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    Congestive Heart Failure: Adopted From: Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series

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    karika70
    This document provides an overview of congestive heart failure (CHF), including the clinical presentation, predisposing cardiac diseases, cardiac physiology, classification, physical exam findings, clinical data, treatment, and sample admission orders. CHF is not a diagnosis itself but rather represents the clinical presentation of underlying cardiovascular diseases or precipitating factors that result in the heart failing to adequately pump blood. Treatment focuses on addressing precipitating factors and reducing preload, afterload, and increasing contractility.

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    Congestive Heart Failure: Adopted From: Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series

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    karika70
    74 views27 pages
    This document provides an overview of congestive heart failure (CHF), including the clinical presentation, predisposing cardiac diseases, cardiac physiology, classification, physical exam findings, clinical data, treatment, and sample admission orders. CHF is not a diagnosis itself but rather represents the clinical presentation of underlying cardiovascular diseases or precipitating factors that result in the heart failing to adequately pump blood. Treatment focuses on addressing precipitating factors and reducing preload, afterload, and increasing contractility.

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    Congestive Heart Failure

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    This document provides an overview of congestive heart failure (CHF), including the clinical presentation, predisposing cardiac diseases, cardiac physiology, classification, physical exam findings, clinical data, treatment, and sample admission orders. CHF is not a diagnosis itself but rather represents the clinical presentation of underlying cardiovascular diseases or precipitating factors that result in the heart failing to adequately pump blood. Treatment focuses on addressing precipitating factors and reducing preload, afterload, and increasing contractility.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    74 views27 pages

    Congestive Heart Failure: Adopted From: Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series

    Uploaded by

    karika70
    This document provides an overview of congestive heart failure (CHF), including the clinical presentation, predisposing cardiac diseases, cardiac physiology, classification, physical exam findings, clinical data, treatment, and sample admission orders. CHF is not a diagnosis itself but rather represents the clinical presentation of underlying cardiovascular diseases or precipitating factors that result in the heart failing to adequately pump blood. Treatment focuses on addressing precipitating factors and reducing preload, afterload, and increasing contractility.

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    Congestive Heart Failure

    ADOPTED FROM: Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series

    Congestive Heart Failure


    Clinical presentation of disease NOT a diagnosis in and of itself Differential includes
    Underlying cardiovascular disease Precipitating factors

    Predisposing Cardiac Diseases


    Myocardial infarction Chronic ischemia Cardiomyopathy Arrhythmias Diastolic dysfunction Valvular diseases
    Aortic Stenosis Mitral Stenosis Mitral Regurgitation

    Cardiac Physiology
    (remember this?) CO = SV x HR HR: parasympathetic and sympathetic tone SV: preload, afterload, contractility

    Preload
    Def: Passive stretch of muscle prior to contraction Measurement: Swan-Ganz
    LVEDP

    Really a function of LVEDV Affected by compliance


    Low compliance = higher LVEDP @ lower LVEDV False high estimate of preload

    Frank-Starling right?

    Afterload
    Def: Force opposing/stretching muscle after contraction begins Measurement: SVR Really a function of:
    SVR Chamber radius (dilated cardiomyopathies) Wall thickness (hypertrophy)

    Contractility
    Def: Normal ability of the muscle to contract at a given force for a given stretch, independent of preload or afterload forces In other words:
    How healthy is your heart muscle?

    Ischemia, Hypertrophy (?), Muscle loss

    Classifying Heart Failure


    Anatomically
    Left versus Right

    Physiologically
    Systolic versus Diastolic

    Functionally
    How symptomatic is your patient?

    Left versus Right Failure


    Left Heart Failure - Dyspnea - Dec. exercise tolerance - Cough - Orthopnea - Pink, frothy sputum Right Heart Failure - Dec. exercise tolerance - Edema - HJR / JVD - Hepatomegaly - Ascites

    Systolic versus Diastolic


    Systolic cant pump
    Aortic Stenosis HTN Aortic Insufficiency Mitral Regurgitation Muscle Loss
    Ischemia Fibrosis Infiltration

    Diastolic- cant fill


    Mitral Stenosis Tamponade Hypertrophy Infiltration Fibrosis

    Physical Exam
    no distress at rest, except for feeling uncomfortable when lying flat for more than a few minutes Decreased pulse pressure cool peripheral extremities and cyanosis of the lips and nail beds Increased jugular venous pressure Rales Hepatomegaly Peripheral edema

    Clinical Data
    CXR
    Kerleys lines : A and B Pulmonary Edema Cephalization Pleural Effusions (bilateral)

    EKG
    Left atrial enlargement Arrhythmias Hypertrophy (left or right)

    Cardiomyopathy

    Pulmonary Edema

    Clinical Data
    HEART SOUNDS!!! Systolic Murmurs
    Mitral Regurg Aortic Stenosis

    Diastolic Murmurs
    Mitral Stenosis Aortic Insufficiency

    S3: Rapid filling of a diseased ventricle

    Clinical Data
    Laboratory Data Chemistry
    Renal Function: Be Wary

    BNP
    Used in ER departments the world over Good negative correlation Need baseline for positivity Pulmonary versus cardiac dyspnea

    Treatment of CHF
    Treat Precipitating Factor(s)!!!! Adjust Heart Rate Decrease Preload Decrease Afterload Increase Contractility Increase Oxygenation

    Treatment of CHF
    Oxygen nasal, BiPAP, intubation Morphine Preload Reduction
    Loop diuretics Nitrates ACEi / ARB Morphine

    Treatment of CHF
    Afterload Reduction
    IV NTG, Nitroprusside Hydralazine ACEi / ARB

    Ionotropic Support
    Dopamine / Dobutamine Amrinone / Milrinone Digoxin (chronic) Mechanical (ABP)

    Treatment of CHF
    Beta-Blockers
    Chronic > Acute Carvedilol (Coreg), Metoprolol (Toprol XL)

    Fluid Balance
    Restrict fluid / salt intake Monitor I/Os and daily weight Dialysis if needed

    Aspirin

    Precipitating Factors
    Infection Pulm Embolus Noncompliance Arrhythmia Myocardial Infarction Stress reaction Sodium Intake Medications!!! Anemia Thyroid disorders Endocarditis

    Admission Orders
    Admit: Telemetry or ICU EKG STAT, then daily x 3 days 2D Echo CXR Labs: BMP, CBC, CE x 3, Coags, LFTs, UA Pulse ox (ABG) Oxygen ASA 325mg PO daily

    Admission Orders
    Nitroglycerin
    Paste: 1 ACW TID Holding parameters IV: 50mg in 250cc D5W Titrate

    Morphine 1-5mg IV q10-20 min prn Lasix 20-200mg IV (q 6-8 hours) ACEi
    Captopril 6.25-50mg PO q8h Enalapril 2.5-20mg PO BID (0.625-2.5mg IV q6h)

    Hydralazine 10-100mg PO q6-8 h

    Admission Orders
    Beta Blocker
    Probably not acutely Start Coreg or Toprol XL prior to discharge

    Fluid Restrict 1000ml daily Low salt diet Daily patient weights Daily I/Os

    Admission Orders
    Dobutamine 500mg in 250cc D5W
    3-10ug/kg/min

    Digoxin
    Probably not acutely Titrate to effective dose prior to discharge

    IABP
    Cardiogenic shock unresponsive to above tx

    Dialysis
    Critical renal failure patients

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