Congestive Heart Failure
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Congestive Heart Failure Presentation Transcript

  • 1. Congestive Heart Failure Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series
  • 2. Congestive Heart Failure • Clinical presentation of disease • NOT a diagnosis in and of itself • Differential includes – Underlying cardiovascular disease – Precipitating factors
  • 3. Predisposing Cardiac Diseases • Myocardial infarction • Chronic ischemia • Cardiomyopathy • Arrhythmias • Diastolic dysfunction • Valvular diseases – Aortic Stenosis – Mitral Stenosis – Mitral Regurgitation
  • 4. Cardiac Physiology (remember this?) • CO = SV x HR • HR: parasympathetic and sympathetic tone • SV: preload, afterload, contractility
  • 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. Afterload • Def: Force opposing/stretching muscle after contraction begins • Measurement: SVR • Really a function of: – SVR – Chamber radius (dilated cardiomyopathies) – Wall thickness (hypertrophy)
  • 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. Classifying Heart Failure • Anatomically – Left versus Right • Physiologically – Systolic versus Diastolic • Functionally – How symptomatic is your patient?
  • 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. 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. 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. Cardiomyopathy Pulmonary Edema
  • 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. 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. Treatment of CHF • Treat Precipitating Factor(s)!!!! • Adjust Heart Rate • Decrease Preload • Decrease Afterload • Increase Contractility • Increase Oxygenation
  • 16. Treatment of CHF • Oxygen – nasal, BiPAP, intubation • Morphine • Preload Reduction – Loop diuretics – Nitrates – ACEi / ARB – Morphine
  • 17. Treatment of CHF • Afterload Reduction – IV NTG, Nitroprusside – Hydralazine – ACEi / ARB • Ionotropic Support – Dopamine / Dobutamine – Amrinone / Milrinone – Digoxin (chronic) – Mechanical (ABP)
  • 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. Precipitating Factors • Infection • Sodium Intake • Pulm Embolus • Medications!!! • Noncompliance • Anemia • Arrhythmia • Thyroid disorders • Myocardial Infarction • Endocarditis • Stress reaction
  • 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. 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. 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. 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