S7C57 - CHF and Acute pulmonary edema

Question 1

CHF - prognosis

Answer 1

annual mortality 18.7%

• symptom severity predicts outcome
• cardiogenic shock - 85% will die w/in 1 week

Question 2

Acute heart failur

Answer 2

• decreased CO leads to increased SVR which further reduces CO
• small elevations in BP can cause decreased CO

Question 3

Classification of Acute HF

Answer 3

-hypertensive acute heart failure (preserved LV fxn, SBP >140, pulm ed on CXR, symptom onset

Question 4

HF classification

Answer 4

-systolic heart failure = EF

Question 5

R vs L heart failure

Answer 5

• Left : dyspnea, orthopnea

- Right: peripheral edema, JVD, RUQ pain, hepatojugular reflex, no pulm symptoms

Question 6

S3

Answer 6

• 99% specific for elevated pulmonary capillary wedge pressure
• but only detectable 20% of the time

Question 7

orthopnea - specificity of 88%

Answer 7

a

Question 8

CXR

Answer 8

• 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

Question 9

Precipitants of Acute HF

Answer 9

-noncompliance: meds/fluids
-cardiac causes: arrhythmia, a. fib, ACS, HTN
-iatrogenic: CCB, BB, NSAID
Noncardiac causes: Infxn, COPD, pulm embolus
-volume overload - renal failure

Question 10

Treatment

Answer 10

-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

Question 11

Nitroprusside

Answer 11

• 0.3mcg/kg/min titrate up to 10mcg/kg/min

- complications: HoTN, cyanide toxicity

Question 12

Contraindications to vasodilation

Answer 12

• 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

Question 13

Hyotensive Heart Failure

Answer 13

• 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

Question 14

Diuretic of choice if sulfa allergy:

Answer 14

ethacrynic

Question 15

Diuretics in CHF

Answer 15

• 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

Question 16

Vasodilators and CHF

Answer 16

-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

Question 17

Nitrogylcerin

Answer 17

• 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

Question 18

Nitroprusside

Answer 18

• afterload reduction
• used if nitroglycerin >200mcg/min and not getting desired effect
• increased cardiac output
  0. 3mcg/kg/min titrate q5-10min
• cyanide toxicity

Question 19

ACEi and CHF

Answer 19

-decrease mortality if EF

Question 20

ARB and CHF

Answer 20

-prevents aldosterone release and thereby prevents LV remodeling (+ apoptosis), arterial constriction, renal damage

Question 21

Hydralazine in CHF

Answer 21

• decreases preload and afterload

- increase dose for african american

Question 22

Beta blockers

Answer 22

mortality benefit in CHF

Question 23

Digoxin

Answer 23

-use if BB, ACEi and diuretics fail to control CHF

Question 24

Spironolactone and CHF

Answer 24

• decreases mortality in NYHA class 3/4

- SE: hyperkalemia, gynecomastia

Question 25

Drugs to avoid In CHF

Answer 25

• CCB - may cause pulm edema and cardiogenic shock

- may increase the risk of worsening CHF

Question 26

Complications of CHF:

Answer 26

• sudden death

- ventricular arrhythmias