CONGESTIVE HEART FAILURE AND ACUTE PULMONARY EDEMA Flashcards
In CHF … predict the outcome.
Symptom severity
Natriuretic peptides result in (5)
vasodilation,
natriuresis,
decreased levels of endothelin, and
inhibition of the renin-angiotensin-aldosterone system and the sympathetic nervous systems.
Common Causes of Heart Failure and Pulmonary Edema
Myocardial ischemia: acute and chronic* Valvular dysfunction Aortic valve disease Aortic stenosis Aortic insufficiency Aortic dissection Infectious endocarditis Mitral valve disease Mitral stenosis Mitral regurgitation Papillary muscle dysfunction or rupture Ruptured chordae tendineae Infectious endocarditis Prosthetic valve malfunction Other causes of left ventricular outflow obstruction Supravalvular aortic stenosis Membranous subvalvular aortic stenosis Cardiomyopathy* Hypertrophic cardiomyopathy Dilated Restrictive Acquired cardiomyopathy Toxic: alcohol, cocaine, doxorubicin Metabolic: thyrotoxicosis, myxedema Myocarditis: radiation, infection Constrictive pericarditis Cardiac tamponade Systemic hypertension* Miscellaneous Anemia Cardiac dysrhythmias*
Right-side heart failure is characterized by
peripheral edema, JVD, right upper quadrant pain, hepatojugular reflex, without pulmonary symptoms.
The differentiation between right and left heart failure has greatest applicability when there is suspicion
of valvular heart disease or
right ventricular infarction
High-output heart failure can occur when the normally intact myocardium is unable to meet excess functional demands , etiologies (5)
anemia thyrotoxicosis large atrioventricular shunts, beriberi, Paget disease of the bone.
The best physical finding suggestive of an elevated pulmonary capillary wedge pressure is the
S3
The radiographic findings of left-side heart failure are, in descending order of frequency,
“Lag clinical appearance by 6 hours”
1 dilated upper lobe vessels, 2 cardiomegaly, 3 interstitial edema, 4 enlarged pulmonary artery, 5 pleural effusion, 6 alveolar edema, 7 prominent superior vena cava, 8 Kerley lines.
…. must always be considered as a potential cause of the heart failure exacerbation until excluded.
Acute myocardial infarction
Differential Diagnoses for Heart
1 Dyspneic states Asthma exacerbation Chronic obstructive pulmonary disease exacerbation Pleural effusion Pneumonia or other pulmonary infection Pneumothorax Pulmonary embolus Physical deconditioning or obesity 2 Fluid retentive states Dependent edema or deep vein thrombosis Hypoproteinemia Liver failure or cirrhosis Portal vein thrombosis Renal failure or nephrotic syndrome 3 Impaired cardiac output states Acute myocardial infarction Acute valvular insufficiency Drug overdose/effect Dysrhythmias Pericardial tamponade Tension hydro- or pneumothorax 4 High output states Sepsis Anemia Thyroid dysfunction
Precipitants of an Acute Heart Failure Syndrome
1 Noncompliance Excess salt* Medication noncompliance* 2 Cardiac causes New arrhythmia Rapid atrial fibrillation* Acute coronary syndrome or acute myocardial infarction* Uncontrolled hypertension 3 Iatrogenic Use of calcium channel blocker, beta-blocker, or NSAIDs Inappropriate therapy reduction Antiarrhythmic agents within 48 h 4 Noncardiac causes Infections Exacerbation of comorbidity (e.g., chronic obstructive pulmonary disease) Pulmonary embolus 5 Volume overload Renal failure (especially missed dialysis)*
What is the initial Nitro dose in CHF and acute pulmonary edema
repeated sublingual administration of nitroglycerin, 0.4 milligrams, at a rate of up to one per minute, until IV nitroglycerin (0.5 to 0.7 micrograms/kg/min) is initiated
Frusemide dosing in Acute CHF/P edema
If naive, 40 mg IV, oral dose IV if on lassie, increase by 30 min if no output.
If there is coexistent shock in the setting of hypertrophic cardiomyopathy, …. may be the preferred pressor, as it results in peripheral vasoconstriction without increasing cardiac contractility.
phenylephrine (40 to 100 micrograms/min IV)
What are the preload dependant conditions that can make aggressive vasodilation in CHF management challenging: (4)
these are the flow-limiting, preload-dependent states that include right ventricular infarction, aortic stenosis, volume depletion. Hypertrophic cardiomyopathy
Management of Hypotensive Acute Heart Failure
- Assess for falling blood pressure, decreased capillary refill, altered mental status, cool extremities. Evidence of shock may exist at systolic blood pressures >90 mm Hg.
- Assess ECG for ST elevation myocardial infarction criteria.
- Initiate inotrope: dobutamine or dopamine; target range, 90-100 mm Hg SBP.
- Admit to intensive care unit or coronary care unit.
- May require addition of vasodilator in combination with inotropic agent.
Angiotensin-converting enzyme inhibitor contraindications
1 Angioedema
2 Progressive azotemia (creatinine >3 milligrams/dL or increasing)
3 Bilateral renal artery stenosis
4 Systemic hypotension (systolic blood pressure
Beta-Blocker contraindications
1 Unstable hemodynamics or congested and requiring IV diuresis (most ED patients)
2 Severe bronchospastic airway disease
3 Symptomatic bradycardia
4 Advanced heart block
5 Acute vascular insufficiency or worsening claudication/rest pain
6 Class IV HF
7 Inotropic therapy or cardiogenic shock
8 Severe conduction system disease (unless protected by a pacemaker)
…. is the only loop diuretic that can be used in patients with a significant sulfa allergy.
Ethacrynic acid (dose is 50 milligrams IV).
Causes of Hypotension after Vasodilator Use (8)
1 Excessive vasodilation 2 Hypertrophic obstructive cardiomyopathy 3 Intravascular volume depletion 4 Right ventricular infarction 5 Cardiogenic shock/myocardial infarction 6 Aortic stenosis 7 Anaphylaxis 8 Unsuspected sepsis
… is the only CCB that can be used in CHF.
Amlodipine
3 drug classes that are contraindicated in CHF
1 CCB
2 NSAIDs
3 Antiarrhythmics
Admission criteria for CHF without Pul edema (8)
1 new-onset heart failure, 2 poor social support, 3 hypoxemia, 4 hypercarbia, 5 concurrent infection, 6 respiratory distress, 7 syncope, 8 symptomatic hypotension
