Congestive Heart Failure

Question 1

What are the general symptoms and signs of CHF?

Answer 1

• Fatigue
• Ventricular hypertrophy on ECG
• Dyspnea
• S3 or S4 sound on cardiac examination
• Cardiomegaly on chest radiography
• Specific left-sided and right-sided findings

Question 2

What symptoms and signs help to determine whether CHF is due to left or right ventricular failure?

Answer 2

Left ventricular failure: orthopnea (shortness of breath when lying down; the patient sleeps on more than one pillow or even sitting up); paroxysmal nocturnal dyspnea; pulmonary congestion (rales); Kerley B lines on chest radiography; pulmonary vascular congestion and edema; bilateral pleural effusions.

Right ventricular failure: peripheral edema, jugular venous distention, hepatomegaly, ascites, underlying lung disease (cor pulmonale; see later discussion).

Note: Both ventricles are commonly affected, so a mixed pattern is often seen.

Question 3

How is chronic CHF treated?

Answer 3

Chronic CHF is treated on an outpatient basis with sodium restriction, ACEIs (first-line agents that reduce mortality), beta-blockers (somewhat counterintuitive but proven to work), diuretics (furosemide, spironolactone, metolazone), digoxin (not used in diastolic dysfunction; usually reserved for moderate to severe CHF with a low ejection fraction or systolic dysfunction), and vasodilators (arterial and venous).

Question 4

How is acute CHF treated?

Answer 4

on an inpatient basis by addressing (1) oxygenation, (2) preload reduction, and (3) contractility.

1. Arrange for upright positioning of the patient. Titrate O2 to greater than 92% with supplemental oxygen and noninvasive positive-pressure ventilation continuous positive airway pressure/biphasis positive airway pressure (CPAP/BiPAP) as needed. Severe exacerbations may require intubation.
2. Preload reduction is accomplished through the use of diuretics (furosemide). In cases of respiratory distress, nitroglycerin can rapidly reduce preload by causing vasodilation.
3. In cases of cardiogenic shock, norepinephrine is used to maintain tissue perfusion. Digoxin may be used if the patient is stable. Intravenous sympathomimetics (dobutamine, dopamine, amrinone) may also be required for severe CHF.

Question 5

What factors precipitate exacerbations in previously stable patients with CHF?

Answer 5

The most common factor is noncompliance with dietary recommendations or medication regimens, but watch for MI, severe hypertension, arrhythmias, infections and fever, pulmonary embolus, anemia, thyrotoxicosis, and myocarditis.

Question 6

Define cor pulmonale. With what clinical scenarios is it associated?

Answer 6

Cor pulmonale is right ventricular enlargement, hypertrophy, and heart failure caused by primary lung disease. Common causes are chronic obstructive pulmonary disease and pulmonary embolus. In a young woman (20 to 40 years of age) with no other medical history or risk factors, think of idiopathic pulmonary arterial hypertension. Treat with prostacyclins (parenteral epoprostenol), antiendothelins (bosentant), phosphodiesterase 5 inhibitors, and CCBs while awaiting heart-lung transplantation. Sleep apnea can also cause cor pulmonale; look for an obese snorer who is sleepy during the day. Patients with cor pulmonale may have tachypnea, cyanosis, clubbing, parasternal heave, and loud P2 and right-sided S4 sounds, in addition to the signs and symptoms of pulmonary disease.