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Congestive Heart Failure

Michele Ritter, M.D.
Argy – February, 2007

Heart Failure

 Results from any structural or
functional abnormality that impairs
the ability of the ventricle to eject
blood (Systolic Heart Failure) or
to fill with blood (Diastolic Heart

The Vicious Cycle of Congestive Heart

LV Dysfunction causes Decreased Blood Pressure and
Decreased cardiac output Decreased Renal perfusion

Stimulates the Release
of renin, Which allows
conversion of
to Angiotensin II.
Angiotensin II stimulates
Aldosterone secretion which
causes retention of
Na+ and Water,
increasing filling pressure

Types of Heart Failure
 Low-Output Heart Failure
 Systolic Heart Failure:
 decreased cardiac output
 Decreased Left ventricular ejection fraction
 Diastolic Heart Failure:
 Elevated Left and Right ventricular end-diastolic
 May have normal LVEF
 High-Output Heart Failure
 Seen with peripheral shunting, low-systemic vascular
resistance, hyperthryoidism, beri-beri, carcinoid, anemia
 Often have normal cardiac output
 Right-Ventricular Failure
 Seen with pulmonary hypertension, large RV infarctions.

Causes of Low-Output Heart Failure  Systolic Dysfunction  Coronary Artery Disease  Idiopathic dilated cardiomyopathy (DCM)  50% idiopathic (at least 25% familial)  9 % mycoarditis (viral)  Ischemic heart disease. hypertension. connective tissue disease. HIV. substance abuse. doxorubicin  Hypertension  Valvular Heart Disease  Diastolic Dysfunction  Hypertension  Coronary artery disease  Hypertrophic obstructive cardiomyopathy (HCM)  Restrictive cardiomyopathy . perpartum.

Clinical Presentation of Heart Failure  Due to excess fluid accumulation:  Dyspnea (most sensitive symptom)  Edema  Hepatic congestion  Ascites  Orthopnea. Paroxysmal Nocturnal Dyspnea (PND)  Due to reduction in cardiac ouput:  Fatigue (especially with exertion(  Weakness .

cyanotic extremities  Have sinus tachycardia. pale.Physical Examination in Heart Failure  S3 gallop  Low sensitivity. but highly specific  Cool. diaphoresis and peripheral vasoconstriction  Crackles or decreased breath sounds at bases (effusions) on lung exam  Elevated jugular venous pressure  Lower extremity edema  Ascites  Hepatomegaly  Splenomegaly  Displaced PMI  Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement> .

Measuring Jugular Venous Pressure .

 Iron studies  To screen for hereditary hemochromatosis as cause of heart failure.Lab Analysis in Heart Failure  CBC  Since anemia can exacerbate heart failure  Serum electrolytes and creatinine  before starting high dose diuretics  Fasting Blood glucose  To evaluate for possible diabetes mellitus  Thyroid function tests  Since thyrotoxicosis can result in A. and hypothyroidism can results in HF.  ANA  To evaluate for possible lupus  Viral studies  If viral mycocarditis suspected . Fib.

.Laboratory Analysis (cont. atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures  Usually is > 400 pg/mL in patients with dyspnea due to heart failure.)  BNP  With chronic heart failure.

Chest X-ray in Heart Failure  Cardiomegaly  Cephalization of the pulmonary vessels  Kerley B-lines  Pleural effusions .

Cardiomegaly .

Pulmonary vessel congestion .

Pulmonary Edema due to Heart Failure .

Kerley B lines .

Cardiac Testing in Heart Failure  Electrocardiogram:  May show specific cause of heart failure:  Ischemic heart disease  Dilated cardiomyopathy: first degree AV block. LBBB. Left anterior fascicular block  Amyloidosis: pseudo-infarction pattern  Idiopathic dilated cardiomyopathy: LVH  Echocardiogram:  Left ventricular ejection fraction  Structural/valvular abnormalities .

degree of left ventricular dysfunction.  Measure cardiac output.Further Cardiac Testing in Heart Failure  Exercise Testing  Should be part of initial evaluation of all patients with CHF. and left ventricular end-diastolic pressure. and in patients with known or suspected coronary artery disease who do not have angina.  Coronary arteriography  Should be performed in patients presenting with heart failure who have angina or significant ischemia  Reasonable in patients who have chest pain that may or may not be cardiac in origin. in whom cardiac anatomy is not known. .

Further testing in Heart Failure  Endomyocardial biopsy  Not frequently used  Really only useful in cases such as viral- induced cardiomyopathy .

Classification of Heart Failure  New York Heart Association (NYHA)  Class I – symptoms of HF only at levels that would limit normal individuals.  Class II – symptoms of HF with ordinary exertion  Class III – symptoms of HF on less than ordinary exertion  Class IV – symptoms of HF at rest .

without structural heart disease or symptoms  Stage B – Heart disease with asymptomatic left ventricular dysfunction  Stage C – Prior or current symptoms of HF  Stage D – Advanced heart disease and severely symptomatic or refractory HF .Classification of Heart Failure (cont.)  ACC/AHA Guidelines  Stage A – High risk of HF.

Chronic Treatment of Systolic Heart Failure  Correction of systemic factors  Thyroid dysfunction  Infections  Uncontrolled diabetes  Hypertension  Lifestyle modification  Lower salt intake  Alcohol cessation  Medication compliance  Maximize medications  Discontinue drugs that may contribute to heart failure (NSAIDS. antiarrhythmics. calcium channel blockers) .

Loop diuretics 2. Beta blockers 4. Hydralazine. Nitrate 6. Digoxin 5. Potassium sparing diuretcs . ACE inhibitor (or ARB if not tolerated) 3.Order of Therapy 1.

and to help relieve symptoms  Potassium-sparing diuretics  Spironolactone. buteminide  For Fluid control. eplerenone  Help enhance diuresis  Maintain potassium  Shown to improve survival in CHF .Diuretics  Loop diuretics  Furosemide.

25 mg po TID  Lisinopril – 5 mg po QDaily  If cannot tolerate.  Begin therapy low and titrate up as possible:  Enalapril – 2.5 mg po BID  Captopril – 6.ACE Inhibitor  Improve survival in patients with all severities of heart failure. may try ARB .

24 sec.Beta Blocker therapy  Certain Beta blockers (carvedilol. 2nd or 3rd degree block . bisoprolol) can improve overall and event free survival in NYHA class II to III HF.  Contraindicated:  Heart rate <60 bpm  Symptomatic bradycardia  Signs of peripheral hypoperfusion  COPD. metoprolol. asthma  PR interval > 0. probably in class IV.

titrated up to 100 mg po TID  Isosorbide dinitrate  Started at 40 mg po TID/QID  Decreased mortality. lower rates of hospitalization.Hydralazine plus Nitrates  Dosing:  Hydralazine  Started at 25 mg po TID. . and improvement in quality of life.

. but no benefit in terms of overall mortality.Digoxin  Given to patients with HF to control symptoms such as fatigue. exercise intolerance  Shown to significantly reduce hospitalization for heart failure. dyspnea.

 Some studies have shown a possible benefit specifically in HF with statin therapy  Improved LVEF  Reversal of ventricular remodeling  Reduction in inflammatory markers (CRP.Statins  Statin therapy is recommended in CHF for the secondary prevention of cardiovascular disease. IL-6.Other important medication in Heart Failure -. TNF-alphaII) .

and pioglitazone (Actos)  Cause fluid retention that can exacerbate HF  Metformin  People with HF who take it are at increased risk of potentially lethic lactic acidosis .Meds to AVOID in heart failure  NSAIDS  Can cause worsening of preexisting HF  Thiazolidinediones  Include rosiglitazone (Avandia).

 About one-third of mortality in HF is due to sudden cardiac death. Implantable Cardioverter-Defibrillators for HF  Sustained ventricular tachycardia is associated with sudden cardiac death in HF. NYHA class II to III HF.  Patients with ischemic or nonischemic cardiomyopathy. . and LVEF ≤ 35% have a significant survival benefit from an implantable cardioverter- defibrillator (ICD) for the primary prevention of SCD.

nitroglycerin  Mechanical circulatory support:  Intraaortic balloon pump  Left ventricular assist device (LVAD)  Cardiac Transplantation  A history of multiple hospitalizations for HF  Escalation in the intensity of medical therapy  A reproducable peak oxygen consumption with maximal exercise (VO2max) of < 14 mL/kg per min. milrinone. . or more) is relative indication. dopamine. (normal is 20 mL/kg per min. Management of Refractory Heart Failure  Inotropic drugs:  Dobutamine. while a VO2max < 10 mL/kg per min is a stronger indication. nitroprusside.

 Characterized by the transudation of excess fluid into the lungs secondary to an increase in left atrial and subsequently pulmonary venous and pulmonary capillary pressures.Acute Decompensated Heart Failure  Cardiogenic pulmonary edema is a common and sometimes fatal cause of acute respiratory distress. .

)  Causes:  Acute MI  Rupture of chordae tendinae/acute mitral valve insufficiency  Volume Overload  Transfusions.Acute Decompensaated Heart Failure (cont. diet (high salt intake)  Worsening valvular defect  Aortic stenosis . IV fluids  Non-compliance with diuretics.

S4 or new murmur .Decompensated Heart Failure  Symptoms  Severe dyspnea  Cough  Clinical Findings  Tachypnea  Tachycardia  Hypertension/Hypotension  Crackles on lung exam  Increased JVD  S3.

Labs/Studies in Acute Decompensated Heart Failure  Chemistry. CBC  EKG  Chest X-ray  May consider cardiac enzymes  2D-Echo .

for short term therapy . mechanical ventilation if needed  Loop diuretics (Lasix!)  Morphine  Vasodilator therapy (nitroglycerin)  Nesiritide (BNP) – can help in acute setting.Decompensated Heart Failure  Treatment  Strict I’s and O’s. daily weights  Oxygen.

Patient states that he usually can get up a flight of stairs if he stops half-way. . fevers. DM.Case # 1  A 65-year old male with a history of hypertension. presents with worsening dyspnea on exertion. but over the last several days. has not been able to climb them at all. but denies any recent chest pain. CAD s/p MI and three- vessel CABG in 2002. He states that he occassionally has a dry cough. N/V.

Case # 1 (cont.)  PMH:  CAD – MI and CABG in 2002  Hypertension  Diabetes Mellitus  Hypothyroidism  Allergies:  NKDA  Outpatient Meds:  Synthroid  Metformin  Norvasc .

93% on RA  Gen: Alert and oriented x 3.: soft. nontender. no murmurs. NABS  Ext: 2 + pitting edema bilaterally .6. JVD  Resp: Crackles throughout lungs  Abd.)  Physical Exam:  97. 99. 28. 168/72.Case # 1 (cont. breathing rapidly  CV: RRR. mod.

)  Labs:  Hgb: 13.8  BUN: 18  Cr: 0.8 .01  WBC: 8  CPK: 120  Platelets: 240  Sodium: 139  Potassium: 3.5  Trop.Case # 1 (cont. I – 0.

Case # 1 .

Case # 1  What studies would you like to check in this patient?  What medications would you like to start/change?  What vital signs do you want to monitor? .

Two months ago. she had a flu- like illness with nausea.Case # 2  A 45-year old obese woman with diabetes mellitus is evaluated for a 1-month history of progressive shortness of breath. and sweating. One of her siblings has “heart problems” and her mother died suddenly and unexpectedly at age 55 years. . She has not followed up with a physician regularly. vomiting.

normal S1 and S2 and the presence of an S3. An echocardiogram is significant for left ventricular hypertrophy and severely decreased systolic function (left ventricular ejection fraction. BMI is 32. Cardiac examination reveals regular rhythm. Lung examination reveals a few bibasilar crackles.9. 20%) An electrocardiogram shows a previous anteroseptal MI. There is mild peripheral edema. . Jugular venous pressure is mildly elevated.Case # 2  On examination her heart rate is 75/min and her blood pressure is 185/93 mm Hg.

Case # 2  Which of the following is the most appropriate next diagnostic test? (A) Measurement of plasma BNP (B) Serum Protein Electrophoresis (C) Cardiac Stress Test (D) Cardiac catheterization (E) Endomyocardial biopsy .