Project: Ghana Emergency Medicine Collaborative
Document Title: Acute Congestive Heart Failure
Author(s): Rashmi U. Kothar...
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68	
  y.o.	
  Female	
  with	
  Severe	
  Shortness	
  of	
  
Breath	
  
P=130	
  RR=32	
  BP=220/120	
  P.Oxm=86%è90%	
 ...
68	
  y.o.	
  Female	
  with	
  Severe	
  Shortness	
  
of	
  Breath	
  
•  History	
  
–  Onset	
  (gradual	
  or	
  sudd...
68	
  y.o.	
  Female	
  with	
  Severe	
  Shortness	
  
of	
  Breath	
  
•  Physical	
  Exam	
  
–  VS:	
  (T/RR/HR/BP/Pul...
68	
  y.o.	
  Female	
  with	
  Severe	
  Shortness	
  
of	
  Breath	
  
•  HPI:	
  3-­‐4	
  days,	
  cough,	
  ééworse	...
Goal	
  
•  Review	
  pathophysiology	
  
•  Evaluate	
  diagnosEc	
  findings	
  
–  H&P,	
  CXR,	
  BNP,	
  U/S	
  

•  E...
Acute	
  CongesEve	
  Heart	
  Failure
(CHF)	
  
•  DefiniEon	
  

8	
  
Diagnosis	
  
• 
• 
• 
• 

History	
  &	
  Physical	
  Exam	
  
Chest	
  X-­‐ray	
  
Laboratory	
  tests	
  
Ultrasound	
 ...
Diagnosing	
  CHF	
  

• 
• 
• 
• 
• 

Increased	
  Likelihood	
  
	
  
Hx	
  CHF	
   	
  LR=5.8	
  
PND 	
  	
   	
  LR=2...
Wapcaplet, Wikimedia Commons

Myocardial	
  stretch/stress	
  

Pro-­‐BNP	
  

A. Mukkamala

NT-­‐pro-­‐BNP	
  

BNP	
  
A...
BNP	
  and	
  NT	
  pro-­‐BNP	
  
AGE	
  
Rule	
  out	
  
Sens/Spec	
  

All	
  	
  
<100	
  
90%/74%	
  

BNP	
  	
  	
  ...
Impact	
  of	
  High	
  &	
  Low	
  BNP	
  on	
  Pre-­‐
Test	
  ProbabiliEes	
  
Pre-­‐test	
  
Probability	
  

Post-­‐te...
Causes	
  of	
  Elevated	
  BNP	
  
• 
• 
• 
• 

Acute	
  CHF	
  
Renal	
  Failure	
  
Sepsis	
  
Pulmonary	
  Embolism	
 ...
BNP	
  Decreases	
  LOS	
  &	
  Cost	
  
6.3	
  hrs	
  

$6,129	
  

5.8	
  hrs	
  

P=0.031	
  
Reference:	
  Mueller	
  ...
Summary	
  of	
  BNP	
  
•  Combining	
  clinical	
  judgment	
  &	
  BNP	
  
	
  may	
  improve	
  accuracy	
  of	
  diag...
Diagnosing	
  CHF	
  by	
  Ultrasound	
  
•  Extravascular	
  lung	
  fluid	
  
–  Look	
  for	
  “comet	
  tails”	
  

•  ...
Ultrasound	
  B-­‐lines	
  (Lung	
  Rockets)	
  in	
  
CHF	
  
•  Pros:	
  
–  Easy	
  windows	
  
–  80-­‐90%	
  sensiEvi...
Lung	
  Ultrasound	
  for	
  
B-­‐Lines	
  (Lung	
  Rockets)	
  

•  Use	
  a	
  3-­‐5	
  MHz	
  Probe	
  
•  PosiEon	
  1...
Measuring	
  IVC	
  by	
  Ultrasound	
  in	
  AHF	
  
•  Pros:	
  
–  Rapid	
  
–  69%PPV	
  &	
  91%	
  NPV	
  
–  Accura...
Management	
  of	
  Acute	
  CHF	
  
•  Oxygen	
  
•  DiureEcs	
  
•  Nitroglycerin	
  
•  Morphine	
  

21	
  
CPAP/BiPAP	
  Decreases	
  Mortality	
  &	
  
IntubaEon	
  
45%	
  	
  mortality*	
  
25%	
  

IntubaCon*	
  

35%	
  
0....
CPAP	
  &	
  BiPAP	
  Equivalent	
  
CPAP	
  =	
  Bipap	
  
•  Mortality	
  	
  
•  IntubaEon	
  rates	
  
•  AMI	
  

Mor...
ED	
  Study	
  of	
  NIPPV	
  vs.	
  Standard	
  Medical	
  
Care	
  (SMC)	
  
•  1069	
  ED	
  
•  Randomized	
  for	
  2...
No	
  Difference	
  NIPPV	
  vs.	
  SMC	
  
•  No	
  Difference	
  
–  Mortality	
  
–  IntubaEon	
  rates	
  
	
  

•  NIPP...
Why	
  Discrepancy	
  Between	
  Studies?	
  
Study	
  

Mortality	
  	
  

IntubaCon	
  
Rate	
  

Gray	
  et	
  al.	
  N...
Reason	
  for	
  Discrepancy	
  
Change	
  in	
  Treatment	
  

Standard	
  Oxygen	
  
(N=367)	
  

IntubaEon	
  
CPAP	
  ...
Summary	
  of	
  NIPPV	
  
•  Most	
  likely:	
  
–  Decreases	
  mortality	
  
–  Decreases	
  intubaEon	
  rate	
  
–  D...
68	
  y.o.	
  Female	
  in	
  Severe	
  CHF.	
  Home	
  
Meds	
  80	
  mg	
  Lasix	
  
•  How	
  much	
  IV	
  Lasix	
  sh...
Decreased	
  EffecEveness	
  of	
  Loop	
  
DiureEcs	
  in	
  CHF	
  
•  Delayed	
  onset	
  of	
  acEon	
  
–  15-­‐30	
  ...
Cardiac	
  Effects	
  of	
  Lasix	
  
Physiological	
  Effect	
  
•  Venous	
  dilataEon	
  
–  Healthy	
  subjects	
  
–  M...
Worsening	
  CreaEnine	
  and	
  Acute	
  
CongesEve	
  Heart	
  Failure	
  

	
  

•  Occurs	
  in	
  72%	
  of	
  paEent...
Increased	
  Mortality	
  Associated	
  with	
  
Worsening	
  CreaEnine	
  
RelaCve	
  Risk	
  of	
  Death	
  

3	
  

2.9...
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GEMC- Acute Congestive Heart Failure- for Residents

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This is a lecture by Rashmi U. Kothari from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- Acute Congestive Heart Failure- for Residents

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Acute Congestive Heart Failure Author(s): Rashmi U. Kothari (Michigan State University), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. 2  
  3. 3. 68  y.o.  Female  with  Severe  Shortness  of   Breath   P=130  RR=32  BP=220/120  P.Oxm=86%è90%       DifferenEal  Diagnosis   •  •  •  •  •  •  PE   CHF/Pulmonary  edema   Pneumonia   COPD   Pneumothorax   Pericardial  effusion   3  
  4. 4. 68  y.o.  Female  with  Severe  Shortness   of  Breath   •  History   –  Onset  (gradual  or  sudden)   –  Cough,  fever,  unilateral  leg  swelling   –  Orthopnea,  PND,  DOE,  Swelling   –  PMH:  CAD,  CHF,  PE/DVT,  ESRD   –  Same  it  past?   4  
  5. 5. 68  y.o.  Female  with  Severe  Shortness   of  Breath   •  Physical  Exam   –  VS:  (T/RR/HR/BP/Pulse  Oxm)   –  Neck:  JVD   –  Chest:  ê  BS,  rales,  wheezing,  rhonchi   –  Heart:  Afib,  bradycardia,  distant  HS,  S3   –  ExtremiEes:  edema,  unilateral  swelling,  cord,   tenderness   5  
  6. 6. 68  y.o.  Female  with  Severe  Shortness   of  Breath   •  HPI:  3-­‐4  days,  cough,  ééworse  this  am   •  PMH:  COPD,  CHF,  CAD,  &  HTN   •  PE:  Obese,  severe  resp.  distress   –  T=36.6  P=130  RR=32  BP=220/120  NRB=89-­‐91%   •  Chest:  ê  BS,  ?rales,  ?wheezing   •  Cardiac:  RRR  no  Murmur   •  ExtremiEes:  2+  bilateral  edema     6  
  7. 7. Goal   •  Review  pathophysiology   •  Evaluate  diagnosEc  findings   –  H&P,  CXR,  BNP,  U/S   •  Evaluate  medical  management     –  Oxygen  delivery,  nitroglycerin,  lasix,  morphine   7  
  8. 8. Acute  CongesEve  Heart  Failure (CHF)   •  DefiniEon   8  
  9. 9. Diagnosis   •  •  •  •  History  &  Physical  Exam   Chest  X-­‐ray   Laboratory  tests   Ultrasound   9  
  10. 10. Diagnosing  CHF   •  •  •  •  •  Increased  Likelihood     Hx  CHF    LR=5.8   PND      LR=2.6   S3        LR=11   +  CXR        LR=12   Afib        LR=3.8   •  •  •  •  •    Decreased  Likelihood     No  hx  CHF    LR=.45   No  DOE            LR=.48   No  rales      LR=.51   -­‐Cardiomegaly    LR=.51   EKG  WNL            LR=.64   Wang  et  al.  JAMA  2005   10  
  11. 11. Wapcaplet, Wikimedia Commons Myocardial  stretch/stress   Pro-­‐BNP   A. Mukkamala NT-­‐pro-­‐BNP   BNP   A. Mukkamala 11   BotanyBRA, Wikimedia Commons
  12. 12. BNP  and  NT  pro-­‐BNP   AGE   Rule  out   Sens/Spec   All     <100   90%/74%   BNP                      NT  pro-­‐BNP   <50   50-­‐70   >70   <300   <300     <1200   99%/85%   99%/85%   97%/55%   Rule  in   Sens/Spec   >400   81%/90%   >450   93%/95%   References:     Korenstein  BM  Emerg  Med  2007   Jannuzi  et  al  Am  J  Card  2005   Berdague  et  al.,  Am  Heart  J     >900   91%/80%   >4500   64%/86%   12  
  13. 13. Impact  of  High  &  Low  BNP  on  Pre-­‐ Test  ProbabiliEes   Pre-­‐test   Probability   Post-­‐test  Probability     for  BNP<105  pg/ml   Post-­‐test  Probability     for    BNP  >300  pg/ml   10%   30%   50%   70%     90%   2%   5%   12%   25%     56%   46%   77%   88%   95%   99%   Reference:  Korenstein  Et.  al.,BM  Emerg  Med  2007   13  
  14. 14. Causes  of  Elevated  BNP   •  •  •  •  Acute  CHF   Renal  Failure   Sepsis   Pulmonary  Embolism   14  
  15. 15. BNP  Decreases  LOS  &  Cost   6.3  hrs   $6,129   5.8  hrs   P=0.031   Reference:  Mueller  et.al.,    NEJM   P=0.023   Reference:  Moe  et.  al.,  Circ  2007   15  
  16. 16. Summary  of  BNP   •  Combining  clinical  judgment  &  BNP    may  improve  accuracy  of  diagnosis       •  Most  helpful  when  diagnosis  unclear  (e.g.   COPD)   •  Can  be  elevated  in  ARF,  sepsis  or  PE   16  
  17. 17. Diagnosing  CHF  by  Ultrasound   •  Extravascular  lung  fluid   –  Look  for  “comet  tails”   •  Elevated  Rt  heart  filling  pressures   –  Examine  IVC  within  2  cm  of  Rt  atrium   17  
  18. 18. Ultrasound  B-­‐lines  (Lung  Rockets)  in   CHF   •  Pros:   –  Easy  windows   –  80-­‐90%  sensiEvity  &  specificity   •  Cons:   –  Takes  2-­‐5  minutes   –  Limited  data  from  ED     18  
  19. 19. Lung  Ultrasound  for   B-­‐Lines  (Lung  Rockets)   •  Use  a  3-­‐5  MHz  Probe   •  PosiEon  1:  anterior  chest  view   •  PosiEon  2:  lateral  chest  views     Drickey, Wikimedia Commons 19  
  20. 20. Measuring  IVC  by  Ultrasound  in  AHF   •  Pros:   –  Rapid   –  69%PPV  &  91%  NPV   –  Accuracy  83%  for  é  Atrial  Pressures   •  Cons:   –  CorrelaEon  é  Atrial  Pressures  to  AHF   –  Technically  challenging   Reference:  Blair  JE,  et  al:  Am  J  Card  2009   20  
  21. 21. Management  of  Acute  CHF   •  Oxygen   •  DiureEcs   •  Nitroglycerin   •  Morphine   21  
  22. 22. CPAP/BiPAP  Decreases  Mortality  &   IntubaEon   45%    mortality*   25%   IntubaCon*   35%   0.2   20%   0.31   30%   25%   15%   20%   0.11   0.18   15%   10%   10%   5%   5%   0%   0%   NIPVV   *p<0.001   42%   Standard   Reference:  Masip  et  al.  JAMA  2005   NIPVV   Standard   Reference:  Masip  et  al.  JAMA  2006   22  
  23. 23. CPAP  &  BiPAP  Equivalent   CPAP  =  Bipap   •  Mortality     •  IntubaEon  rates   •  AMI   Mortality   CPAP   BiPAP   6%   7%   Reference:  Masip  et  al.  JAMA  2005   23  
  24. 24. ED  Study  of  NIPPV  vs.  Standard  Medical   Care  (SMC)   •  1069  ED   •  Randomized  for  2  hrs  of  treatment   –  CPAP   –  BiPAP   –  Oxygen  by  NC  or  FM   Gray  et  al.  NEJM  2008   24  
  25. 25. No  Difference  NIPPV  vs.  SMC   •  No  Difference   –  Mortality   –  IntubaEon  rates     •  NIPPV  beser   –  ê  Respiratory   distress   –  ê  Metabolic   disturbances   12%   0.095   NIPPV   Standard   0.098   10%   8%   6%   4%   0.029   0.028   2%   0%   Moratlity   IntubaEon   Reference:  Gray  et  al.  NEJM  2008   25  
  26. 26. Why  Discrepancy  Between  Studies?   Study   Mortality     IntubaCon   Rate   Gray  et  al.  NEJM   16.5%???   2.8%   Masip  et  al  JAMA   20%   31%   Cochrane     20%   30%   26  
  27. 27. Reason  for  Discrepancy   Change  in  Treatment   Standard  Oxygen   (N=367)   IntubaEon   CPAP   NIPPV   Standard  treatment   Type  treatment  not  noted   3   43   13   -­‐-­‐-­‐   6   65/367  (18%)  PaCents  Crossed  Over  in   Standard  Treatment  Group   27  
  28. 28. Summary  of  NIPPV   •  Most  likely:   –  Decreases  mortality   –  Decreases  intubaEon  rate   –  Decreases  respiratory  distress   •  Use  in  PaEents  with:   –  Significant  respiratory  distress   –  O2  SaturaEon  <90%   28  
  29. 29. 68  y.o.  Female  in  Severe  CHF.  Home   Meds  80  mg  Lasix   •  How  much  IV  Lasix  should  you  give   her?   –  None   –  40  mg   –  80  mg   –  160  mg   29  
  30. 30. Decreased  EffecEveness  of  Loop   DiureEcs  in  CHF   •  Delayed  onset  of  acEon   –  15-­‐30  minutes  normal  paEents   –  45-­‐120  minutes  in  CHF       •  Drug  resistance  in  chronic  users     30  
  31. 31. Cardiac  Effects  of  Lasix   Physiological  Effect   •  Venous  dilataEon   –  Healthy  subjects   –  Maximized  @  20  mg   •  Arterial  constricEon   –  CHF  paEents   –  Predominates  early   PVR   é   SVR   é   MAP   é   HR   é   RtAFP   é   SV??   ê   Catecholamines   é   31  
  32. 32. Worsening  CreaEnine  and  Acute   CongesEve  Heart  Failure     •  Occurs  in  72%  of  paEents  with  CHF   •  Increased  mortality   •  é LOS   32  
  33. 33. Increased  Mortality  Associated  with   Worsening  CreaEnine   RelaCve  Risk  of  Death   3   2.9   2.5   2   1.91   1.67   1.5   1   1.19   0.89   0.5   0   >0.1   >0.2   >0.3   >0.4   >0.5   CreaCnine  ElevaCon     Reference:  GoJlieb  et  al.  J  Card  Fail  2002   33  

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