Congestive Heart Failure

Objectives

definition of CHF Pathophysiology signs and symptoms of CHF causes of CHF precipitating factors investigation of patient with CHF monitoring of patient with CHF important lines of management

Important message

• Clinical presentation of disease• NOT a diagnosis

Cardiac Physiology(remember this?)

• CO = SV x HR

• HR: parasympathetic and sympathetic tone

• SV: preload, afterload, contractility

Preload

• Def: Passive stretch of muscle prior to contraction• Measurement: Swan-Ganz– LVEDP

• Really a function of diastole • Affected by compliance– Low compliance = higher LVEDP @ lower LVEDV

Afterload

• Def: Force opposing/stretching muscle after contraction begins

• Measurement: SVR

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

Predisposing Cardiac Diseases

• Myocardial infarction• Chronic ischemia• Cardiomyopathy• Arrhythmias• Diastolic dysfunction• Valvular diseases– AS , AI– MR

Precipitating Factors

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

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

Classifying Heart Failure

• Anatomically– Left versus Right

• Physiologically– Systolic versus Diastolic

• Functionally– How symptomatic is your patient?

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

Systolic versus Diastolic

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

• Ischemia• Fibrosis• Infiltration

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

Clinical Data

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

• EKG– Left atrial enlargement– Arrhythmias– Hypertrophy (left or right)

CardiomyopathyCardiomyopathy Pulmonary EdemaPulmonary Edema

Clinical Data

• HEART SOUNDS!!!• Systolic Murmurs– Mitral Regurg– Aortic Stenosis

• Diastolic Murmurs– Aortic Insufficiency

• S3: Rapid filling of a diseased ventricle

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

Treatment of CHF

• Treat Precipitating Factor(s)!!!!

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

Treatment of CHF

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

Treatment of CHF

• Afterload Reduction– IV NTG, Nitroprusside– Hydralazine– ACEi / ARB

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

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 81mg PO daily

Treatment of CHF

• Beta-Blockers– Chronic > Acute– Carvedilol , Metoprolol , Bisoprolol

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

• Aspirin

• Nitroglycerin– IV:10-200 mcg/min

• 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

• Hydralazine 10-100mg PO q6-8 h

• 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

• Dobutamine 500mg in 250cc D5W– 3-10 mcg/kg/min

• Digoxin– Titrate to effective dose prior to discharge– Not in renal faliure

• IABP– Cardiogenic shock unresponsive to above tx

• Dialysis– Critical renal failure patients

Questions