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  1. 1. CHF in the ED Bryce C Inman, MD Loma Linda University Medical Center
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. Diagnosis: History • Dyspnea at rest • Dyspnea upon exertion • Orthopnea • Cough: Frothy pink sputum highly predictive of CHF • Nonspecifics: weakness, dizziness, malaise, etc.
  6. 6. 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)
  7. 7. 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 hours However, a CXR is useful to exclude other processes (e.g., pneumothorax)
  8. 8. Pleural effusion
  9. 9. Pulmonary Edema
  10. 10. 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.
  11. 11. 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
  12. 12. What else looks like acute CHF?
  13. 13. 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.
  14. 14. 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?
  15. 15. 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
  16. 16. 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 wall IV: Start at 20 mcg/min IV and rate to effect in 5-10 mcg increments q3-5min • The failing heart is sensitive to increases in afterload; these measures alleviate the pulmonary edema from CHF.
  17. 17. Don’t venodilate when…. • Preload dependent states exist such as; – Right ventricular infarct – Critical aortic stenosis – Volume depletion
  18. 18. 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
  19. 19. 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 administration • Metolazone, a thiazide diuretic, can be added for effect.
  20. 20. 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
  21. 21. 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
  22. 22. 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