Congestive Heart Failure Flashcards
Definition
Congestive heart failure (CHF) inability of the heart to meet the demands of the body
Latrogenic volume overload is the most common cause of CHF
Etiology
Systolic Dysfunction
Weakened pumping function of the heart via
Ischemic heart disease
Chronic hypertension
Cardiomyopathy (viral or idiopathic) in younger patients
Etiology
Diastolic Dysfunction
The inability of the heart to relax / fill via
Hypertension with LVH
Hypertrophic cardiomyopathy
Amyloidosis
Sarcoidosis
Hemochromatosis
Scleroderma
Post-operative/raditation fibrosis
Other etiologies
Valvular dysfunction
Arrhythmias
Precipitting Factors
Acute MI
Long-standing HTN
Chronic anemia
Acute and/or recurrent pulmonary embolism
Chronic endocarditis
Post-partum females
Thyrotoxicosis
Risk Factors
CAD
Family history of hypertrophic cardiomyopathy
HTN
Valvular heart disease
ETOH abuse
Myocarditis
Drug side effects (i.e. doxorubicin)
Smoking
Exacerbations (FAILURE)
Forgetting medication
Arrhythmia
Ischemia
Lifestyle (salt and obesity)
Upregulation (pregnancy and hyperthyroidism)
Renal failure
Embolus (pulmonary)
Symptoms of Left Sided CHF
Lower extremity swelling
Left-sided failure results in right-sided failure, producing ankle-swelling
Abdominal fullness
Exertional dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Symptoms of Right Sided CHF
Abdominal fullness
Exertional dyspnea
Ankle-swelling
3rd heart sound is first sign of left or right failure
Physical Exam Left Sided
Bibasilar crackles
Diffuse, left displaced PMI
S3 (systolic) , S4 (diastolic gallop)
Physical Exam Right Sided
atrial fibrillation
JVD
Hepatojugular reflex
Hepatomegaly
Lower-extremity edema
Evaluation
Echocardiogram
Echocardiogram and clinical picture provide definitive diagnosis
Shows impaired cardiac function
Decreased EF in left-sided heart failure
Normal-to-elevated EF in right-sided heart failure
Systolic heart failure is characterized by:
1) decreased cardiac index
2) increased systemic vascular resistance,
3) increased left ventricular end diastolic pressure
Evaluation
CXR
Cephalization of pulmonary vessels
Cardiomegaly
Pleural effusions
Evaluation
Cardiac Biopsy
Indicated if infiltrative or viral myocarditis is suspected
BNP and NT-proBNP
New York Heart Association Functional Classification of Heart Failure
Class 1
Limitations of Physical Activity: none
Heart Failure Symptoms: none
New York Heart Association Functional Classification of Heart Failure
Class II
Limitations of Physical Activity : Mild
Heart Failure Symptoms: Symptoms with significant exertion; comfortable at rest or mild activity
New York Heart Association Functional Classification of Heart Failure
Class III
Limitations of Physical Activity : Marked Limitation
Heart Failure Symptoms: Symptoms with mild exertion; only comfortable at rest
New York Heart Association Functional Classification of Heart Failure
Class IV
Limitations of Physical Activity : Discomfort with
any activity
Heart Failure Symptoms: Symptoms occur at rest
Differential
Deconditioning, chronic lung disease, MI, angina, pericarditis, renal failure, cirrhosis, or
other causes of lower-extremity edema (venous insufficiency, hypoproteinemia,
nephrosis, etc)
Treatment Acute Cases
If the patient has worsening dyspnea and other symptoms then
Diurese aggressively
Use ACE inhibitors in all patients who can tolerate them
Dobutamine (“dobutamine holiday”) for inotropy
Nitroprusside for afterload reduction.
Treatment Chronic Cases
Lifestyle modifications
Limit dietary sodium intake
Pharmacologic
ACE inhibitors are first-line have been shown to improve survival
Digitalis and diuretics improve symptoms but not proven to improve survival
Warfarin indicated with
Severe dilated cardiomyopathy
Atrial fibrillation
Previous embolic episode
Maintenance medications include
B-blockers
Afterload reduction via ACEi/ARB
Spironolactone if K level is not high
Hydralazine and long-acting nitrates in African-Americans
Arrythmia medications
Treat arrhythmia as they arise
Operative
AICDs should be used
Indicated when EF < 35%
Shown to decrease mortality from VT/VF
Treatment Chronic Cases
Lifestyle modifications
Limit dietary sodium intake
Pharmacologic
ACE inhibitors are first-line have been shown to improve survival
Digitalis and diuretics improve symptoms but not proven to improve survival
Warfarin indicated with
Severe dilated cardiomyopathy
Atrial fibrillation
Previous embolic episode
Maintenance medications include
B-blockers
Afterload reduction via ACEi/ARB
Spironolactone if K level is not high
Hydralazine and long-acting nitrates in African-Americans
Arrythmia medications
Treat arrhythmia as they arise
Operative
AICDs should be used
Indicated when EF < 35%
Shown to decrease mortality from VT/VF
Treat/control underlying etiologies if identified and possible such as thyrotoxicosis, anemia, CAD, HTN, etc
avoid overdiuresis
Exacerbation in chronic patients
Treat with loop diuretics such as furosemide when patient is volume- overloaded
Prognosis, Prevention, and Complications
Manage underlying etiologies such as
Thryoid dysfunction
Long-standing hypertension
Reverse alcoholic dilated cardiomyopathy by abstaining from EtOH
Reverse tachycardia-induced cardiomyopathy via medication or treating afibrillation/other arrythmias
If left untreated almost certainly will lead to death via dry drowning/oxygen deprivation or pneumonia (sepsis)
