mahus chf

Congestive Heart FailureCongestive Heart Failure

Mr. Mahadev prasad,Inscol Academy, Lecture

Mr. Mahadev prasad,Inscol Academy, Lecture

Congestive Heart FailureCongestive Heart Failure

• Heart failure is the term used when heart is unable to pump enough blood to meet the metabolic needs of body at rest or during exercise even though filling pressures are adequate.

Predisposing Cardiac Diseases

Predisposing Cardiac Diseases

• Myocardial infarction• Chronic ischemia• Cardiomyopathy• Arrhythmias• Diastolic dysfunction• Valvular diseases

– Aortic Stenosis– Mitral Stenosis– Mitral Regurgitation

• Myocardial infarction• Chronic ischemia• Cardiomyopathy• Arrhythmias• Diastolic dysfunction• Valvular diseases

– Aortic Stenosis– Mitral Stenosis– Mitral Regurgitation

Cardiac Physiology(remember this?)

Cardiac Physiology(remember this?)

• CO = SV x HR

• HR: parasympathetic and sympathetic tone

• SV: preload, afterload, contractility

• CO = SV x HR

• HR: parasympathetic and sympathetic tone

• SV: preload, afterload, contractility

PreloadPreload

• Def: Passive stretch of muscle prior to contraction

• Measurement: Swan-Ganz– LVEDP

• Really a function of LVEDV• Affected by compliance

– Low compliance = higher LVEDP @ lower LVEDV– False high estimate of preload

• Frank-Starling right?

• Def: Passive stretch of muscle prior to contraction

• Measurement: Swan-Ganz– LVEDP

• Really a function of LVEDV• Affected by compliance

– Low compliance = higher LVEDP @ lower LVEDV– False high estimate of preload

• Frank-Starling right?

AfterloadAfterload

• Def: Force opposing/stretching muscle after contraction begins

• Measurement: SVR• Really a function of:

– SVR– Chamber radius (dilated

cardiomyopathies)– Wall thickness (hypertrophy)

• Def: Force opposing/stretching muscle after contraction begins

• Measurement: SVR• Really a function of:

– SVR– Chamber radius (dilated

cardiomyopathies)– Wall thickness (hypertrophy)

ContractilityContractility

• 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

• 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

Classifying Heart FailureClassifying Heart Failure

• Anatomically– Left versus Right

• Physiologically– Systolic versus Diastolic

• Functionally– How symptomatic is your patient?

• Anatomically– Left versus Right

• Physiologically– Systolic versus Diastolic

• Functionally– How symptomatic is your patient?

Left versus Right FailureLeft versus Right Failure

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

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

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

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

Systolic versus DiastolicSystolic versus Diastolic

• Systolic– “can’t pump”– Aortic Stenosis– HTN– Aortic Insufficiency– Mitral Regurgitation– Muscle Loss

• Ischemia• Fibrosis• Infiltration

• Systolic– “can’t pump”– Aortic Stenosis– HTN– Aortic Insufficiency– Mitral Regurgitation– Muscle Loss

• Ischemia• Fibrosis• Infiltration

• Diastolic- “can’t fill”– Mitral Stenosis– Tamponade– Hypertrophy– Infiltration– Fibrosis

• Diastolic- “can’t fill”– Mitral Stenosis– Tamponade– Hypertrophy– Infiltration– Fibrosis

Clinical DataClinical Data

• CXR– Kerley’s lines : A and B– Pulmonary Edema– Cephalization– Pleural Effusions (bilateral)

• CXR– Kerley’s lines : A and B– Pulmonary Edema– Cephalization– Pleural Effusions (bilateral)

CardiomyopathyCardiomyopathy Pulmonary EdemaPulmonary Edema

Clinical DataClinical Data

• HEART SOUNDS!!!• Systolic Murmurs

– Mitral Regurg– Aortic Stenosis

• Diastolic Murmurs– Mitral Stenosis– Aortic Insufficiency

• S3: Rapid filling of a diseased ventricle

• HEART SOUNDS!!!• Systolic Murmurs

– Mitral Regurg– Aortic Stenosis

• Diastolic Murmurs– Mitral Stenosis– Aortic Insufficiency

• S3: Rapid filling of a diseased ventricle

Treatment of CHFTreatment of CHF

• Treat Precipitating Factor(s)!!!!

• Adjust Heart Rate• Decrease Preload• Decrease Afterload• Increase Contractility• Increase Oxygenation

• Treat Precipitating Factor(s)!!!!

• Adjust Heart Rate• Decrease Preload• Decrease Afterload• Increase Contractility• Increase Oxygenation

Treatment of CHFTreatment of CHF

• Oxygen – nasal, BiPAP, intubation• Morphine• Preload Reduction

– Loop diuretics– Nitrates– ACE– Morphine

• Oxygen – nasal, BiPAP, intubation• Morphine• Preload Reduction

– Loop diuretics– Nitrates– ACE– Morphine

Treatment of CHFTreatment of CHF

• Afterload Reduction– IV NTG, Nitroprusside– Hydralazine– ACE

• Ionotropic Support– Dopamine / Dobutamine– Amrinone / Milrinone– Digoxin (chronic)

• Afterload Reduction– IV NTG, Nitroprusside– Hydralazine– ACE

• Ionotropic Support– Dopamine / Dobutamine– Amrinone / Milrinone– Digoxin (chronic)

Treatment of CHFTreatment of CHF

• Beta-Blockers– Chronic > Acute– Carvedilol (Coreg), Metoprolol (Toprol XL)

• Fluid Balance– Restrict fluid / salt intake– Monitor I/Os and daily weight– Dialysis if needed

• Aspirin

• Beta-Blockers– Chronic > Acute– Carvedilol (Coreg), Metoprolol (Toprol XL)

• Fluid Balance– Restrict fluid / salt intake– Monitor I/Os and daily weight– Dialysis if needed

• Aspirin

Precipitating FactorsPrecipitating Factors

• Infection• Pulm Embolus• Noncompliance• Arrhythmia• Myocardial

Infarction• Stress reaction

• Infection• Pulm Embolus• Noncompliance• Arrhythmia• Myocardial

Infarction• Stress reaction

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

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

Admission OrdersAdmission Orders

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

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

Admission OrdersAdmission 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

• 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

Admission OrdersAdmission 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

• 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

Admission OrdersAdmission 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

• 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