The document discusses congestive heart failure by describing the clinical presentation, underlying cardiac diseases that can cause it, how cardiac physiology relates to concepts like preload, afterload and contractility, classifications of heart failure, clinical exam findings, treatment approaches focusing on reducing preload and afterload and increasing contractility, and sample admission orders for an inpatient with heart failure.

1. Congestive Heart Failure
Jarrod Eddy, PGY2
Internal Medicine
Sub-I Lecture Series

3. Congestive Heart Failure
• Clinical presentation of disease
• NOT a diagnosis in and of itself
• Differential includes
– Underlying cardiovascular disease
– Precipitating factors

4. Predisposing Cardiac Diseases
• Myocardial infarction
• Chronic ischemia
• Cardiomyopathy
• Arrhythmias
• Diastolic dysfunction
• Valvular diseases
– Aortic Stenosis
– Mitral Stenosis
– Mitral Regurgitation

5. Cardiac Physiology
(remember this?)
• CO = SV x HR
• HR: parasympathetic and sympathetic tone
• SV: preload, afterload, contractility

6. 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?

7. Afterload
• Def: Force opposing/stretching muscle
after contraction begins
• Measurement: SVR
• Really a function of:
– SVR
– Chamber radius (dilated cardiomyopathies)
– Wall thickness (hypertrophy)

8. 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

9. Classifying Heart Failure
• Anatomically
– Left versus Right
• Physiologically
– Systolic versus Diastolic
• Functionally
– How symptomatic is your patient?

10. 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

11. 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

12. Clinical Data
• CXR
– Kerley’s lines : A and B
– Pulmonary Edema
– Cephalization
– Pleural Effusions (bilateral)
• EKG
– Left atrial enlargement
– Arrhythmias
– Hypertrophy (left or right)

13. Cardiomyopathy Pulmonary Edema

14. Clinical Data
• HEART SOUNDS!!!
• Systolic Murmurs
– Mitral Regurg
– Aortic Stenosis
• Diastolic Murmurs
– Mitral Stenosis
– Aortic Insufficiency
• S3: Rapid filling of a diseased ventricle

15. 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

16. Treatment of CHF
• Treat Precipitating Factor(s)!!!!
• Adjust Heart Rate
• Decrease Preload
• Decrease Afterload
• Increase Contractility
• Increase Oxygenation

18. Treatment of CHF
• Oxygen – nasal, BiPAP, intubation
• Morphine
• Preload Reduction
– Loop diuretics
– Nitrates
– ACEi / ARB
– Morphine

19. Treatment of CHF
• Afterload Reduction
– IV NTG, Nitroprusside
– Hydralazine
– ACEi / ARB
• Ionotropic Support
– Dopamine / Dobutamine
– Amrinone / Milrinone
– Digoxin (chronic)
– Mechanical (ABP)

21. 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

22. Precipitating Factors
• Infection • Sodium Intake
• Pulm Embolus • Medications!!!
• Noncompliance • Anemia
• Arrhythmia • Thyroid disorders
• Myocardial Infarction • Endocarditis
• Stress reaction

23. 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

24. 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

25. 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

26. 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