Management of CHF Flashcards
Forward Failure results
Forward failure – decreased cardiac output
Exercise intolerance, lethargy, syncope
Backward failure results
Backward failure – congestive heart failure
left sided – dyspnoea, tachypnoea
right sided - dyspnoea, tachypnoea, heaptomegaly, ascites
Where do these congenital issues develop CHF first? Aortic stenosis Pulmonic stenosis Patent ductus arteriosus Ventricular septal defect Mitral dysplasia Tricuspid dysplasia Tetralogy of Fallot
Congenital: Aortic stenosis L Pulmonic stenosis R Patent ductus arteriosus L Ventricular septal defect L Mitral dysplasia L Tricuspid dysplasia R Tetralogy of Fallot x
Where do these aquired issues develop CHF first? Pericardial effusion Dilated cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy Endocardiosis Endocarditis
Acquired: Pericardial effusion R Dilated cardiomyopathy L/R Hypertrophic cardiomyopathy L Restrictive cardiomyopathy L Endocardiosis L/R Endocarditis L
Treatment of LHS CHF
Cage rest
Oxygen
Preload reduction - I/V frusemide, glyceryl trinitrate
Opioid sedation if very distressed
Thoracocentesis if pleural effusion present
iv pimobendan/dobutamine if poor systolic function
Treatment of RHS CHF
Identify and drain pericardial effusions causing tamponade
Drain large pleural effusions
Only drain an abdominal effusion if it is causing severe respiratory compromise
Once stable obtain a diagnosis
ALWAYS identify cases that need surgical intervention e.g. pulmonic stenosis
Long term management
- decrease preload
- decrease afterlaod
- positive inotropic support
- improving diastolic function
- management of arrhythmias
- prevention of remodelling
Decreasing preload
Diuretic
- Frusemide (1st choice)
- Spironolactone weak diuretic but used to spare frusemide and for remodelling
- Refractory cases may require– amiloride/chlorthiazide or torasemide
generally always used in CHF: only contraindicated when CHF is secondary to pericardial effusion: constricting heart making it hard to pump: diuretic will worsen this.
Decreasing Afterload
ACE inhibitors
- Decrease angiotensin II
- Decrease vasconstriction
- Decrease ADH secretion
- Decrease aldosterone
- Decrease sympathetic stimulation
Pimobenden
- inodilator
- positive inotrope & vasodilator
Positive inotropic support
Pimobendan – inodilator (IV or ORAL)
Digoxin – poor positive inotrope but good negative chronotrope (ORAL)
Dobutamine infusion - expensive, will buy some time for a patient with severe systolic failure (IV)
Improving diastolic function
- Positive lusitrope : diltiazem
- Negative chronotropes: betablocker/ diltiazem
- Negative inotropes: beta blocker/ diltiazem
Indicated with abnormal diastolic function typically seen with myocardial concentric hypertrophy such as acquired HCM or congenital AS/PS
TAKE CARE IN THE USE OF NEGATIVE INOTROPES IN THE PRESENCE OF CHF REGARDLESS OF THE DISEASE TYPE
Management of Arrhythmias
Arrhythmias may be contributing to CHF
Treat supraventricular arrhythmias
Treat ventricular arrhythmias
Treat bradyarrhythmias
If high HR, use B blockers (but also may worsen due to decrease in systolic function)
Remember anti-arrhythmic drugs are all negative inotropes except digoxin and may make CHF worse initially – monitor carefully.
Prevention of Remodelling
Remodelling is the response of the cardiac chambers to chronic volume or pressure overload .
Some drugs have been shown to slow down remodelling.
ACE inhibitors
Spironolactone
Pimobendan
These drug are all used in the presence of CHF for other reasons
Pulmonic Stenosis Treatment
Manage CHF prior to balloon valvuloplasty
Use diuretics and ACE inhibitors
Pericardial Effusion Treatment
pericardiocentesis/pericardiectomy
