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Congestive Heart Failure

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by

Ajay Dharod

on 30 May 2015

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Transcript of Congestive Heart Failure

Clinical Features
Symptoms
General Characteristics
Congestive Heart Failure
Ajay Dharod
Diagnosis
Treatment
Systolic Dysfunction
Acute Decompensated
Heart Failure

Acute Dyspnea associated with elevated left-sided filling pressures, with or without pulmonary edema

Flash pulmonary edema refers to a severe form of heart failure with rapid accumulation of fluid in the lungs.

DDx: pulmonary embolism, asthma, and pneumonia, all of which can cause rapid respiratory distress

Hospital Admission is indicated. Dietary sodium restriction. daily weights.

Oxygenation and ventilatory assistance with non-rebreather face mask, NPPV, or even intubation as indicated

Diuretics to treat volume overload and congestive symptoms (most important intervention).
Decreases preload.

Nitrates (IV Nitroglycerin vasodilator) in patients without hypotension.
Decreases afterload.

Patients who have pulmonary edema despite use of oxygen, diuretics, and nitrates may benefit from use of inotropic agents (dobutamine).

Digoxin not indicated in acute setting b/c takes several weeks to work.
Pathophysiology
High-Output Heart Failure
Systolic Dysfunction
Diastolic Dysfunction
Decreased CO
Activation of Renin-Angiotensin-Aldosterone system causes Volume Retention
Normally, increased venous return (increased preload) maintains cardiac output
In CHF, increased preload does not result in increased cardiac output
Elevated LVEDV, Elevated LVEDP = PULMONARY CONGESTION
References
Impaired Contractility
Causes of Systolic Dysfunction
EF = SV/EDV = (EDV-ESV)/EDV
In high output HF, an increase in CO is required for the peripheral tissues to appropriately oxygenate.

In the presence of underlying heart disease... chronic anemia, pregnancy, hyperthyroidism, AV fistulas, wet beriberi (thiamine deficiency), paget's disease, mitral regurgitation & aortic insufficiency can result in heart failure very quickly.
Impaired ventricular relaxation and/or increased ventricular stiffness.
I: impaired relaxation, II: moderate diastolic dysfunction (pseudonormal), III: restrictive left ventricular filling (impaired LV compliance)
Mitral inflow
Mitral Annular Velocities
Pulmonary Venous Flow
Velocity of Flow Progression
Causes include...
Most common cause of diastolic dysfunction
Dyspnea
Orthopnea
PND
Nocturnal Cough
Confusion & Memory Impairment
Diaphoresis & Cool Extremities
Signs
rapid filling phase into non-compliant LV
s3 is extremely specific sign of CHF
heard best at apex with bell
atrial systole into noncompliant LV
heard best at left sternal border with bell
crackles = pulmonary edema
Right Heart Failure
nocturia
RV heave
What tests do you want to order for a new patient with CHF? Answer...
CXR (pulmonary edema, cardiomegaly, r/o COPD)
ECG
Cardiac Enzymes (r/o MI)
CBC (anemia)
Echocardiogram (estimate EF, r/o pericardial effusion)
What value of BNP correlates strongly with the presence of decompensated CHF and what other cause of dyspnea does a BNP help differentiate? Answer...
BNP >100
COPD
CXR Findings
Prominent Interstitial Markings
Pleural Effusions
TTE is the initial test of choice
Also determines systolic vs. diastolic dysfunction
Or is the cause of CHF pericardial, myocardial or valvular?
Estimates EF <40 or >40
Shows chamber dilation and/or hypertrophy.
Lets start with something interesting....
EKG is nonspecific
but can be useful for detecting chamber enlargement....
Radionuclide "Nuclear" Ventriculography
RBCs tagged with radioisotope are imaged during exercise & rest.
Provides a PRECISE measurement of the left and right ventricular EF (and can assess wall motion in ischemic heart disease).
Useful when ECHO is suboptimal (severe pulmonary disease, Obesity)
Not often used anymore
Coronary Angiography
Mostly useful to exclude CAD as underlying cause of CHF, but can provide LV function.
Stress Testing
Identifies ischemia and/or infarction
Quantitates level of conditioning
Can differentiate cardiac versus pulmonary etiology of dyspnea.
Assess dynamic responses of HR, heart rhythm & BP.
Less than 4g/day
Weight loss
Smoking Cessation
Check Weights Daily
Lifestyle Modifications
Diuretics are the most effective means of
symptomatic relief (dyspnea, peripheral edema)
to patients with moderate to severe CHF, although they
have not been shown to reduce mortality or improve prognosis
.
Diuretics
Spironolactone (aldosterone antagonist)
What makes a patient NYHA class III or IV? Answer...
Class III: symptoms occur with usual ADLs, such as walking across the room or getting dressed. Markedly limiting.
Class IV: Symptoms occur at rest, incapacitating.
What did the RALES trial show? Answer...
What is the standard treatment of CHF? Answer...
Spironolactone reduces morbidity and mortality in patients with class III or class IV heart failure.

Notably, the drug is contraindicated in renal failure.
Standard: A loop diuretic, ACEi, Beta-blocker

Depending on patient severity & symptoms: Digoxin, Hydralazine/Nitrate, Spironolactone
What is the most common cause of death in CHF? Answer....
The COMET trial determined _________ increased survival compared with ________ in patients receiving treatment for CHF? Answer...
Carvedilol > Metoprolol
Ventricular Arrhythmias

Note that ischemia provokes ventricular arrhythmias
Proven effective to
prolong survival in pts w/ NYHA Class III or IV CHF.
Must monitor potassium and GFR.
Eplerenone is another option if pts develop gynecomastia with spironolactone
ACE inhibitors/ARBs
Cause venous and arterial dilation
Decrease preload and afterload!!
Indicated for LV systolic function (EF<40%)
CONSENSUS & SOLVD
trials demonstrate reduced mortality prolonged survival and alleviation of symptoms.
Monitor BP, K+, and BUN/Cr.
Combination of ACEi and Diuretic is almost always the initial treatment in most symptomatic CHF patients.
Medications
ARBs only used if patient does not tolerate ACEi 2/2 side effect.
Beta blockers
Proven to
decrease mortality in patients with post-MI heart failure.
Slows tissue remodeling
Decreased in HR leads to decreased O2 consumption
Antiarrhythmic effect (AV & SA) node
Only
start in stable patients
with CHF.
Evidence only supports use of Bisoprolol, Carvedilol, and Metoprolol,
Digitalis
Hydralazine and Isosorbide Dinitrate
*Positive Inotrope
*Use in EF<40% with symptoms despite optimal therapy
*Severe CHF, severe atrial fibrillation
*Will control symptoms and decrease hospitalizations
*Eoes NOT decrease mortality
Often used in patients who do not tolerate ACE inhibitors
Also has been shown to improve mortality (approx 40%) in black patients with severe heart failure (NYHA Class III and IV) in addition to standard therapy
What medications are proven to lower mortality in CHF? Answer...
ACEi/ARBs
BB
Spironolactone
Hydralazine + Nitrate
What are signs of digoxin toxicity? Answer...
GI: Nausea/vomiting, anorexia
Cardiac: Ectopic (ventricular) beats, Bradycardia, AV block
CNS: visual disturbances, disorientation
Which CCBs are safe for use in the treatment of CHF in patients with CHF? Answer...
Amlodipine
Felodipine
Contraindicated Meds
Metformin may cause lethal lactic acidosis
NSAIDs increase the risk of CHF exacerbations
Thiazolidinediones cause fluid retention
Meds with negative inotropic effects (some anti-arrhythmics)
Devices
Diastolic Dysfunction
ICD (implantable cardioverter defibrillator) and CRT (cardiac resynchronization therapy)
ICDs reduce mortality by preventing Sudden Cardiac Death from primarily ventricular arrhythmia.
Indicated for patients at least 40 days post-MI, EF<35%, and class II or class III symptoms despite optimal medical therapy
ICD =Shocks
CRT = Pacemaker
CRT indications are similar to ICD, except must also have prolonged QRS >120ms.
Ventricular Assist Device (VAD)
Most products on market represent research technology over past 5 decades. But they're still new...
VADs can support left heart (LVAD), right heart (RVAD) or both ventricles (BiVAD).
Pump is in abdominal cavity.
Initially VADs were a bridge to transplant, but now being used as "destination therapy"
Devices are very thrombogenic. Patients require
lifelong anticoagulation without exceptions.
May also be used for hemodynamic support related to acute cardiogenic shock (STEMI or myocarditis).
Fewer therapeutic options, patients are treated symptomatically
Beta-Blockers have a clear benefit, definitely use them.
Diuretics
are used for symptom control similar to systolic dysfunction

ACEi/ARBs do not show a clear benefit

Do not use Digoxin or Spironolactone
Mild CHF (NYHA Class I to II)
Sodium restriction, Physical Activity, Loop Diuretic, ACEi
Mild to Moderate CHF (NYHA Class II to III)
Add a Beta-Blocker.
Moderate to Severe CHF (NYHA Class III to IV)
Add Spironolactone
Add Digoxin to improve symptoms
So...
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