Congestive Heart Failure

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Congestive Heart Failure

• ADOPTED FROM
• Jarrod Eddy, PGY2
• Internal Medicine
• Sub-I Lecture Series

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Congestive Heart Failure

• Clinical presentation of disease
• NOT a diagnosis in and of itself
• Differential includes
• Underlying cardiovascular disease
• Precipitating factors

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Predisposing Cardiac Diseases

• Myocardial infarction
• Chronic ischemia
• Cardiomyopathy
• Arrhythmias
• Diastolic dysfunction
• Valvular diseases
• Aortic Stenosis
• Mitral Stenosis
• Mitral Regurgitation

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Cardiac Physiology(remember this?)

• CO SV x HR
• HR parasympathetic and sympathetic tone
• SV preload, afterload, contractility

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Preload

• Def Passive stretch of muscle prior to
  contraction
• Measurement Swan-Ganz
• LVEDP
• Really a function of LVEDV
• Affected by compliance
• Low compliance higher LVEDP _at_ lower LVEDV
• False high estimate of preload
• Frank-Starling right?

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Afterload

• Def Force opposing/stretching muscle after
  contraction begins
• Measurement SVR
• Really a function of
• SVR
• Chamber radius (dilated cardiomyopathies)
• Wall thickness (hypertrophy)

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Contractility

• Def Normal ability of the muscle to contract at
  a given force for a given stretch, independent of
  preload or afterload forces
• In other words
• How healthy is your heart muscle?
• Ischemia, Hypertrophy (?), Muscle loss

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Classifying Heart Failure

• Anatomically
• Left versus Right
• Physiologically
• Systolic versus Diastolic
• Functionally
• How symptomatic is your patient?

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Left versus Right Failure

• Left Heart Failure
• - Dyspnea
• - Dec. exercise tolerance
• - Cough
• - Orthopnea
• - Pink, frothy sputum

• Right Heart Failure
• - Dec. exercise tolerance
• - Edema
• - HJR / JVD
• - Hepatomegaly
• - Ascites

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Systolic versus Diastolic

• Systolic cant pump
• Aortic Stenosis
• HTN
• Aortic Insufficiency
• Mitral Regurgitation
• Muscle Loss
• Ischemia
• Fibrosis
• Infiltration

• Diastolic- cant fill
• Mitral Stenosis
• Tamponade
• Hypertrophy
• Infiltration
• Fibrosis

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Physical Exam

• no distress at rest, except for feeling
  uncomfortable when lying flat for more than a few
  minutes
• Decreased pulse pressure
• cool peripheral extremities and cyanosis of the
  lips and nail beds
• Increased jugular venous pressure
• Rales
• Hepatomegaly
• Peripheral edema

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Clinical Data

• CXR
• Kerleys lines A and B
• Pulmonary Edema
• Cephalization
• Pleural Effusions (bilateral)
• EKG
• Left atrial enlargement
• Arrhythmias
• Hypertrophy (left or right)

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Pulmonary Edema
Cardiomyopathy
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Clinical Data

• HEART SOUNDS!!!
• Systolic Murmurs
• Mitral Regurg
• Aortic Stenosis
• Diastolic Murmurs
• Mitral Stenosis
• Aortic Insufficiency
• S3 Rapid filling of a diseased ventricle

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Clinical Data

• Laboratory Data
• Chemistry
• Renal Function Be Wary
• BNP
• Used in ER departments the world over
• Good negative correlation
• Need baseline for positivity
• Pulmonary versus cardiac dyspnea

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Treatment of CHF

• Treat Precipitating Factor(s)!!!!
• Adjust Heart Rate
• Decrease Preload
• Decrease Afterload
• Increase Contractility
• Increase Oxygenation

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Treatment of CHF

• Oxygen nasal, BiPAP, intubation
• Morphine
• Preload Reduction
• Loop diuretics
• Nitrates
• ACEi / ARB
• Morphine

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Treatment of CHF

• Afterload Reduction
• IV NTG, Nitroprusside
• Hydralazine
• ACEi / ARB
• Ionotropic Support
• Dopamine / Dobutamine
• Amrinone / Milrinone
• Digoxin (chronic)
• Mechanical (ABP)

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Treatment of CHF

• Beta-Blockers
• Chronic gt Acute
• Carvedilol (Coreg), Metoprolol (Toprol XL)
• Fluid Balance
• Restrict fluid / salt intake
• Monitor I/Os and daily weight
• Dialysis if needed
• Aspirin

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Precipitating Factors

• Infection
• Pulm Embolus
• Noncompliance
• Arrhythmia
• Myocardial Infarction
• Stress reaction

• Sodium Intake
• Medications!!!
• Anemia
• Thyroid disorders
• Endocarditis

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Admission Orders

• Admit Telemetry or ICU
• EKG STAT, then daily x 3 days
• 2D Echo
• CXR
• Labs BMP, CBC, CE x 3, Coags, LFTs, UA
• Pulse ox (ABG)
• Oxygen
• ASA 325mg PO daily

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Admission Orders

• Nitroglycerin
• Paste 1 ACW TID Holding parameters
• IV 50mg in 250cc D5W Titrate
• Morphine 1-5mg IV q10-20 min prn
• Lasix 20-200mg IV (q 6-8 hours)
• ACEi
• Captopril 6.25-50mg PO q8h
• Enalapril 2.5-20mg PO BID (0.625-2.5mg IV q6h)
• Hydralazine 10-100mg PO q6-8 h

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Admission Orders

• Beta Blocker
• Probably not acutely
• Start Coreg or Toprol XL prior to discharge
• Fluid Restrict 1000ml daily
• Low salt diet
• Daily patient weights
• Daily I/Os

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Admission Orders

• Dobutamine 500mg in 250cc D5W
• 3-10ug/kg/min
• Digoxin
• Probably not acutely
• Titrate to effective dose prior to discharge
• IABP
• Cardiogenic shock unresponsive to above tx
• Dialysis
• Critical renal failure patients