Congestive heart failure

Background

• Assume valvular problem in new-onset CHF
• Assume valve thrombosis in CHF with a prosthetic valve
• Do not give vasodilators in aortic stenosis, HOCM; yes in mitral regurgitation

NYHA Classes

1. No Sx
2. Sx with every day activity
3. Severely limits activity
4. Sx at rest

Etiology

• CAD
• HTN
• Cardiomyopathy
• Valvular Emergency
• High-output
• Peripartum Cardiomyopathy
• Cardiac Tamponade
• Dysrhythmias

Diagnosis

Pitting pedal edema

Pulmonary edema with small pleural effusions on both sides.

• CBC (r/o anemia)
• Chem
• ECG
• CXR
  • Cephalization
  • Interstitial edema
  • Pulmonary venous congestion
  • Pleural effusion
  • Alveolar edema
  • Cardiomegaly
• Troponin?
• Ultrasound
  • Bedside to assess global function, B lines, assessment of IVC
  • Formal TTE/TEE

Brain natriuretic peptide (BNP)

• <100 (Sn 90%, NPV 89%)
• > 500 (Sp 87%, PPV 90%)
• Elevated in:
  • Elderly, kidney failure, PE
• Decreased in:
  • Obese

Differential Diagnosis

• Cardiovascular
  • ACS
  • Acute Valve Dysfunction
  • Aortic Dissection
  • Dysrhthymia
  • Endocarditis
  • Hypertensive Emergency
  • Pericardial Tamponade
• Pulmonary
  • COPD
  • PE
  • PNA
• Other
  • Pure volume overload
    • Renal Failure
    • Post-Transfusion
  • Sepsis

Causes of Decompensation

• Medication noncompliance
• Dietary noncompliance
• Uncontrolled HTN
• MI
• Valvular Dysfunction
• Arrhythmias
• Infection
• Inappropriate medications (e.g., negative inotropes)
• Fluid overload
• Missed dialysis
• Thyrotoxicosis
• Anemia
• Alcohol Withdrawal

Treatment

Acute Pulmonary Edema and Hypertensive Heart Failure

See Pulmonary Edema

Hypotensive Heart Failure

See Cardiogenic Shock

Inotropic Agents

• Dobutamine generally first line
• Milrinone if pt on Betablockers
• consider in severe LV dysfunction and low output syndrome
  • dimunished peripheral perfusion and end organ damage
• vasodilatory treatment inadequate response or limited by symptomatic hypotension
• must have obvious evidence of elevated filling pressures
  • JVD, noncollapsing IVC, etc
• Inotropes are not indicated in setting of preserved systolic function

Heart Failure Without Pulmonary Edema

UNLOAD+

1. Upright Position
2. Nitrates - ask about sildenafil
   • start SL 0.4mg delivered over 5 min = 0.15mg/min
   • if no improvment IV NTG gtt, start 0.3-0.5mcg/kg/min, but may increase to 3-5mcg/kg/min
     • Keep BP >95
   • Consider nitroprusside 0.3 mcg/kg/min if HTN or NTG ineffective
3. Lasix
   • hold if no sxs of fluid overload
   • Give nitrates first
   • Give double home dose, or up to 2.5x dose.
     • if lasix 40mg po qd, then lasix 40-100mg IV
4. Oxygen
   • CPAP/BiPAP -give early
5. ACEI
   • Enalapril at 0.004mg/kg as IVB or 1mg gtt over 2hr
     • Avoid in pregnancy, hyperK+
6. Digoxin
   • Indicated for a fib rate control

Disposition

Admission Criteria

CCORT

• 7 day mortality risk score calculator for pts presenting to the ED with decompensated HF
• http://www.ccort.ca/calculator.aspx

AHCPR '00

1. ACS
2. Pulm edema/resp distress
3. O2 sat < 90% on room air
4. Severe complicating illness
5. CHF refractory to outpt therapy
6. Anasarca
7. Symptomatic hypotension or syncope
8. Arrythmia (e.g. new a. fib)
9. Inadequate outpt support

External Links

• MDCalc - Emergency Heart Failure Mortality Risk Grade (EHMRG)

See Also

• Pulmonary Edema
• CHF Meds

Source

EB Medicine, UpToDate