Download Congestive Heart Failure

Congestive Heart Failure
ADOPTED FROM:
Jarrod Eddy, PGY2
Internal Medicine
Sub-I Lecture Series
Congestive Heart Failure
• Clinical presentation of disease
• NOT a diagnosis in and of itself
• Differential includes
– Underlying cardiovascular disease
– Precipitating factors
Predisposing Cardiac Diseases
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Myocardial infarction
Chronic ischemia
Cardiomyopathy
Arrhythmias
Diastolic dysfunction
Valvular diseases
– Aortic Stenosis
– Mitral Stenosis
– Mitral Regurgitation
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 LVEDV
• Affected by compliance
– Low compliance = higher LVEDP @ lower LVEDV
– False high estimate of preload
• Frank-Starling right?
Afterload
• Def: Force opposing/stretching muscle
after contraction begins
• Measurement: SVR
• Really a function of:
– SVR
– Chamber radius (dilated cardiomyopathies)
– Wall thickness (hypertrophy)
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
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”
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Aortic Stenosis
HTN
Aortic Insufficiency
Mitral Regurgitation
Muscle Loss
• Ischemia
• Fibrosis
• Infiltration
• Diastolic- “can’t fill”
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Mitral Stenosis
Tamponade
Hypertrophy
Infiltration
Fibrosis
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
Clinical Data
• CXR
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Kerley’s lines : A and B
Pulmonary Edema
Cephalization
Pleural Effusions (bilateral)
• EKG
– Left atrial enlargement
– Arrhythmias
– Hypertrophy (left or right)
Cardiomyopathy
Pulmonary Edema
Clinical Data
• HEART SOUNDS!!!
• Systolic Murmurs
– Mitral Regurg
– Aortic Stenosis
• Diastolic Murmurs
– Mitral Stenosis
– Aortic Insufficiency
• S3: Rapid filling of a diseased ventricle
Clinical Data
• Laboratory Data
• Chemistry
– Renal Function: Be Wary
• BNP
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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)!!!!
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Adjust Heart Rate
Decrease Preload
Decrease Afterload
Increase Contractility
Increase Oxygenation
Treatment of CHF
• Oxygen – nasal, BiPAP, intubation
• Morphine
• Preload Reduction
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Loop diuretics
Nitrates
ACEi / ARB
Morphine
Treatment of CHF
• Afterload Reduction
– IV NTG, Nitroprusside
– Hydralazine
– ACEi / ARB
• Ionotropic Support
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Dopamine / Dobutamine
Amrinone / Milrinone
Digoxin (chronic)
Mechanical (ABP)
Treatment 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
Precipitating Factors
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Infection
Pulm Embolus
Noncompliance
Arrhythmia
Myocardial Infarction
Stress reaction
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Sodium Intake
Medications!!!
Anemia
Thyroid disorders
Endocarditis
Admission Orders
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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
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
Admission Orders
• Beta Blocker
– Probably not acutely
– Start Coreg or Toprol XL prior to discharge
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Fluid Restrict 1000ml daily
Low salt diet
Daily patient weights
Daily I/Os
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