8/9/2019 Shelly CHF
1/45
Congestive Heart Failure
Michele Ritter, M.D.
Argy – February, 2007
8/9/2019 Shelly CHF
2/45
Heart Failure
Results from any structural orfunctional abnormality that impairsthe ability of the ventricle to eectbloo! "Systolic Heart Failure# orto fill $ith bloo! "Diastolic HeartFailure#.
8/9/2019 Shelly CHF
3/45
The Vicious Cycle of Congestive Heart
Failure
Decrease! %loo! &ressure an!Decrease! Renal perfusion
'timulates the Releaseof renin, (hich allo$s
conversion ofAngiotensin
to Angiotensin II. Angiotensin )) stimulates
Aldosterone secretion $hichcauses retention of
*a+ an! (ater, increasing filling pressure
- Dysfunction causesDecrease! car!iac output
8/9/2019 Shelly CHF
4/45
Types of Heart Failure
Low-Output Heart Failure 'ystolic eart Failure/
!ecrease! car!iac output Decrease! eft ventricular eection fraction
Diastolic eart Failure/ levate! eft an! Right ventricular en!1!iastolic
pressures May have normal -F
High-Output Heart Failure 'een $ith peripheral shunting, lo$1systemic vascular
resistance, hyperthryoi!ism, beri1beri, carcinoi!, anemia ften have normal car!iac output
Right-Ventricular Failure 'een $ith pulmonary hypertension, large R- infarctions.
8/9/2019 Shelly CHF
5/45
Causes of Low-Output Heart Failure
Systolic Dysfunction 3oronary Artery Disease )!iopathic !ilate! car!iomyopathy "D3M#
405 i!iopathic "at least 245 familial# 6 5 mycoar!itis "viral# )schemic heart !isease, perpartum, hypertension,
)-, connective tissue !isease, substance abuse,!oorubicin
ypertension -alvular eart Disease
Diastolic Dysfunction ypertension 3oronary artery !isease ypertrophic obstructive car!iomyopathy "3M# Restrictive car!iomyopathy
8/9/2019 Shelly CHF
6/45
Clinical Presentation of Heart Failure
Due to ecess flui! accumulation/ Dyspnea "most sensitive symptom#
!ema
epatic congestion Ascites
rthopnea, &aroysmal *octurnal Dyspnea"&*D#
Due to re!uction in car!iac ouput/ Fatigue "especially $ith eertion"
(ea8ness
8/9/2019 Shelly CHF
7/45
8/9/2019 Shelly CHF
8/45
easuring !ugular Venous Pressure
8/9/2019 Shelly CHF
9/45
La" #nalysis in Heart Failure
3%3 'ince anemia can eacerbate heart failure
'erum electrolytes an! creatinine before starting high !ose !iuretics
Fasting %loo! glucose ;o evaluate for possible !iabetes mellitus
;hyroi! function tests 'ince thyrotoicosis can result in A. Fib, an! hypothyroi!ism can results in F.
)ron stu!ies ;o screen for here!itary hemochromatosis as cause of heart
failure.
A*A ;o evaluate for possible lupus
-iral stu!ies )f viral mycocar!itis suspecte!
8/9/2019 Shelly CHF
10/45
La"oratory #nalysis $cont%&
%*&(ith chronic heart failure, atrial mycotes
secrete increase amounts of atrial natriuretic
pepti!e "A* an! brain natriuretic pepeti!e"%* in response to high atrial an!ventricular filling pressures
m in patients $ith!yspnea !ue to heart failure.
8/9/2019 Shelly CHF
11/45
Chest '-ray in Heart Failure
3ar!iomegaly
3ephali?ation of the pulmonary
vessels @erley %1lines
&leural effusions
8/9/2019 Shelly CHF
12/45
Car(iomegaly
8/9/2019 Shelly CHF
13/45
Pulmonary vessel congestion
8/9/2019 Shelly CHF
14/45
Pulmonary E(ema (ue to Heart Failure
8/9/2019 Shelly CHF
15/45
)erley * lines
8/9/2019 Shelly CHF
16/45
Car(iac Testing in Heart Failure
lectrocar!iogram/May sho$ specific cause of heart failure/
)schemic heart !isease
Dilate! car!iomyopathy/ first degree AVblock, LBBB, Left anterior fascicular block
Amyloi!osis/ pseudo-infarction pattern )!iopathic !ilate! car!iomyopathy/ LVH
chocar!iogram/ eft ventricular eection fraction'tructural>valvular abnormalities
8/9/2019 Shelly CHF
17/45
Further Car(iac Testing in Heart Failure
ercise ;esting 'houl! be part of initial evaluation of all patients
$ith 3F. 3oronary arteriography
'houl! be performe! in patients presenting $ithheart failure $ho have angina or significantischemia
Reasonable in patients $ho have chest pain thatmay or may not be car!iac in origin, in $homcar!iac anatomy is not 8no$n, an! in patients $ith8no$n or suspecte! coronary artery !isease $ho !onot have angina.
Measure car!iac output, !egree of left ventricular!ysfunction, an! left ventricular en!1!iastolicpressure.
8/9/2019 Shelly CHF
18/45
Further testing in Heart Failure
n!omyocar!ial biopsy *ot freuently use!
Really only useful in cases such as viral1
in!uce! car!iomyopathy
8/9/2019 Shelly CHF
19/45
Classification of Heart Failure
*e$ Bor8 eart Association "*BA#lass I – symptoms of F only at
levels that $oul! limit normal
in!ivi!uals.
lass II – symptoms of F $ithor!inary eertion
lass III – symptoms of F on lessthan or!inary eertion
lass IV – symptoms of F at rest
8/9/2019 Shelly CHF
20/45
Classification of Heart Failure $cont%&
A33>AA Cui!elinesStage A – igh ris8 of F, $ithout
structural heart !isease or symptomsStage ! – eart !isease $ith
asymptomatic left ventricular!ysfunction
Stage – &rior or current symptoms
of FStage D – A!vance! heart !isease an!
severely symptomatic or refractory F
8/9/2019 Shelly CHF
21/45
Chronic Treatment of +ystolic Heart
Failure
3orrection of systemic factors ;hyroi! !ysfunction )nfections
8/9/2019 Shelly CHF
22/45
8/9/2019 Shelly CHF
23/45
,iuretics
oop !iuretics Furose"ide# $ute"inide
For Flui! control, an! to help relieve
symptoms
&otassium1sparing !iuretics Spironolactone# eplerenone
elp enhance !iuresis
Maintain potassium
'ho$n to improve survival in 3F
8/9/2019 Shelly CHF
24/45
#CE nhi"itor
)mprove survival in patients $ith allseverities of heart failure.
%egin therapy lo$ an! titrate up aspossible/ nalapril – 2.4 mg po %)D
3aptopril – E.24 mg po ;)D
isinopril – 4 mg po Daily )f cannot tolerate, may try AR%
8/9/2019 Shelly CHF
25/45
*eta *loc.er therapy
3ertain %eta bloc8ers "car%edilol,"etoprolol, $isoprolol# can improveoverall an! event free survival in *BA
class )) to ))) F, probably in class )-. 3ontrain!icate!/
eart rate GE0 bpm
'ymptomatic bra!ycar!ia
'igns of peripheral hypoperfusion
3&D, asthma
&R interval : 0.2= sec, 2n! or 9r! !egree bloc8
8/9/2019 Shelly CHF
26/45
Hy(rala/ine plus 0itrates
Dosing/y!rala?ine
'tarte! at 24 mg po ;)D, titrate! up to 00
mg po ;)D
)sosorbi!e !initrate 'tarte! at =0 mg po ;)D>)D
Decrease! mortality, lo$er rates of
hospitali?ation, an! improvement inuality of life.
8/9/2019 Shelly CHF
27/45
,igoxin
Civen to patients $ith F to controlsymptoms such as fatigue, !yspnea,eercise intolerance
'ho$n to significantly re!ucehospitali?ation for heart failure, butno benefit in terms of overall
mortality.
8/9/2019 Shelly CHF
28/45
Other important me(ication in Heart
Failure -- +tatins
'tatin therapy is recommen!e! in3F for the secon!ary prevention ofcar!iovascular !isease.
'ome stu!ies have sho$n apossible benefit specifically in F$ith statin therapy
)mprove! -F Reversal of ventricular remo!eling Re!uction in inflammatory mar8ers "3R&,
)1E, ;*F1alpha))#
8/9/2019 Shelly CHF
29/45
e(s to #VO, in heart failure
*'A)D' 3an cause $orsening of preeisting F
;hia?oli!ine!iones )nclu!e rosiglita?one "Avan!ia#, an!
pioglita?one "Actos#
3ause flui! retention that can eacerbate F
Metformin &eople $ith F $ho ta8e it are at increase!
ris8 of potentially lethic lactic aci!osis
8/9/2019 Shelly CHF
30/45
mplanta"le Car(ioverter-,efi"rillators
for HF
'ustaine! ventriculartachycar!ia is associate! $ithsu!!en car!iac !eath in F.
About one1thir! of mortality inF is !ue to su!!en car!iac!eath.
&atients $ith ischemic ornonischemic car!iomyopathy,*BA class )) to ))) F, an!-F H 945 have a significantsurvival benefit from animplantable car!ioverter1!efibrillator ")3D# for the
primary prevention of '3D.
8/9/2019 Shelly CHF
31/45
anagement of 1efractory Heart
Failure
)notropic !rugs/ Dobutamine, !opamine, milrinone,
nitroprussi!e, nitroglycerin Mechanical circulatory support/
)ntraaortic balloon pump eft ventricular assist !evice "-AD# 3ar!iac ;ransplantation
A history of multiple hospitali?ations for F scalation in the intensity of me!ical therapy A repro!ucable pea& o'ygen consu"ption with
"a'i"al e'ercise (VO)"a'* of + , "L&g per "in. "normal is 20 m>8g per min. or more#is relative in!ication, $hile a -2ma + ,/"L&g per "in is a stronger in!ication.
8/9/2019 Shelly CHF
32/45
#cute ,ecompensate( Heart Failure
3ar!iogenic pulmonary e!ema is acommon an! sometimes fatal causeof acute respiratory !istress.
3haracteri?e! by the transu!ation ofecess flui! into the lungssecon!ary to an increase in leftatrial an! subseuently pulmonaryvenous an! pulmonary capillarypressures.
8/9/2019 Shelly CHF
33/45
#cute ,ecompensaate( Heart Failure
$cont%&
3auses/ Acute 0I
Rupture of chor!ae ten!inae>acute mitral
valve insufficiency Volu"e O%erload
;ransfusions, )- flui!s
*on1compliance $ith !iuretics, !iet "highsalt inta8e#
1orsening %al%ular defect Aortic stenosis
8/9/2019 Shelly CHF
34/45
,ecompensate( Heart Failure
'ymptoms 'evere !yspnea
3ough
3linical Fin!ings ;achypnea
;achycar!ia
ypertension>ypotension
3rac8les on lung eam )ncrease! I-D
'9, '= or ne$ murmur
8/9/2019 Shelly CHF
35/45
La"s2+tu(ies in #cute ,ecompensate(
Heart Failure
3hemistry, 3%3
@C
3hest J1ray May consi!er car!iac en?ymes
2D1cho
8/9/2019 Shelly CHF
36/45
,ecompensate( Heart Failure
;reatment'trict )Ks an! Ks, !aily $eights
ygen, mechanical ventilation ifnee!e!
oop !iuretics "asiL#
Morphine
-aso!ilator therapy "nitroglycerin#*esiriti!e "%* – can help in acute
setting, for short term therapy
8/9/2019 Shelly CHF
37/45
Case 3 4
A E41year ol! male $ith a history ofhypertension, DM, 3AD s>p M) an! three1vessel 3A%C in 2002, presents $ith
$orsening !yspnea on eertion. estates that he occassionally has a !rycough, but !enies any recent chest pain,fevers, *>-. &atient states that he usuallycan get up a flight of stairs if he stops
half1$ay, but over the last several !ays,has not been able to climb them at all.
8/9/2019 Shelly CHF
38/45
Case 3 4 $cont%&
&M/ 3AD – M) an! 3A%C in 2002 ypertension
Diabetes Mellitus ypothyroi!ism
Allergies/ *@DA
utpatient Me!s/ 'ynthroi!Metformin *orvasc
8/9/2019 Shelly CHF
39/45
Case 3 4 $cont%&
&hysical am/ 67.E, E>72, 66, 2, 695 on RA
Cen/ Alert an! oriente! 9, breathingrapi!ly
3-/ RRR, no murmursN mo!. I-D
Resp/ 3rac8les throughout lungs
Ab!./ soft, nonten!er, *A%' t/ 2 + pitting e!ema bilaterally
8/9/2019 Shelly CHF
40/45
Case 3 4 $cont%&
abs/ gb/ 9.4
(%3/
&latelets/ 2=0 'o!ium/ 96
&otassium/ 9.
%
8/9/2019 Shelly CHF
41/45
Case 3 4
8/9/2019 Shelly CHF
42/45
Case 3 4
(hat stu!ies $oul! you li8e tochec8 in this patientO
(hat me!ications $oul! you li8e tostart>changeO
(hat vital signs !o you $ant tomonitorO
8/9/2019 Shelly CHF
43/45
8/9/2019 Shelly CHF
44/45
Case 3 5
n eamination her heart rate is 74>min an! herbloo! pressure is 4>69 mm g. %M) is 92.6.Iugular venous pressure is mil!ly elevate!. ungeamination reveals a fe$ bibasilar crac8les.
3ar!iac eamination reveals regular rhythm,normal ' an! '2 an! the presence of an '9.;here is mil! peripheral e!ema. Anechocar!iogram is significant for left ventricularhypertrophy an! severely !ecrease! systolicfunction "left ventricular eection fraction, 205#
An electrocar!iogram sho$s a previousanteroseptal M).
8/9/2019 Shelly CHF
45/45
Case 3 5
(hich of the follo$ing is the mostappropriate net !iagnostic testO
"A#
Measurement of plasma %*&"%# 'erum &rotein lectrophoresis
"3# 3ar!iac 'tress ;est
"D#
3ar!iac catheteri?ation"# n!omyocar!ial biopsy
Top Related