CHF in the ED

Bryce C Inman, MDLoma Linda University Medical Center

Loma Linda University Medical Center

Loma Linda Medical Center

• Level I trauma center with 50,000 patients per year & 65,000 patients per year at our affiliated hospital

• 900 Beds in hospital• Emphasis on Pediatric Emergency Medicine and

International Medicine

Congestive Heart Failure

• Congestive heart failure is an imbalance in pump function in which the heart is unable to maintain adequate forward blood flow.

• 10% of those > 80 years old• Most common cause of death is progressive

heart failure

CHF: 2 types

Systolic• EF < 40%• Impaired ventricular

contraction• Most commonly from

ischemic heart disease

Diastolic• EF > 60%• Impaired ventricular

relaxation• Most commonly from

chronic HTN and LVH

Prognosis

• Heart failure has an overall poor prognosis• Symptoms predict outcome

– 5-10% mortality per year in moderate CHF – 30-40% mortality per year in severe CHF

Diagnosis: History

• Dyspnea at rest• Dyspnea upon exertion• Orthopnea• Cough: Frothy pink sputum highly predictive

of CHF• Nonspecifics: weakness, dizziness, malaise,

etc.

Diagnosis: Exam

• Acute pulmonary edema: Severe respiratory distress , relative hypertension, diaphoretic skin. Bilateral crackles can typically be heard

• An S3 has 99 percent specificity for an elevated capillary wedge pressure (but 20% sensitivity)

• JVD has 94 percent specificity for elevated capillary wedge pressure (but 39% sensitivity)

Imaging

• 1/5 CHF patients admitted to the hospital lacked signs on CXR

• Congestive signs on CXR are unreliable in chronic CHF

• Sensitivity for CHF with a portable CXR is poor. • CXR findings often lag behind clinical

manifestions by several hoursHowever, a CXR is useful to exclude other

processes (e.g., pneumothorax)

Pleural effusion

Pulmonary Edema

What about labs and EKG?

• Lack sensitivity and specificity– Occasionally you might see an elevated AST/ALT

or prerenal azotemia– EKG may show ischemia or previous MI,

dysrhythmias, etc.

Natriuretic peptides

• 70 y/o M presents with respiratory distress. His 02 saturations are in the 70’s, he has mild retractions, and breath sounds are difficult to auscultate.– Is this CHF or COPD?

• A BNP of <100 almost entirely excludes CHF

What else looks like acute CHF?

TREAT!

70 y/o M presents with respiratory distress. His 02 saturations are in the 70’s, he has mild retractions, and breath sounds are difficult to auscultate.

Airway Management

• Airway management supercedes all other priorities in these patients, particularly those who are critically ill.

• Hypoxia is a greater risk than hypercarbia so CO2 retention is not an immediate concern

o What is the best way to manage the airway?

Intubation vs NIPPV

Intubation• Typically for those in severe

distress or those who are non-cooperative.

BiPAP/CPAP• May decrease the need for

intubations, but no significant change in mortality

Pressure Control• Systolic pressure acceptable?

– Start nitroglycerin (0.4 mg PO q2-3 min) – Nitrospray: Single spray (0.4 mg) up to a max of 1.2 mg

Ointment: Apply 1-2 inches of nitropaste to chest wallIV: Start at 20 mcg/min IV and rate to effect in 5-10 mcg increments q3-5min

– Not working? IV nitroprusside may be required

• The failing heart is sensitive to increases in afterload; these measures alleviate the pulmonary edema from CHF.

Don’t venodilate when….

• Preload dependent states exist such as;– Right ventricular infarct– Critical aortic stenosis– Volume depletion

Most require only oxygen, blood pressure control, and diuresis

-Vasoconstricted patients require vasodilators.-Congested patients required diuretics

★Diastolic HF patients respond better to BP management than diuresis

Diuresis

• First line therapy is a diuretic such as furosemide.– 10-20 mg IV for symptomatic CHF and diuretic naïve.

40-80 mg IV for patients already using diuretics80-120 mg IV for patients whose symptoms are refractory to the initial dose after 1 h of its administration

• Metolazone, a thiazide diuretic, can be added for effect.

If hypotensive…

• Inotropes including dobutamine and dopamine are used primarily– Dopamine starts at 5 mcg/kg/min IV and increase

at 5 mcg/kg/min increments to a 20 mcg/kg/min dose

– Dobutamine starts at 2.5 mcg/kg/min IV; generally therapeutic in the range of 10-40 mcg/kg/min

Admit or go home?

• With few exceptions, most patients presenting with symptoms of CHF require admission. Those who respond well to initial interventions may require only basic ward admission with telemetry.

• Those who had a gradual onset dyspnea, rapid response to therapy, good oxygen saturations, and ACS/MI unlikely as the inciting event may be stable for discharge

In conclusion

• Airway management is goal– IF NIPPV easily available, begin immediately and

monitor for progress or decline• Control Pressure

– Use nitroglycerin and titrate to effect– If known diastolic CHF, attempt to reduce

afterload• Pressor support if hypotensive

– Dobutamine/dopamine

References

• Mueller C, Laule-Kilian K, Frana B, et al. Use of B-type natriuretic peptide in the management of acute dyspnea in patients with pulmonary disease. Am Heart J. Feb 2006;151(2):471-7.

• Grossman, S. Congestive Heart Failure and Pulmonary Edema. Emedicine.medscape.com. Accessed 28Aug2010

• Steinhart B, Thorpe KE, Bayoumi AM, Moe G, Januzzi JL Jr, Mazer CD. Improving the diagnosis of acute heart failure using a validated prediction model. J Am Coll Cardiol. Oct 13 2009;54(16):1515-21.

• Collins SP, Lindsell CJ, Storrow AB. Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Ann Emerg Med. Jan 2006;47(1):13-8

• Lin M, Yang YF, Chiang HT. Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term follow-up. Chest. May 1995;107(5):1379-86.

• Tintinalli, JE. Congestive Heart Failure and Acute Pulmonary Edema. Emergency Medicine 6th Edition. 364-372