Congestive Heart Failure

Question 1

Definition

Answer 1

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

Question 2

Etiology
Systolic Dysfunction

Answer 2

Weakened pumping function of the heart via
Ischemic heart disease
Chronic hypertension
Cardiomyopathy (viral or idiopathic) in younger patients

Question 3

Etiology
Diastolic Dysfunction

Answer 3

The inability of the heart to relax / fill via

Hypertension with LVH
Hypertrophic cardiomyopathy
Amyloidosis
Sarcoidosis
Hemochromatosis
Scleroderma
Post-operative/raditation fibrosis

Question 4

Other etiologies

Answer 4

Valvular dysfunction
Arrhythmias

Question 5

Precipitting Factors

Answer 5

Acute MI
Long-standing HTN
Chronic anemia
Acute and/or recurrent pulmonary embolism
Chronic endocarditis
Post-partum females
Thyrotoxicosis

Question 6

Risk Factors

Answer 6

CAD
Family history of hypertrophic cardiomyopathy
HTN
Valvular heart disease
ETOH abuse
Myocarditis
Drug side effects (i.e. doxorubicin)
Smoking

Question 7

Exacerbations (FAILURE)

Answer 7

Forgetting medication
Arrhythmia
Ischemia
Lifestyle (salt and obesity)
Upregulation (pregnancy and hyperthyroidism)
Renal failure
Embolus (pulmonary)

Question 8

Symptoms of Left Sided CHF

Answer 8

Lower extremity swelling
Left-sided failure results in right-sided failure, producing ankle-swelling
Abdominal fullness
Exertional dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea

Question 9

Symptoms of Right Sided CHF

Answer 9

Abdominal fullness
Exertional dyspnea
Ankle-swelling
3rd heart sound is first sign of left or right failure

Question 10

Physical Exam Left Sided

Answer 10

Bibasilar crackles
Diffuse, left displaced PMI
S3 (systolic) , S4 (diastolic gallop)

Question 11

Physical Exam Right Sided

Answer 11

atrial fibrillation
JVD
Hepatojugular reflex
Hepatomegaly
Lower-extremity edema

Question 12

Evaluation
Echocardiogram

Answer 12

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

Question 13

Evaluation
CXR

Answer 13

Cephalization of pulmonary vessels
Cardiomegaly
Pleural effusions

Question 14

Evaluation
Cardiac Biopsy

Answer 14

Indicated if infiltrative or viral myocarditis is suspected
BNP and NT-proBNP

Question 15

New York Heart Association Functional Classification of Heart Failure
Class 1

Answer 15

Limitations of Physical Activity: none
Heart Failure Symptoms: none

Question 16

New York Heart Association Functional Classification of Heart Failure
Class II

Answer 16

Limitations of Physical Activity : Mild
Heart Failure Symptoms: Symptoms with significant exertion; comfortable at rest or mild activity

Question 17

New York Heart Association Functional Classification of Heart Failure
Class III

Answer 17

Limitations of Physical Activity : Marked Limitation
Heart Failure Symptoms: Symptoms with mild exertion; only comfortable at rest

Question 18

New York Heart Association Functional Classification of Heart Failure
Class IV

Answer 18

Limitations of Physical Activity : Discomfort with
any activity
Heart Failure Symptoms: Symptoms occur at rest

Question 19

Differential

Answer 19

Deconditioning, chronic lung disease, MI, angina, pericarditis, renal failure, cirrhosis, or
other causes of lower-extremity edema (venous insufficiency, hypoproteinemia,
nephrosis, etc)

Question 20

Treatment Acute Cases

Answer 20

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.

Question 21

Treatment Chronic Cases

Answer 21

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

Question 22

Treatment Chronic Cases

Answer 22

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

Question 23

Exacerbation in chronic patients

Answer 23

Treat with loop diuretics such as furosemide when patient is volume- overloaded

Question 24

Prognosis, Prevention, and Complications

Answer 24

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)