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congestive heart failure

. Congestive Heart Failure. Clinical presentation of diseaseNOT a diagnosis in and of itselfDifferential includesUnderlying cardiovascular diseasePrecipitating factors. Predisposing Cardiac Diseases. Myocardial infarctionChronic ischemiaCardiomyopathyArrhythmiasDiastolic dysfunctionValvular diseasesAortic StenosisMitral StenosisMitral Regurgitation.

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congestive heart failure

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

    11. Systolic versus Diastolic 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

    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)

    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 Pulm Embolus Noncompliance Arrhythmia Myocardial Infarction Stress reaction Sodium Intake Medications!!! Anemia Thyroid disorders Endocarditis

    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

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