Congestive Heart Failure



 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
  –...
Predisposing Cardiac Diseases
•   Myocardial infarction
•   Chronic ischemia
•   Cardiomyopathy
•   Arrhythmias
•   Diasto...
Cardiac Physiology
              (remember this?)
• CO = SV x HR

• HR: parasympathetic and sympathetic tone

• SV: preloa...
Preload
• Def: Passive stretch of muscle prior to
  contraction
• Measurement: Swan-Ganz
  – LVEDP
• Really a function of ...
Afterload
• Def: Force opposing/stretching muscle
  after contraction begins
• Measurement: SVR
• Really a function of:
  ...
Contractility
• Def: Normal ability of the muscle to
  contract at a given force for a given
  stretch, independent of pre...
Classifying Heart Failure
• Anatomically
  – Left versus Right


• Physiologically
  – Systolic versus Diastolic


• Funct...
Left versus Right Failure
Left Heart Failure        Right Heart Failure
  - Dyspnea                 - Dec. exercise
  - De...
Systolic versus Diastolic
• Systolic– “can’t pump”     • Diastolic- “can’t fill”
  –   Aortic Stenosis           –   Mitra...
Clinical Data
• CXR
  –   Kerley’s lines : A and B
  –   Pulmonary Edema
  –   Cephalization
  –   Pleural Effusions (bila...
Cardiomyopathy   Pulmonary Edema
Clinical Data
• HEART SOUNDS!!!
• Systolic Murmurs
  – Mitral Regurg
  – Aortic Stenosis
• Diastolic Murmurs
  – Mitral St...
Clinical Data
• Laboratory Data

• Chemistry
  – Renal Function: Be Wary

• BNP
  –   Used in ER departments the world ove...
Treatment of CHF
• Treat Precipitating Factor(s)!!!!

•   Adjust Heart Rate
•   Decrease Preload
•   Decrease Afterload
• ...
Treatment of CHF
• Oxygen – nasal, BiPAP, intubation
• Morphine
• Preload Reduction
  –   Loop diuretics
  –   Nitrates
  ...
Treatment of CHF
• Afterload Reduction
  – IV NTG, Nitroprusside
  – Hydralazine
  – ACEi / ARB
• Ionotropic Support
  –  ...
Treatment of CHF
• Beta-Blockers
  – Chronic > Acute
  – Carvedilol (Coreg), Metoprolol (Toprol XL)
• Fluid Balance
  – Re...
Precipitating Factors
•   Infection               •   Sodium Intake
•   Pulm Embolus            •   Medications!!!
•   Non...
Admission Orders
•   Admit: Telemetry or ICU
•   EKG STAT, then daily x 3 days
•   2D Echo
•   CXR
•   Labs: BMP, CBC, CE ...
Admission Orders
• Nitroglycerin
  – Paste: 1” ACW TID – Holding parameters
  – IV: 50mg in 250cc D5W – Titrate
• Morphine...
Admission Orders
• Beta Blocker
    – Probably not acutely
    – Start Coreg or Toprol XL prior to discharge
•   Fluid Res...
Admission Orders
• Dobutamine 500mg in 250cc D5W
  – 3-10ug/kg/min
• Digoxin
  – Probably not acutely
  – Titrate to effec...
A R F
A R F
A R F
Upcoming SlideShare
Loading in …5
×

A R F

810 views
721 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
810
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
31
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

A R F

  1. 1. Congestive Heart Failure Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series
  2. 2. Congestive Heart Failure • Clinical presentation of disease • NOT a diagnosis in and of itself • Differential includes – Underlying cardiovascular disease – Precipitating factors
  3. 3. Predisposing Cardiac Diseases • Myocardial infarction • Chronic ischemia • Cardiomyopathy • Arrhythmias • Diastolic dysfunction • Valvular diseases – Aortic Stenosis – Mitral Stenosis – Mitral Regurgitation
  4. 4. Cardiac Physiology (remember this?) • CO = SV x HR • HR: parasympathetic and sympathetic tone • SV: preload, afterload, contractility
  5. 5. 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?
  6. 6. Afterload • Def: Force opposing/stretching muscle after contraction begins • Measurement: SVR • Really a function of: – SVR – Chamber radius (dilated cardiomyopathies) – Wall thickness (hypertrophy)
  7. 7. 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
  8. 8. Classifying Heart Failure • Anatomically – Left versus Right • Physiologically – Systolic versus Diastolic • Functionally – How symptomatic is your patient?
  9. 9. Left versus Right Failure Left Heart Failure Right Heart Failure - Dyspnea - Dec. exercise - Dec. exercise tolerance tolerance - Edema - Cough - HJR / JVD - Orthopnea - Hepatomegaly - Pink, frothy sputum - Ascites
  10. 10. Systolic versus Diastolic • Systolic– “can’t pump” • Diastolic- “can’t fill” – Aortic Stenosis – Mitral Stenosis – HTN – Tamponade – Aortic Insufficiency – Hypertrophy – Mitral Regurgitation – Infiltration – Muscle Loss – Fibrosis • Ischemia • Fibrosis • Infiltration
  11. 11. Clinical Data • CXR – Kerley’s lines : A and B – Pulmonary Edema – Cephalization – Pleural Effusions (bilateral) • EKG – Left atrial enlargement – Arrhythmias – Hypertrophy (left or right)
  12. 12. Cardiomyopathy Pulmonary Edema
  13. 13. Clinical Data • HEART SOUNDS!!! • Systolic Murmurs – Mitral Regurg – Aortic Stenosis • Diastolic Murmurs – Mitral Stenosis – Aortic Insufficiency • S3: Rapid filling of a diseased ventricle
  14. 14. Clinical 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
  15. 15. Treatment of CHF • Treat Precipitating Factor(s)!!!! • Adjust Heart Rate • Decrease Preload • Decrease Afterload • Increase Contractility • Increase Oxygenation
  16. 16. Treatment of CHF • Oxygen – nasal, BiPAP, intubation • Morphine • Preload Reduction – Loop diuretics – Nitrates – ACEi / ARB – Morphine
  17. 17. Treatment of CHF • Afterload Reduction – IV NTG, Nitroprusside – Hydralazine – ACEi / ARB • Ionotropic Support – Dopamine / Dobutamine – Amrinone / Milrinone – Digoxin (chronic) – Mechanical (ABP)
  18. 18. 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
  19. 19. Precipitating Factors • Infection • Sodium Intake • Pulm Embolus • Medications!!! • Noncompliance • Anemia • Arrhythmia • Thyroid disorders • Myocardial Infarction • Endocarditis • Stress reaction
  20. 20. Admission 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
  21. 21. 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
  22. 22. Admission 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
  23. 23. 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

×