S7C57 - CHF and Acute pulmonary edema Flashcards
CHF - prognosis
annual mortality 18.7%
- symptom severity predicts outcome
- cardiogenic shock - 85% will die w/in 1 week
Acute heart failur
- decreased CO leads to increased SVR which further reduces CO
- small elevations in BP can cause decreased CO
Classification of Acute HF
-hypertensive acute heart failure (preserved LV fxn, SBP >140, pulm ed on CXR, symptom onset
HF classification
-systolic heart failure = EF
R vs L heart failure
- Left : dyspnea, orthopnea
- Right: peripheral edema, JVD, RUQ pain, hepatojugular reflex, no pulm symptoms
S3
- 99% specific for elevated pulmonary capillary wedge pressure
- but only detectable 20% of the time
orthopnea - specificity of 88%
a
CXR
- negative for congestion in 18% of cases
- signs of Left heart failure( in desc order of frequency): dilated upper vessels, cardiobmegaly, insterstitial edema, enlarged pulm artery, pleural effusion, alveolar edema, prominent superior vena cava, kerley lines
Precipitants of Acute HF
-noncompliance: meds/fluids
-cardiac causes: arrhythmia, a. fib, ACS, HTN
-iatrogenic: CCB, BB, NSAID
Noncardiac causes: Infxn, COPD, pulm embolus
-volume overload - renal failure
Treatment
-IV, O2, monitor, ECG, frequent vitals
-BiPAP
-foley if severely ill
-afterload reduction with vasodilators:
SL nitro
IV nitro (0.5-0.7 mcg/kg/min) to control BP
IV nitroprusside (vasodilator)
-diuretics if volume overload (lasix)
**morphine increases intubation and ICU admission
Nitroprusside
- 0.3mcg/kg/min titrate up to 10mcg/kg/min
- complications: HoTN, cyanide toxicity
Contraindications to vasodilation
- flow-limiting, preload-dependent states
- eg. RV infarction, Ao stenosis, volume depletion
- HOCM - if combined with pulm edema, the administration of an agent that increases cardiac contractility will increase the outflow obstruction. Best to treat with phenylephrine
Hyotensive Heart Failure
- ACS may be precipitant
1. assess for declining BP, altered mental status
2. assess ECG for STEMI
3. initiate inotrope: dobutamine or dopamine (target 90-100 systolic)
4. ICU
5. may require addition of vasodilator in combo with inotrope
Diuretic of choice if sulfa allergy:
ethacrynic
Diuretics in CHF
- improve symptoms but not outcomes
- can repeat dosing in 30-60mins depending on response
- u/o should be >500cc in 2h if normal renal fxn
Vasodilators and CHF
-eg. nitroglycerine, nitroprusside
-do not use if cardiogenic shock, cardiomyopathy, Ao stenosis
-causes of HoTN after vasodilator administration:
>too much vasodilation
>HOCM
>volume depletion
>RV infarct
>cardiogenic shock/MI
>Ao stenosis
>anaphylaxis
>sepsis
Nitrogylcerin
- useful if HTN
- short-acting, rapid-onset, systemic venous and arterial dilator
- decreases MAP
- reduces afterload and preload
- IV nitro: 0.5-0.7mcg/kg/min (eg. 25-50mcg/min), rapidly increase by 10-20mcg/min to titrate to BP
Nitroprusside
- afterload reduction
- used if nitroglycerin >200mcg/min and not getting desired effect
- increased cardiac output
0. 3mcg/kg/min titrate q5-10min - cyanide toxicity
ACEi and CHF
-decrease mortality if EF
ARB and CHF
-prevents aldosterone release and thereby prevents LV remodeling (+ apoptosis), arterial constriction, renal damage
Hydralazine in CHF
- decreases preload and afterload
- increase dose for african american
Beta blockers
mortality benefit in CHF
Digoxin
-use if BB, ACEi and diuretics fail to control CHF
Spironolactone and CHF
- decreases mortality in NYHA class 3/4
- SE: hyperkalemia, gynecomastia
Drugs to avoid In CHF
- CCB - may cause pulm edema and cardiogenic shock
- may increase the risk of worsening CHF
Complications of CHF:
- sudden death
- ventricular arrhythmias
