CHF Flashcards
SOB( dyspnea) - essential feature of
CHF
Low ejection fraction and dilation of heart(CHF)
Systolic dysfunction
- EF is preserved ( CHF)
* heart can’t relax and pump blood
Diastolic dysfunction
Causes of systolic dysfunction
HTN=> cardiomyopathy, preservation of EF=> over time heart dilates=> syst dysf and low EF
Valvular heart disease if all types results in
CHF
MI is a very common cause of
Dilated cardiomyopathy and decreased EF
Most common cause of hospital admission in USA
CHF
MI death rate down from
- thrombolitics
- BB
- angioplasty
- aspirin, clopidogrel
Causes of systolic dysfunction CHF
Infarction => dilation => regurgitation=> CHF
Less common causes of systolic dysfunction CHF
Alcohol,postviral( idiopathic) myocarditis,radiation,
adriamycin( doxorubicin) use, Chagas ds, hemochromatosis, thyroid disease
, peripartum cardiomyopathy, thiamine deficiency
Hemochromatosis causes …. cardiomyopathy
Restrictive
CHF presentation
- Orthopnea( worse when lying flat, relieved when sitting up or standing)
- peripheral edema
- rales on lung exam
CHF presentation
- paroxysmal nocturnal dyspnea( sudden worsening at night, during sleep)
- S3 gallop
Sudden onset dyspnea, clear lungs
Pulmonary embolus
Sudden onset dyspnea,wheezing, increased expiratory phase
Asthma
Dyspnea slower, fever, sputum, unilateral rales/rhonchi
Pneumonia
Decreased breath sounds unilaterally, tracheal deviation
Pneumothorax
Circumoral numbness, caffeine use, history of anxiety, dyspnea
Panic attack
Dyspnea, pallor, gradual over days to weeks
Anemia
Pulsus paradoxus, decreased heart sounds, JVD, dyspnea
Tamponade
Palpitations, syncope, dyspnea
Arrhythmia
Dyspnea, dullness to percussion at base
Pleural effusion
Long smoking history, barrel chest, dyspnea
COPD
Recent anesthetic use, brown blood not improved with 02, clear lungs on auscultation, cyanosis
Methemoglobinemia
Burning building ir car, woodburnung stove in winter, suicide attempt
Carbon monoxide poisoning
Orthopnea/PVD, S3, diagnostic test
CHF=> echocardiography( distinguish systolic vs diastolic)
CHF. What is the best initial test?
Transthoracic echo
CHF.What’s the most accurate test?
Multiple-gated acquisition scan( MUGA) or nuclear ventriculography
More accurate for valves
Transesophageal echocardiography
When should you answer” nuclear ventriculography”?
- rarely needed
- person receiving chemotx with doxorubicin
- trying to give max dose to cure lymphoma, but not to cause cardiomyopathy
Atrial natriuretic peptid( BNP)
Acute SOB, etiology unclear, you can’t wait for echo
Normal BNP excludes
CHF
Distinguishes CHF from ARDS; not routine
Swans-Ganz right heart catheterization
Systolic dysfunction (low EF) tx
- ACE inh or ARBs
- BB ( carvedilol, bisoprolol, metoprolol)
- aldosterone antagonists( spironolactone, eplerenone)
- diuretics
- digoxin
CHF tx: antiischemic, decrease heart rate, decrease O2 consumption, antiarrhythmic
BB
What is the MCC of death from CHF?
Arrhythmia/sudden death
Only proven for more advanced CHF( class III and IV) with dyspnea on minimal exertion or at rest
Spironolactone
MC adverse effect of spironolactone
Hyperkalemia, gynecomastia
Antiandrogenic effect
Spironolactone
CHF tx . Diuretics( furosemide, torsemide, bumetanide) . ED/office
ED: acute pulmonary edema
Office: combination with ACEi or ARB
Control symptoms of CHF. Do not lower mortality
Diuretic, digoxin
Is not used at doses where it has a diuretic effect. CHF
Spironolactone
Decrease frequency if hospitalizations, control symptoms
Digoxin
No positive inotropic agent has been proven to lower mortality
Digoxin, milrinone, amrinone, dobutamine
Devices with mortality benefit. CHF
Implantable defibrillator: ischemic CM & EF < 35%
EF < 35%& wide QRS > 120ms with persistent symptoms
Biventricular pacemaker
Has wire in R atrium and R ventricle
Dual-chamber pacer
Not a dual-chamber pacemaker
Biventricular pacemaker
Resynchronizes the heart when there’s a conduction defect
Biventricular pacemaker
Defers/delays need for cardiac transplantation
Defers/ delays need for cardiac transplantation
Symptoms despite maximal medical therapy( ACE, BB, spironolactone, diuretics, digoxin) and possibly biventricular pacemaker
Transplantation
CHF. Always wrong in absence of clot in heart
Warfarin
Mortality benefit in systolic dysfunction
- ACEi/ARBs
- BB. • Spironolactone.
- Hydralazine/ nitrates
- implantable defibrillator
Can raise mortality
Calcium-channel blockers
Diastolic dysfunction( CHF with preserved EF) tx
- BB
- no mortality benefit in diastolic dysfunction
- digoxin has NO benefit
- diuretics( if fluid overload)
Do not confuse diastolic dysfunction from hypertrophic CM with hypertrophic obstructive cardiomyopathy.Tx
Diuretics are contraindicated in HOCM because they increase obstruction
