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Transcript
Congestive Heart Failure for the Prehospital Provider John Burton, MD- Albany Medical Center-Albany, New York 62 year old male CC: Difficulty Breathing It’s Midnight….suddenly short of breath! History: CHF, CAD, COPD Drugs: coumadin, digoxin, captopril, Inhalers Allg: None ROS: Negative - no chest pain, etc.. Exam: RR 45, Sat 82%RA, HR 130, BP 190/100 Lungs: bilateral rales Ext: 2+ bilateral edema Objectives 1. Discuss core concepts in anatomy and physiology that will enhance your overall understanding of the cardiovascular system 2. Discuss the pathophysiology of CONGESTIVE HEART FAILURE: what it is, what’s it about? 3. Discuss Congestive Heart Failure patient management for the prehospital provider Let’s think a little bit about the Left Ventricle Acquired or Congenital Cardiomyopathies Affecting the Left Ventricle Type of Cardiomyopathies Dilated All four chambers are dilated. The most common cause is chronic alcoholism, though some may be the end-stage of remote viral myocarditis. Single ventricle can dilate as well….as in CHF. Hypertrophic The most common form, idiopathic hypertrophic subaortic stenosis (IHSS) results from asymmetric interventricular septal hypertrophy, resulting in left ventricular outflow obstruction. High blood pressure is also a common cause. Dilated Cardiomyopathy Hypertrophic Cardiomyopathy Dilated Cardiomyopathy Hypertrophic Cardiomyopathy EITHER WAY…THE HEART DOES NOT FUNCTION AS WELL A brief discussion of the works of this thing... The Pump: 1. A Mechanical Component 2. An Electrical Component 65% 1. A Mechanical Component 2. An Electrical Component Filling….Pumping Problems with Filling... Problems with Pumping... PUMPS LESS!!! FILLS LESS!!! Pumping Problems with Pumping... Just how little pumping can one get away with? Pumping Just how little pumping can one get away with? Normal No Symptoms Lethargy, less exercise tolerance Shortness of breath Incompatible with life - 65% 40-65% 30-45% 20 - 30% <15% Break PREload AFTERload Contractility PREload AFTERload Contractility Preload is a passive stretching force exerted on the ventricular muscle at the end of diastole. Preload is caused by the volume of blood in the ventricle at the end of diastole. Afterload is the force resisting the contraction of the cardiac muscle fibers. Afterload can also be considered as the blood pressure exerted on the Atrial Valve during diastole (Diastolic BP). Contractility refers to the ability of cardiac muscle fibers to shorten when stimulated (strength). Normal No Symptoms Lethargy, less exercise tolerance Shortness of breath Incompatible with life - 65% 40-65% 30-45% 20 - 30% <15% CO = SV x HR Where: CO is cardiac output expressed in L/min (normal ~5 L/min) SV is stroke volume per beat CO = SV x HR Both CO and SV are dependent upon Preload Afterload Contractility What have we learned? • Cardiac Anatomy • Cardiac physiology and pathophysiology • How to think of the above using the concepts of preload, afterload, and contractility Filling….Pumping Problems with Filling... Problems with Pumping... DEFINITION CHF “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.” E. Braunwald Diagnosis of CHF: • Pt with symptoms of heart failure - shortness of breath and leg swelling. • Physical exam findings for heart failure - lungs: rales, legs: edema, neck: jvd • Chest XRay findings for CHF • Findings of systolic or diastolic dysfunction: Echocardiograms: Low ejection fraction/poor contractility (hypocontractility) Maisel A. et al. J Am Coll Cardiol 2001 Who gets HEART FAILURE? • Risk factors: hypertension, hyperlipidemia, smoking, diabetes, family history of heart disease. • Patients with history of acute myocardial infarcation. • Patients with previous history or current HEART DISEASE. What does Heart Failure do? “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.” Venous Arterial Legs swell Decreased perfusion…. Neck veins distend Liver congestion Brain Kidneys Lung congestion Everything... Venous Legs swell (Pitting Edema) Neck veins distend (JVD) Liver congestion (HepatoJug Rflx) Lung congestion (Rales) LUNG SOUNDS Normal - Clear Asthma - End Expiratory WHEEZES CHF - Inspiratory RALES Heart Failure • Approximately 5 million Americans have CHF (male to female ratio 1:1) • 550,000 new cases annually • Incidence of 10/1000 > 65 years of age • Hospital discharges 962,000 • Five-year mortality rate as high as 50% • Single largest expense for Medicare AHA Heart and Stroke Statistical Update 2002 HCFA Hospitalization Costs 6 Billions of $ 5 4 3 2 1 0 O’Connell JB. et al. J Heart Lung Transplant 1994;13:S107-12 Heart failure Cancer Myocardial infarction Heart Failure Hospitalizations The number of heart failure hospitalizations is increasing in both men and women 600,000 Discharges 500,000 400,000 300,000 200,000 Women Men 100,000 AHA Heart and Stroke Statistical Update 2002 7 '9 5 '9 3 '9 1 '9 9 '8 7 '8 5 '8 3 '8 1 '8 '7 9 0 Heart Failure Total Direct and Indirect Costs Hospital/Nursing Home 8% 10% Physicians/Other Professionals 9% Drugs/Other Medical Durables 7% Total Direct and Indirect Expenditures = $23.2 billion AHA Heart and Stroke Statistical Update 2002 66% Home Health Care Lost Productivity/Mort ality Causes of Congestive Heart Failure • Hypertension • Ischemia • Sustained Arrhythmias • Cardiomyopathy – EtOH, infiltrative • Valvular Heart Disease • Pericardial Disease CHF: Diagnosis CHF: a CLINICAL diagnosis • History • Physical Exam • Chest X Ray • Echocardiogram • Laboratory testing How do you know an EMS patient has Heart Failure? CHF: a CLINICAL diagnosis • History…. Shortness of Breath!!! ; Leg edema; weakness • Physical Exam …. Legs: Edema; Lungs: Rales • Chest X Ray • Echocardiogram • Laboratory testing How do you know an EMS patient has Heart Failure? Accuracy of Diagnosis: CHF EMS : 50-65% Emergency Doc: 65-80% Cardiologist: 80-85% OR’s for differentiating between patients with and those without CHF 12 11.1 10.7 10 8 Age Hx CHF Hx MI Rales Ceph XR Edema JVD OR 6 4 2.9 2.7 2.2 2 1 0 NEJM 02;347:161-167 Predictor 1.9 How do you know an EMS patient has Heart Failure? Ask 3 Questions: 1. History of Congestive Heart Failure? 2. RALES on Lung Examination? 3. EDEMA to Legs? IN The Emergency Department: Do a Chest XRay Spectrum of Heart Failure Dyspnea at rest PND and orthopnea Dyspnea on exertion Asymptomatic CHF Pulmonary Edema Moderate Cardiogenic Shock What have we learned: CHF • There’s lots of it….and it’s expensive • Diagnosis is tough…mostly shortness of breath and leg edema patients. • – – – Ask 3 Questions and it’s probably CHF: 1. History of CHF? 2. Rales to lungs? 3. Leg Edema? Goals of Therapy in CHF • Relief of symptoms - shortness of breath, leg edema, fatigue • Improve hemodynamic compromise • Minimize complications - decrease cardiac risk of new events Venous Arterial Legs swell Decreased perfusion…. Neck veins distend Liver congestion Brain Kidneys Lung congestion Everything... INCREASED PRELOAD INCREASED AFTERLOAD Current Treatment of Acute Heart Failure High Preload Reduce fluid volume Diuretics LASIX High Afterload Poor Contractility Vasodilate Augment Contractility Vasodilators Nitroglycerin Inotropes -reduce afterload- CHF: The EMS Approach CHF Patient Traditional Approach Lasix Top/SL Nitroglycerin Morphine Diuretics : Lasix Advantages • Alleviate symptoms • Decreases fluid overload Disadvantages • Electrolyte imbalance • Diuretic resistance • Decreases renal perfusion Nitroglycerin Advantages • Decreases preload at low doses • Higher doses can result in arteriolar dilation (afterload reduction) Disadvantages • Tachycardia • Tolerance to therapy • Overtitration can be problematic Arteries VEINS Increasing dose of nitroglycerin Morphine Advantages • Decreases preload at low doses • Higher doses can result in afterload reduction Disadvantages • Sedation • Effects on preload are very difficult to titrate and variable from patient to patient • Overtitration can be problematic hypoxemic or sedated? • Bad Outcomes in studies Odds Ratio for Intubation in Heart Failure Patients 6 5 4 3 2 1 0 Am J Emerg Med 99;17:571-574: 181 pts MI Age Captopril NTG MS Diuretic Continuous Positive Airway Pressure CPAP Advantages • Increases oxygenation • Effects on preload, afterload and contractility are arguable and not completely understood Disadvantages • Cooperation • Cooperation • Studies are few and unclear…although empiric evidence is stong CHF: The Evolving EMS Approach CHF Patient Traditional Approach Evolving Approach Lasix Lasix - smaller doses Top/SL Nitroglycerin Nitroglycerin - higher doses Morphine Morphine - smaller doses/none Continuous Positive Airway Pressure (CPAP) 62 year old male CC: Difficulty Breathing It’s Midnight….suddenly short of breath! History: CHF, CAD, COPD Drugs: coumadin, digoxin, captopril, Inhalers Allg: None ROS: Negative - no chest pain, etc.. Exam: RR 45, Sat 82%RA, HR 130, BP 190/100 Lungs: bilateral rales Ext: 2+ bil edema Is it CHF or is it COPD? CHF • • • • • Hx CHF Hx Heart Disease Hypertensive Rales Leg edema COPD • • • • • • Hx COPD Inhalers/O2 +/- Hx Heart Disease Normotensive +/- Leg edema Sputum EMS Management 62 yo male Chief complaint: Difficulty breathing - Face Mask O2 - Lasix - single dose - 40 mg - Nitroglycerin - titrate to symptoms and pressure - CPAP if ya got it In the ED.…CHF • Face mask O2 • IV NTG • • • • • Lasix IV/Oral ACE inhibitor (captopril): AFTERLOAD BiPaP/CPAP Intubate if respiratory failure Watch for symptoms to improve…. Emergency Department Current Treatment of Acute Heart Failure Vasodilators Diuretics Reduce fluid volume Lasix Decrease Preload And Afterload Lasix Ntg: sl, top, iv MSO4 ACEi BiPAP/CPAP Vasodilate Augment Contractility ACE inhibitor Nitroglycerin Patient Follow-up... 62 yo male Chief complaint: Difficulty breathing In the ED: IV Ntg, Bipap, Captopril.. Got better….admit CICU not intubated Discharged on day 6