congestive heart failure
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Congestive Heart FailureCongestive Heart Failure
Jarrod Eddy, PGY2Internal MedicineSub-I Lecture Series
Jarrod Eddy, PGY2Internal MedicineSub-I Lecture Series
Congestive Heart FailureCongestive Heart Failure
• Clinical presentation of disease• NOT a diagnosis in and of itself• Differential includes
– Underlying cardiovascular disease– Precipitating factors
• Clinical presentation of disease• NOT a diagnosis in and of itself• Differential includes
– Underlying cardiovascular disease– Precipitating factors
Predisposing Cardiac Diseases
Predisposing Cardiac Diseases
• Myocardial infarction• Chronic ischemia• Cardiomyopathy• Arrhythmias• Diastolic dysfunction• Valvular diseases
– Aortic Stenosis– Mitral Stenosis– Mitral Regurgitation
• Myocardial infarction• Chronic ischemia• Cardiomyopathy• Arrhythmias• Diastolic dysfunction• Valvular diseases
– Aortic Stenosis– Mitral Stenosis– Mitral Regurgitation
Cardiac Physiology(remember this?)
Cardiac Physiology(remember this?)
• CO = SV x HR
• HR: parasympathetic and sympathetic tone
• SV: preload, afterload, contractility
• CO = SV x HR
• HR: parasympathetic and sympathetic tone
• SV: preload, afterload, contractility
PreloadPreload
• 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?
• 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?
AfterloadAfterload
• Def: Force opposing/stretching muscle after contraction begins
• Measurement: SVR• Really a function of:
– SVR– Chamber radius (dilated
cardiomyopathies)– Wall thickness (hypertrophy)
• Def: Force opposing/stretching muscle after contraction begins
• Measurement: SVR• Really a function of:
– SVR– Chamber radius (dilated
cardiomyopathies)– Wall thickness (hypertrophy)
ContractilityContractility
• 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
• 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
Classifying Heart FailureClassifying Heart Failure
• Anatomically– Left versus Right
• Physiologically– Systolic versus Diastolic
• Functionally– How symptomatic is your patient?
• Anatomically– Left versus Right
• Physiologically– Systolic versus Diastolic
• Functionally– How symptomatic is your patient?
Left versus Right FailureLeft versus Right Failure
Left Heart Failure- Dyspnea- Dec. exercise tolerance- Cough- Orthopnea- Pink, frothy sputum
Left Heart Failure- Dyspnea- Dec. exercise tolerance- Cough- Orthopnea- Pink, frothy sputum
Right Heart Failure- Dec. exercise tolerance- Edema- HJR / JVD- Hepatomegaly- Ascites
Right Heart Failure- Dec. exercise tolerance- Edema- HJR / JVD- Hepatomegaly- Ascites
Systolic versus DiastolicSystolic versus Diastolic
• Systolic– “can’t pump”– Aortic Stenosis– HTN– Aortic Insufficiency– Mitral Regurgitation– Muscle Loss
• Ischemia• Fibrosis• Infiltration
• Systolic– “can’t pump”– Aortic Stenosis– HTN– Aortic Insufficiency– Mitral Regurgitation– Muscle Loss
• Ischemia• Fibrosis• Infiltration
• Diastolic- “can’t fill”– Mitral Stenosis– Tamponade– Hypertrophy– Infiltration– Fibrosis
• Diastolic- “can’t fill”– Mitral Stenosis– Tamponade– Hypertrophy– Infiltration– Fibrosis
Clinical DataClinical Data
• CXR– Kerley’s lines : A and B– Pulmonary Edema– Cephalization– Pleural Effusions (bilateral)
• EKG– Left atrial enlargement– Arrhythmias– Hypertrophy (left or right)
• CXR– Kerley’s lines : A and B– Pulmonary Edema– Cephalization– Pleural Effusions (bilateral)
• EKG– Left atrial enlargement– Arrhythmias– Hypertrophy (left or right)
CardiomyopathyCardiomyopathy Pulmonary EdemaPulmonary Edema
Clinical DataClinical Data
• HEART SOUNDS!!!• Systolic Murmurs
– Mitral Regurg– Aortic Stenosis
• Diastolic Murmurs– Mitral Stenosis– Aortic Insufficiency
• S3: Rapid filling of a diseased ventricle
• HEART SOUNDS!!!• Systolic Murmurs
– Mitral Regurg– Aortic Stenosis
• Diastolic Murmurs– Mitral Stenosis– Aortic Insufficiency
• S3: Rapid filling of a diseased ventricle
Clinical DataClinical 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
• 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
Treatment of CHFTreatment of CHF
• Treat Precipitating Factor(s)!!!!
• Adjust Heart Rate• Decrease Preload• Decrease Afterload• Increase Contractility• Increase Oxygenation
• Treat Precipitating Factor(s)!!!!
• Adjust Heart Rate• Decrease Preload• Decrease Afterload• Increase Contractility• Increase Oxygenation
Treatment of CHFTreatment of CHF
• Oxygen – nasal, BiPAP, intubation• Morphine• Preload Reduction
– Loop diuretics– Nitrates– ACEi / ARB– Morphine
• Oxygen – nasal, BiPAP, intubation• Morphine• Preload Reduction
– Loop diuretics– Nitrates– ACEi / ARB– Morphine
Treatment of CHFTreatment of CHF
• Afterload Reduction– IV NTG, Nitroprusside– Hydralazine– ACEi / ARB
• Ionotropic Support– Dopamine / Dobutamine– Amrinone / Milrinone– Digoxin (chronic)– Mechanical (ABP)
• Afterload Reduction– IV NTG, Nitroprusside– Hydralazine– ACEi / ARB
• Ionotropic Support– Dopamine / Dobutamine– Amrinone / Milrinone– Digoxin (chronic)– Mechanical (ABP)
Treatment of CHFTreatment 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
• 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
Precipitating FactorsPrecipitating Factors
• Infection• Pulm Embolus• Noncompliance• Arrhythmia• Myocardial
Infarction• Stress reaction
• Infection• Pulm Embolus• Noncompliance• Arrhythmia• Myocardial
Infarction• Stress reaction
• Sodium Intake• Medications!!!• Anemia• Thyroid disorders• Endocarditis
• Sodium Intake• Medications!!!• Anemia• Thyroid disorders• Endocarditis
Admission OrdersAdmission 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
• 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
Admission OrdersAdmission 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
• 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
Admission OrdersAdmission 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
• 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
Admission OrdersAdmission 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
• 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