congestive heart failure

Question 1

SOB (↑ sympathetic system/anxiety: tachycardia, ↑ PVR → worsen heart failure)
-dyspnea on exertion (most sensitive sx)
dull bilaterally, ↓ BS, pleural effusions
cough: pink, frothy
bilateral leg pitting edema
orthopnea
paroxysmal nocturnal dyspnea
cardiomegaly, pansystolic murmur, JVD
low SpO2, HTN
nonspecific: weakness, lightheadedness, ab pain, malaise, wheezing, nausea
+/- hx of HTN, CAD, CM, valve disease

Answer 1

congestive heart failure

Question 2

work-up for congestive heart failure

Answer 2

CXR
serial cardiac enzymes (acute MI could be trigger)
BNP
serial EKG
CBC (infection or anemia (↑ CO) can trigger CHF), electrolytes (response to heart failure: H20 + Na retention, K excretion; ACEi + diuretics can cause abnormalities), BUN, Cr, LFT (↑ venous congestion →↑LFTs)
echocardiogram

Question 3

initial treatment of congestive heart failure

Answer 3

IV furosemide: diuretic + immediate bronchial vasodilation
optimize O2 exchange: O2 by NC, dilate pulm vasculature, ↓ cardiac preload and afterload
morphine sulfate: ↓ anxiety assoc with SOB + venodilator mostly (↓ preload → ↑ CO)
IV nitroglycerin: ↓ myocardial O2 demand by ↓ preload and afterload, ↓ bp
↓ preload + afterload, ↓ cardiac remodeling:
ACEi + B blocker

Question 4

cause of congestive heart failure

Answer 4

most common: CAD, HTN

Question 5

dilated LV → impaired contractility

Answer 5

systolic dysfunction CHF

Question 6

LV can’t relax, fill → can’t eject blood

Answer 6

diastolic dysfunction CHF

Question 7

venous congestion
N/V, distension/bloating, constipation, ab pain, ↓ appetite
pitting edema, weight gain, JVD, hepatojugular reflex, hepatic ascites, slenomegaly

Answer 7

right-sided heart failure

Question 8

pulmonary congestion
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, wheezing, tachypnea, cough
bilateral pulmonary rales, pleural effusion, pulmonary edema (first manifestation of CHF)
S3 gallop rhythm
Cheyne stokes respiration

Answer 8

left-sided heart failure

Question 9

common symptoms of left and right sided heart failure

Answer 9

tachycardia
CM
cyanosis
oliguria
nocturia
peripheral edema
weakness, fatigue, delirium, insomnia, HA, stupor, coma, paroxysmal nocturnal dyspnea

Question 10

gold standard modality in presence of CHF

Answer 10

echocardiogram

Question 11

outpatient management of CHF

Answer 11

↓ Na (2-4 g/day) + fluids
caloric restrictions, exercise
antihypertensive
ACEi (if CHF + ↑ LV function): ↓ preload + afterload, ↑ CO, inhibit RAAS, ↓ mortality, delay symptomatic CHF if asymptomatic with reduced EF
B blocker (systolic or diastolic CHF, if class II or III CHF or if CAD): initial low-dose, titrate up over several weeks, ↓ sympathetic tone, ↓ cardiac remodeling, ↓ mortality if EF

Question 12

ACEi contraindications

Answer 12

pregnant
hypotension
↑ K
bilateral renal artery stenosis
caution if renal insufficiency

Question 13

CCB used with caution in CHF

Answer 13

peripheral vasodilation
↓HR
↓ contractility
↓ cardiac conduction