1. Congestive Heart Failure
Jarrod Eddy, PGY2
Internal Medicine
Sub-I Lecture Series

3. Congestive Heart Failure
• Clinical presentation of disease
• NOT a diagnosis in and of itself
• Differential includes
– Underlying cardiovascular disease
– Precipitating factors

4. Predisposing Cardiac Diseases
• Myocardial infarction
• Chronic ischemia
• Cardiomyopathy
• Arrhythmias
• Diastolic dysfunction
• Valvular diseases
– Aortic Stenosis
– Mitral Stenosis
– Mitral Regurgitation

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

6. 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?

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

8. 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

9. Classifying Heart Failure
• Anatomically
– Left versus Right
• Physiologically
– Systolic versus Diastolic
• Functionally
– How symptomatic is your patient?

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

11. Systolic versus Diastolic
• Systolic– “can’t pump” • Diastolic- “can’t fill”
– Aortic Stenosis – Mitral Stenosis
– HTN – Tamponade
– Aortic Insufficiency – Hypertrophy
– Mitral Regurgitation – Infiltration
– Muscle Loss – Fibrosis
• Ischemia
• Fibrosis
• Infiltration

12. Clinical Data
• CXR
– Kerley’s lines : A and B
– Pulmonary Edema
– Cephalization
– Pleural Effusions (bilateral)
• EKG
– Left atrial enlargement
– Arrhythmias
– Hypertrophy (left or right)

13. Cardiomyopathy Pulmonary Edema

14. Clinical Data
• HEART SOUNDS!!!
• Systolic Murmurs
– Mitral Regurg
– Aortic Stenosis
• Diastolic Murmurs
– Mitral Stenosis
– Aortic Insufficiency
• S3: Rapid filling of a diseased ventricle

15. 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

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

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

19. Treatment of CHF
• Afterload Reduction
– IV NTG, Nitroprusside
– Hydralazine
– ACEi / ARB
• Ionotropic Support
– Dopamine / Dobutamine
– Amrinone / Milrinone
– Digoxin (chronic)
– Mechanical (ABP)

21. 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

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

23. 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

24. 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

25. 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

26. 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