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Congestive heart failure
This document provides information on congestive heart failure (CHF), including its definition, pathophysiology, signs and symptoms, causes, precipitating factors, evaluation, monitoring, and management. CHF can be caused by conditions that weaken the heart muscle such as heart attacks or cardiomyopathy. It occurs when the heart cannot pump sufficiently due to problems with its electrical or mechanical function. Management involves treating underlying causes, reducing preload and afterload on the heart, and increasing cardiac contractility and output with medications, oxygen, and potentially devices like intra-aortic balloon pumps.
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Congestive heart failure
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- 2. Objectives definition ofCHF 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. Important message • Clinicalpresentation of disease • NOT a diagnosis
- 4. Cardiac Physiology (remember this?) • CO = SV x HR • HR: parasympathetic and sympathetic tone • SV: preload, afterload, contractility
- 5. Preload • Def: Passivestretch of muscle prior to contraction • Measurement: Swan-Ganz – LVEDP • Really a function of diastole • Affected by compliance – Low compliance = higher LVEDP @ lower LVEDV
- 6. Afterload • Def: Forceopposing/stretching muscle after contraction begins • Measurement: SVR
- 7. Contractility • Def: Normalability 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. Predisposing Cardiac Diseases • Myocardial infarction • Chronic ischemia • Cardiomyopathy • Arrhythmias • Diastolic dysfunction • Valvular diseases – AS , AI – MR
- 9. Precipitating Factors • Infection • Sodium Intake • Pulm Embolus • Medications!!! • Noncompliance • Anemia • Arrhythmia • Thyroid disorders • Myocardial Infarction • Endocarditis • Stress reaction
- 10. Classifying Heart Failure •Anatomically – Left versus Right • Physiologically – Systolic versus Diastolic • Functionally – How symptomatic is your patient?
- 11. Left versus RightFailure Left Heart Failure Right Heart Failure - Dyspnea - Dec. exercise - Dec. exercise tolerance tolerance - Edema - Cough - HJR / JVD - Orthopnea - Hepatomegaly - Pink, frothy sputum - Ascites
- 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
- 14. Clinical Data • CXR – Kerley’s lines : A and B – Pulmonary Edema – Pleural Effusions (bilateral) • EKG – Left atrial enlargement – Arrhythmias – Hypertrophy (left or right)
- 15. Cardiomyopathy Pulmonary Edema
- 16. Clinical Data • HEARTSOUNDS!!! • Systolic Murmurs – Mitral Regurg – Aortic Stenosis • Diastolic Murmurs – Aortic Insufficiency • S3: Rapid filling of a diseased ventricle
- 17. Clinical Data • LaboratoryData • Chemistry – Renal Function: Be Wary • BNP – Used in ER departments the world over – Good negative correlation – Need baseline for positivity – Pulmonary versus cardiac dyspnea
- 18. Treatment of CHF •Treat Precipitating Factor(s)!!!! • Adjust Heart Rate • Decrease Preload • Decrease Afterload • Increase Contractility • Increase Oxygenation
- 19. Treatment of CHF •Oxygen – nasal, BiPAP, intubation • Morphine • Preload Reduction – Loop diuretics – Nitrates – ACEi / ARB – Morphine
- 20. Treatment of CHF •Afterload Reduction – IV NTG, Nitroprusside – Hydralazine – ACEi / ARB • Ionotropic Support – Dopamine / Dobutamine – Amrinone / Milrinone – Digoxin (chronic) – Mechanical (ABP)
- 22. 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
- 23. 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
- 24. • 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
- 25. • 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. • Dobutamine 500mgin 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
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