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Congestive Heart Failure for the Prehospital Provider. John Burton, MD- Albany Medical Center-Albany, NY. burtonj@mail.amc.edu. 62 year old male CC: Difficulty Breathing It’s Midnight….suddenly short of breath! History: CHF, CAD, COPD Drugs: coumadin, digoxin, captopril, Inhalers
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Congestive Heart Failure for the Prehospital Provider John Burton, MD- Albany Medical Center-Albany, NY
62 year old male CC: Difficulty Breathing It’s Midnight….suddenly short of breath! History: CHF, CAD, COPD Drugs: coumadin, digoxin, captopril, Inhalers Allg: None ROS: Negative - no chest pain, etc.. Exam: RR 45, Sat 82%RA, HR 130, BP 190/100 Lungs: bilateral rales Ext: 2+ bilateral edema
Objectives • Discuss core concepts in anatomy and physiology that will enhance your overall understanding of the cardiovascular system • Discuss the pathophysiology of CONGESTIVE HEART FAILURE: what it is, what’s it about? • Discuss Congestive Heart Failure patient management for the prehospital provider
Let’s think a little bit about the Left Ventricle
Acquired or Congenital Cardiomyopathies Affecting the Left Ventricle Type of Cardiomyopathies Dilated All four chambers are dilated. The most common cause is chronic alcoholism, though some may be the end-stage of remote viral myocarditis. Single ventricle can dilate as well….as in CHF. Hypertrophic The most common form, idiopathic hypertrophic subaortic stenosis (IHSS) results from asymmetric interventricular septal hypertrophy, resulting in left ventricular outflow obstruction. High blood pressure is also a common cause.
Dilated Cardiomyopathy Hypertrophic Cardiomyopathy
Dilated Cardiomyopathy Hypertrophic Cardiomyopathy EITHER WAY…THE HEART DOES NOT FUNCTION AS WELL
The Pump: 1. A Mechanical Component 2. An Electrical Component
65% 1. A Mechanical Component 2. An Electrical Component
Filling….Pumping Problems with Filling... Problems with Pumping...
Pumping Problems with Pumping... Just how little pumping can one get away with?
Pumping Just how little pumping can one get away with? Normal - 65% No Symptoms - 40-65% Lethargy, less exercise tolerance - 30-45% Shortness of breath - 20 - 30% Incompatible with life - <15%
PREload Contractility AFTERload
Preload is a passive stretching force exerted on the ventricular muscle at the end of diastole. Preload is caused by the volume of blood in the ventricle at the end of diastole. Afterload is the force resisting the contraction of the cardiac muscle fibers. Afterload can also be considered as the blood pressure exerted on the Atrial Valve during diastole (Diastolic BP). Contractility refers to the ability of cardiac muscle fibers to shorten when stimulated (strength).
Normal - 65% No Symptoms - 40-65% Lethargy, less exercise tolerance - 30-45% Shortness of breath - 20 - 30% Incompatible with life - <15% CO = SV x HR Where: CO is cardiac output expressed in L/min (normal ~5 L/min) SV is stroke volume per beat
CO = SV x HR Both CO and SV are dependent upon Preload Afterload Contractility
What have we learned? • Cardiac Anatomy • Cardiac physiology and pathophysiology • How to think of the above using the concepts of preload, afterload, and contractility
Filling….Pumping Problems with Filling... Problems with Pumping...
DEFINITION CHF “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.” E. Braunwald
Diagnosis of CHF: • Pt with symptoms of heart failure - shortness of breath and leg swelling. • Physical exam findings for heart failure - lungs: rales, legs: edema, neck: jvd • Chest XRay findings for CHF • Findings of systolic or diastolic dysfunction: Echocardiograms: Low ejection fraction/poor contractility (hypocontractility) Maisel A. et al. J Am Coll Cardiol 2001
Who gets HEART FAILURE? • Risk factors: hypertension, hyperlipidemia, smoking, diabetes, family history of heart disease. • Patients with history of acute myocardial infarcation. • Patients with previous history or current HEART DISEASE.
What does Heart Failure do? “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.”
Venous Legs swell Neck veins distend Liver congestion Lung congestion Arterial Decreased perfusion…. Brain Kidneys Everything...