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Congestive heart failure

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Congestive heart failure

  1. 1. Congestive Heart Failure
  2. 2. Objectives definition of CHF Pathophysiology signs and symptoms of CHF causes of CHF precipitating factors investigation of patient with CHF monitoring of patient with CHF important lines of management
  3. 3. Important message• Clinical presentation of disease• NOT a diagnosis
  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 diastole• Affected by compliance – Low compliance = higher LVEDP @ lower LVEDV
  6. 6. Afterload• Def: Force opposing/stretching muscle after contraction begins• Measurement: SVR
  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. Predisposing Cardiac Diseases• Myocardial infarction• Chronic ischemia• Cardiomyopathy• Arrhythmias• Diastolic dysfunction• Valvular diseases – AS , AI – MR
  9. 9. Precipitating Factors• Infection • Sodium Intake• Pulm Embolus • Medications!!!• Noncompliance • Anemia• Arrhythmia • Thyroid disorders• Myocardial Infarction • Endocarditis• Stress reaction
  10. 10. Classifying Heart Failure• Anatomically – Left versus Right• Physiologically – Systolic versus Diastolic• Functionally – How symptomatic is your patient?
  11. 11. Left versus Right FailureLeft Heart Failure Right Heart Failure - Dyspnea - Dec. exercise - Dec. exercise tolerance tolerance - Edema - Cough - HJR / JVD - Orthopnea - Hepatomegaly - Pink, frothy sputum - Ascites
  12. 12. Systolic versus Diastolic• Systolic– “can’t pump” • Diastolic- “can’t fill” – Aortic Stenosis – Hypertrophy – HTN – Infiltration – Aortic Insufficiency – Fibrosis – Mitral Regurgitation – Muscle Loss • Ischemia • Fibrosis • Infiltration
  13. 13. Clinical Data• CXR – Kerley’s lines : A and B – Pulmonary Edema – Pleural Effusions (bilateral)• EKG – Left atrial enlargement – Arrhythmias – Hypertrophy (left or right)
  14. 14. Cardiomyopathy Pulmonary Edema
  15. 15. Clinical Data• HEART SOUNDS!!!• Systolic Murmurs – Mitral Regurg – Aortic Stenosis• Diastolic Murmurs – Aortic Insufficiency• S3: Rapid filling of a diseased ventricle
  16. 16. 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
  17. 17. Treatment of CHF• Treat Precipitating Factor(s)!!!!• Adjust Heart Rate• Decrease Preload• Decrease Afterload• Increase Contractility• Increase Oxygenation
  18. 18. Treatment of CHF• Oxygen – nasal, BiPAP, intubation• Morphine• Preload Reduction – Loop diuretics – Nitrates – ACEi / ARB – Morphine
  19. 19. Treatment of CHF• Afterload Reduction – IV NTG, Nitroprusside – Hydralazine – ACEi / ARB• Ionotropic Support – Dopamine / Dobutamine – Amrinone / Milrinone – Digoxin (chronic) – Mechanical (ABP)
  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 81mg PO daily
  21. 21. Treatment of CHF• Beta-Blockers – Chronic > Acute – Carvedilol , Metoprolol , Bisoprolol• Fluid Balance – Restrict fluid / salt intake – Monitor I/Os and daily weight – Dialysis if needed• Aspirin
  22. 22. • Nitroglycerin – IV:10-200 mcg/min• 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• Hydralazine 10-100mg PO q6-8 h
  23. 23. • 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
  24. 24. • Dobutamine 500mg in 250cc D5W – 3-10 mcg/kg/min• Digoxin – Titrate to effective dose prior to discharge – Not in renal faliure• IABP – Cardiogenic shock unresponsive to above tx• Dialysis – Critical renal failure patients
  25. 25. Questions

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