RAAS and sympathetic nervous system activation lead to increased norepin, vasopression sodium/water retention Cardiac remodeling
Often missed on CXR, especially if patient is intubated and supine.
High output state e.g. anemia or sepsis
CHF in the ED
Bryce C Inman, MD
Loma Linda University Medical Center
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
CHF: 2 types
• EF < 40%
• Impaired ventricular
• Most commonly from
ischemic heart disease
• EF > 60%
• Impaired ventricular
• Most commonly from
chronic HTN and LVH
• 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
• Dyspnea at rest
• Dyspnea upon exertion
• Cough: Frothy pink sputum highly predictive
• Nonspecifics: weakness, dizziness, malaise,
• 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%
• JVD has 94 percent specificity for elevated
capillary wedge pressure (but 39% sensitivity)
• 1/5 CHF patients admitted to the hospital
lacked signs on CXR
• Congestive signs on CXR are unreliable in
• Sensitivity for CHF with a portable CXR is poor.
• CXR findings often lag behind clinical
manifestions by several hours
However, a CXR is useful to exclude other
processes (e.g., pneumothorax)
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,
• 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
– Is this CHF or COPD?
• A BNP of <100 almost entirely excludes CHF
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 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
• Typically for those in severe
distress or those who are
• May decrease the need for
intubations, but no
significant change in
• 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 wall
IV: Start at 20 mcg/min IV and rate to effect in 5-10 mcg
• The failing heart is sensitive to increases in afterload;
these measures alleviate the pulmonary edema from
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
• 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 diuretics
80-120 mg IV for patients whose symptoms are
refractory to the initial dose after 1 h of its
• Metolazone, a thiazide diuretic, can be added for
• 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
– 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
• 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
• Pressor support if hypotensive