Congestive Heart FailureCongestive Heart Failure

ADOPTED FROM:Jarrod Eddy, PGY2Internal MedicineSub-I Lecture Series

ADOPTED FROM:Jarrod Eddy, PGY2Internal MedicineSub-I Lecture Series

Congestive Heart FailureCongestive Heart Failure

• Clinical presentation of disease• NOT a diagnosis in and of itself• Differential includes

– Underlying cardiovascular disease– Precipitating factors

• Clinical presentation of disease• NOT a diagnosis in and of itself• Differential includes

– Underlying cardiovascular disease– Precipitating factors

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

Physical ExamPhysical 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

• 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 DataClinical Data

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

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

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

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

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

Clinical DataClinical 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

• 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 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– ACEi / ARB– Morphine

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

– Loop diuretics– Nitrates– ACEi / ARB– Morphine

Treatment of CHFTreatment of CHF

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

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

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

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

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, CE x 3, Coags, LFTs,

UA• Pulse ox (ABG)• Oxygen• ASA 325mg PO daily

• 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 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