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Congestive Heart Failure

Explore the clinical presentation and underlying cardiovascular diseases of congestive heart failure. Learn the physiological aspects including preload, afterload, and contractility. Understand how to classify heart failure and its treatment options. Includes detailed information on left and right heart failure, diagnostic data, and treatment strategies.

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Congestive Heart Failure

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

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

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

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

  5. 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?

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

  7. 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

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

  9. Left Heart Failure - Dyspnea - Dec. exercise tolerance - Cough - Orthopnea - Pink, frothy sputum Right Heart Failure - Dec. exercise tolerance - Edema - HJR / JVD - Hepatomegaly - Ascites Left versus Right Failure

  10. 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 Systolic versus Diastolic

  11. no distress at rest, except for feeling uncomfortable when lying flat for more than a few minutes Decreased pulse pressure cool peripheral extremities and cyanosis of the lips and nail beds Increased jugular venous pressure Rales Hepatomegaly Peripheral edema Physical Exam

  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. Pulmonary Edema Cardiomyopathy

  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

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

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

  19. 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

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

  21. 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

  22. 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

  23. 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

  24. 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

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