Sided Heart Failure in Adults?,
  JAMA, Jun 4, 97, Vol277, No. 21.

28
RADIOLOGICAL EVALUATION

• CHEST X-RAY
• STAGE I
• REFLEX PULMONARY CONSTRICTION
• Redistribution to lung apices

29
Radiological evaluation (cont.)

• CHEST X-RAY
• STAGE II
• INTERSTITIAL EDEMA
• Blurring of edges of blood vessels
• Kerley A/B lines

30
Radiological evaluation (cont.)

• CHEST X-RAY
• STAGE III
• ALVEOLAR EDEMA
• Bilateral hazy infiltrates

31
TREATMENTChronic CHF

• DECREASE SODIUM INTAKE
• DIURETICS
• VASODILATOR THERAPY
• ACE inhibitors, Nitrates c Hydralazine
• INOTROPES
• Digoxin
• NEUROHORMONAL REDUCTION
• Beta Blockers

32
Treatment Chronic CHF (cont.)

• PROGNOSIS
• 5 year survival rate 50

33
TREATMENT

• ACUTE PULMONARY EDEMA
• OXYGEN/IV/MONITOR
• POSITIONING
• SEMI-FOWLER'S
• SITTING FORWARD

34
Treatment Acute Pulmonary Edema

• SYSTOLIC CHF
• NITROGLYCERIN (S/L vs IV)
• LASIX
• VENTOLIN
• ? ACE INHIBITORS (PO vs SL vs IV)

35
Treatment Acute Pulmonary Edema

• DIASTOLIC CHF
• PROBLEMATIC
• Ischaemia Control (Nitrates)
• Rate Control (Beta , Ca blocker)
• Hypertension Control (ACEI, Ca blocker)
• BEWARE OF AGGRESSIVE DIURESIS AND VENODILATION
• May aggravate situation

36
BEWARE!

• Morphine
• Histamine release
• Negative inotrope
• Respiratory depressant
• Lasix
• Diagnosis of CHF difficult
• May worsen other diseases

37
Treatment Acute Pulmonary Edema (cont.)

• If refractory, consider
• CPAP, PEEP
• INOTROPIC SUPPORT
• Dopamine, Dobutamine, ?Amrinone
• MECHANICAL CIRCULATORY SUPPORT
• Intra-aortic balloon pump

38
Treatment Acute Pulmonary Edema (cont.)

• PROGNOSIS
• In hospital mortality 15
• 1 year survival 35

39
CASE 1

• 73 y.o female with 1 month hx of increasing leg
  swelling, dyspnea on exertion and fatigue.
• PMHx CHF, Hypertension
• Meds Lasix, K-dur, Digoxin
• O/E NAD H/N JVP 4 cm asa
• CVS 2 pitting dependant edema
• Resp Mild bibasilar fine crackles

40
CASE 2

• 61 y.o. male with sudden onset SOB, RSCP for 30
  min., diaphoresis
• PMHx NIDDM, CHF, angina
• Meds Diabeta, NTG, Lasix, K-dur
• HR 72/min BP 175/100 RR 20/min
• OE Mod distress H/N JVP 6cm asa
• Resp Coarse crackles globally

41
CASE 3

• 79 y.o female unable to breath
• PMHx palpitations Meds vitamins
• HR 180/min BP 115/80 RR 24/min
• OE Mild distress H/N JVP N
• CVS Rapid HR
• Resp Fine bibasilar crackles

42
CASE 4

• 84 y.o male collapsed in the waiting room of his
  private physician.
• PMHx S.S.S., Pacemaker Meds Digoxin
• HR 35/min BP 80 palp RR None
• O/E Mottled, cyanotic
• H/N Subcutaneous Pacemaker
• CVS Bradycardic
• Resp Gurgling up frothy, red sputum

43
QUESTIONS?
44
SUMMARY

• Diagnosing CHF is difficult
• There are many different causes of CHF which
  require different therapies
• Primarily, do no harm.