Post on 07-May-2015
transcript
Congestive Heart Failure
Michele Ritter, M.D.Argy – February, 2007
Heart Failure
Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure).
The Vicious Cycle of Congestive Heart Failure
Decreased Blood Pressure andDecreased Renal perfusion
Stimulates the Release of renin, Which allows
conversion of Angiotensin
to Angiotensin II. Angiotensin II stimulates
Aldosterone secretion which causes retention of
Na+ and Water, increasing filling pressure
LV Dysfunction causesDecreased cardiac output
Types of Heart Failure
Low-Output Heart Failure Systolic Heart Failure:
decreased cardiac output Decreased Left ventricular ejection fraction
Diastolic Heart Failure: Elevated Left and Right ventricular end-diastolic
pressures May have normal LVEF
High-Output Heart Failure Seen with peripheral shunting, low-systemic vascular
resistance, hyperthryoidism, beri-beri, carcinoid, anemia Often have normal cardiac output
Right-Ventricular Failure Seen with pulmonary hypertension, large RV infarctions.
Causes of Low-Output Heart Failure
Systolic Dysfunction Coronary Artery Disease Idiopathic dilated cardiomyopathy (DCM)
50% idiopathic (at least 25% familial) 9 % mycoarditis (viral) Ischemic heart disease, perpartum, hypertension,
HIV, connective tissue disease, substance abuse, doxorubicin
Hypertension Valvular Heart Disease
Diastolic Dysfunction Hypertension Coronary artery disease Hypertrophic obstructive cardiomyopathy (HCM) Restrictive cardiomyopathy
Clinical Presentation of Heart Failure
Due to excess fluid accumulation: Dyspnea (most sensitive symptom) Edema Hepatic congestion Ascites Orthopnea, Paroxysmal Nocturnal Dyspnea
(PND) Due to reduction in cardiac ouput:
Fatigue (especially with exertion( Weakness
Physical Examination in Heart Failure
S3 gallop Low sensitivity, but highly specific
Cool, pale, cyanotic extremities Have sinus tachycardia, diaphoresis and peripheral
vasoconstriction Crackles or decreased breath sounds at bases
(effusions) on lung exam Elevated jugular venous pressure Lower extremity edema Ascites Hepatomegaly Splenomegaly Displaced PMI
Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement>
Measuring Jugular Venous Pressure
Lab Analysis in Heart Failure
CBC Since anemia can exacerbate heart failure
Serum electrolytes and creatinine before starting high dose diuretics
Fasting Blood glucose To evaluate for possible diabetes mellitus
Thyroid function tests Since thyrotoxicosis can result in A. Fib, and hypothyroidism can results in HF.
Iron studies To screen for hereditary hemochromatosis as cause of heart
failure. ANA
To evaluate for possible lupus Viral studies
If viral mycocarditis suspected
Laboratory Analysis (cont.)
BNP With chronic heart failure, atrial mycotes
secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures
Usually is > 400 pg/mL in patients with dyspnea due to heart failure.
Chest X-ray in Heart Failure
Cardiomegaly Cephalization of the pulmonary
vessels Kerley B-lines Pleural effusions
Cardiomegaly
Pulmonary vessel congestion
Pulmonary Edema due to Heart Failure
Kerley B lines
Cardiac Testing in Heart Failure
Electrocardiogram: May show specific cause of heart
failure: Ischemic heart disease Dilated cardiomyopathy: first degree AV
block, LBBB, Left anterior fascicular block Amyloidosis: pseudo-infarction pattern Idiopathic dilated cardiomyopathy: LVH
Echocardiogram: Left ventricular ejection fraction Structural/valvular abnormalities
Further Cardiac Testing in Heart Failure
Exercise Testing Should be part of initial evaluation of all patients
with CHF. Coronary arteriography
Should be performed in patients presenting with heart failure who have angina or significant ischemia
Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina.
Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.
Further testing in Heart Failure
Endomyocardial biopsy Not frequently used Really only useful in cases such as viral-
induced cardiomyopathy
Classification of Heart Failure
New York Heart Association (NYHA) Class I – symptoms of HF only at levels
that would limit normal individuals. Class II – symptoms of HF with
ordinary exertion Class III – symptoms of HF on less than
ordinary exertion Class IV – symptoms of HF at rest
Classification of Heart Failure (cont.)
ACC/AHA Guidelines Stage A – High risk of HF, without
structural heart disease or symptoms Stage B – Heart disease with
asymptomatic left ventricular dysfunction
Stage C – Prior or current symptoms of HF
Stage D – Advanced heart disease and severely symptomatic or refractory HF
Chronic Treatment of Systolic Heart Failure
Correction of systemic factors Thyroid dysfunction Infections Uncontrolled diabetes Hypertension
Lifestyle modification Lower salt intake Alcohol cessation Medication compliance
Maximize medications Discontinue drugs that may contribute to heart
failure (NSAIDS, antiarrhythmics, calcium channel blockers)
Order of Therapy
1. Loop diuretics2. ACE inhibitor (or ARB if not
tolerated)3. Beta blockers4. Digoxin5. Hydralazine, Nitrate6. Potassium sparing diuretcs
Diuretics
Loop diuretics Furosemide, buteminide For Fluid control, and to help relieve
symptoms
Potassium-sparing diuretics Spironolactone, eplerenone Help enhance diuresis Maintain potassium Shown to improve survival in CHF
ACE Inhibitor
Improve survival in patients with all severities of heart failure.
Begin therapy low and titrate up as possible:
Enalapril – 2.5 mg po BID Captopril – 6.25 mg po TID Lisinopril – 5 mg po QDaily
If cannot tolerate, may try ARB
Beta Blocker therapy
Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to III HF, probably in class IV.
Contraindicated: Heart rate <60 bpm Symptomatic bradycardia Signs of peripheral hypoperfusion COPD, asthma PR interval > 0.24 sec, 2nd or 3rd degree block
Hydralazine plus Nitrates
Dosing: Hydralazine
Started at 25 mg po TID, titrated up to 100 mg po TID
Isosorbide dinitrate Started at 40 mg po TID/QID
Decreased mortality, lower rates of hospitalization, and improvement in quality of life.
Digoxin
Given to patients with HF to control symptoms such as fatigue, dyspnea, exercise intolerance
Shown to significantly reduce hospitalization for heart failure, but no benefit in terms of overall mortality.
Other important medication in Heart Failure -- Statins
Statin therapy is recommended in CHF for the secondary prevention of cardiovascular disease.
Some studies have shown a possible benefit specifically in HF with statin therapy
Improved LVEF Reversal of ventricular remodeling Reduction in inflammatory markers (CRP,
IL-6, TNF-alphaII)
Meds to AVOID in heart failure
NSAIDS Can cause worsening of preexisting HF
Thiazolidinediones Include rosiglitazone (Avandia), and
pioglitazone (Actos) Cause fluid retention that can exacerbate HF
Metformin People with HF who take it are at increased
risk of potentially lethic lactic acidosis
Implantable Cardioverter-Defibrillators for HF
Sustained ventricular tachycardia is associated with sudden cardiac death in HF.
About one-third of mortality in HF is due to sudden cardiac death.
Patients with ischemic or nonischemic cardiomyopathy, NYHA class II to III HF, and LVEF ≤ 35% have a significant survival benefit from an implantable cardioverter-defibrillator (ICD) for the primary prevention of SCD.
Management of Refractory Heart Failure
Inotropic drugs: Dobutamine, dopamine, milrinone,
nitroprusside, nitroglycerin Mechanical circulatory support:
Intraaortic balloon pump Left ventricular assist device (LVAD)
Cardiac Transplantation A history of multiple hospitalizations for HF Escalation in the intensity of medical therapy A reproducable peak oxygen consumption with
maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.
Acute Decompensated Heart Failure
Cardiogenic pulmonary edema is a common and sometimes fatal cause of acute respiratory distress.
Characterized by the transudation of excess fluid into the lungs secondary to an increase in left atrial and subsequently pulmonary venous and pulmonary capillary pressures.
Acute Decompensaated Heart Failure (cont.)
Causes: Acute MI
Rupture of chordae tendinae/acute mitral valve insufficiency
Volume Overload Transfusions, IV fluids Non-compliance with diuretics, diet (high
salt intake) Worsening valvular defect
Aortic stenosis
Decompensated Heart Failure
Symptoms Severe dyspnea Cough
Clinical Findings Tachypnea Tachycardia Hypertension/Hypotension Crackles on lung exam Increased JVD S3, S4 or new murmur
Labs/Studies in Acute Decompensated Heart Failure
Chemistry, CBC EKG Chest X-ray May consider cardiac enzymes 2D-Echo
Decompensated Heart Failure
Treatment Strict I’s and O’s, daily weights Oxygen, mechanical ventilation if
needed Loop diuretics (Lasix!) Morphine Vasodilator therapy (nitroglycerin) Nesiritide (BNP) – can help in acute
setting, for short term therapy
Case # 1
A 65-year old male with a history of hypertension, DM, CAD s/p MI and three-vessel CABG in 2002, presents with worsening dyspnea on exertion. He states that he occassionally has a dry cough, but denies any recent chest pain, fevers, N/V. Patient states that he usually can get up a flight of stairs if he stops half-way, but over the last several days, has not been able to climb them at all.
Case # 1 (cont.)
PMH: CAD – MI and CABG in 2002 Hypertension Diabetes Mellitus Hypothyroidism
Allergies: NKDA
Outpatient Meds: Synthroid Metformin Norvasc
Case # 1 (cont.)
Physical Exam: 97.6, 168/72, 99, 28, 93% on RA Gen: Alert and oriented x 3, breathing
rapidly CV: RRR, no murmurs; mod. JVD Resp: Crackles throughout lungs Abd.: soft, nontender, NABS Ext: 2 + pitting edema bilaterally
Case # 1 (cont.)
Labs: Hgb: 13.5 WBC: 8 Platelets: 240 Sodium: 139 Potassium: 3.8 BUN: 18 Cr: 0.8
Trop. I – 0.01 CPK: 120
Case # 1
Case # 1
What studies would you like to check in this patient?
What medications would you like to start/change?
What vital signs do you want to monitor?
Case # 2
A 45-year old obese woman with diabetes mellitus is evaluated for a 1-month history of progressive shortness of breath. Two months ago, she had a flu-like illness with nausea, vomiting, and sweating. She has not followed up with a physician regularly. One of her siblings has “heart problems” and her mother died suddenly and unexpectedly at age 55 years.
Case # 2
On examination her heart rate is 75/min and her blood pressure is 185/93 mm Hg. BMI is 32.9. Jugular venous pressure is mildly elevated. Lung examination reveals a few bibasilar crackles. Cardiac examination reveals regular rhythm, normal S1 and S2 and the presence of an S3. There is mild peripheral edema. An echocardiogram is significant for left ventricular hypertrophy and severely decreased systolic function (left ventricular ejection fraction, 20%) An electrocardiogram shows a previous anteroseptal MI.
Case # 2
Which of the following is the most appropriate next diagnostic test?
(A) Measurement of plasma BNP(B) Serum Protein Electrophoresis(C) Cardiac Stress Test(D) Cardiac catheterization(E) Endomyocardial biopsy