Congestive heart failure: Difference between revisions
| Line 38: | Line 38: | ||
**Formal TTE/TEE | **Formal TTE/TEE | ||
{{BNP value}} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Revision as of 14:08, 1 June 2015
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
- No symptoms
- Symptoms with every day activity
- Severely limits activity
- Symptoms at rest
Etiology
- CAD
- HTN
- Cardiomyopathy
- Valvular Emergency
- High-output
- Peripartum Cardiomyopathy
- Cardiac Tamponade
- Dysrhythmias
Diagnosis
- 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)[1]
- Measurement
- <100 pg/mL: Negative for acute CHF (Sn 90%, NPV 89%)
- 100-500 pg/mL: Indeterminate (Consider differential diagnosis and pre-test probability)
- >500 pg/mL: Positive for acute CHF (Sp 87%, PPV 90%)
- Combination of BNP with clinician judgment 94% sensitive 70% specific (compared to 49% sn and 96% spec clinical judgement alone) [2]
NT-proBNP[3][4][5]
- <300 pg/mL → CHF unlikely
- CHF likely in:
- >450 pg/mL in age < 50 years old
- >900 pg/mL in 50-75 years old
- >1800 pg/mL in > 75 years old
Differential Diagnosis
- Cardiovascular
- Pulmonary
- Other
- Pure volume overload
- Renal Failure
- Post-Transfusion
- Sepsis
- Pure volume overload
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
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+
- Upright Position
- 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
- 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
- Oxygen
- ACEI
- Enalapril at 0.004mg/kg as IVB or 1mg gtt over 2hr
- Avoid in pregnancy, hyperK+
- Enalapril at 0.004mg/kg as IVB or 1mg gtt over 2hr
- 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
- ACS
- Pulm edema/resp distress
- O2 sat < 90% on room air
- Severe complicating illness
- CHF refractory to outpt therapy
- Anasarca
- Symptomatic hypotension or syncope
- Arrythmia (e.g. new a. fib)
- Inadequate outpatient support
External Links
See Also
References
- ↑ Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347(3):161-167. doi:10.1056/NEJMoa020233.
- ↑ McCullough et al. B-Type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from breathing not properly (BNP) multinational study. Circulation. 2002:DOI: 10.1161/01.CIR.0000025242.79963.4
- ↑ Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J. 2006 Feb. 27(3):330-7.
- ↑ Kragelund C, Gronning B, Kober L, Hildebrandt P, Steffensen R. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med. 2005 Feb 17. 352(7):666-75.
- ↑ Moe GW, Howlett J, Januzzi JL, Zowall H,. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study. Circulation. 2007 Jun 19. 115(24):3103-10.