نارسایی احتقانی قلب، CHF

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Congestive Wewt Puture 

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Wet Puiu © 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 Failure). 

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Whe Oivious Opcle oe Cownyestive Wewt Puhr LV Dysfunction causes Decreased Blood Pressure and Decreased cardiac output Decreased Renal perfusion Stimulates the Release of renin, Which allows conversion of Angiotensin to Angiotensin Il. Angiotensin Il stimulates Aldosterone secretion which causes retention of Na+ and Water, Increasing filing pressure 

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Tppes oF Wem Pure © 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 pressures > 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. 

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Cues ve Low-Output Wen (Puhure © Systolic Dysfunction © Coronary Artery Disease © Idiopathic dilated cardiomyopathy (DCM) © 50% idiopathic (at least 25% familial) © 9 % mycoarditis (viral) © Ischemic heart disease, perpartum, hypertension, HIV, connective tissue disease, substance abuse, doxorubicin © Hypertension © Valvular Heart Disease © Diastolic Dysfunction © Hypertension © Coronary artery disease 6 Hypertrophic obstructive cardiomyopathy (HCM) © Restrictive cardiomyopathy 

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Claicd Preseutatica oP Wea Paihure © Due to excess fluid accumulation: © Dyspnea (most sensitive symptom) * Edema ۶ Hepatic congestion © Ascites © Orthopnea, Paroxysmal Nocturnal Dyspnea (PND) © Due to reduction in cardiac ouput: © Fatigue (especially with exertion( * Weakness 

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Physicd Exacvicatiod io Wet (Puiune © $3 gallop Low sensitivity, but highly specific © Cool, pale, cyanotic extremities * Have sinus tachycardia, 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> 0 و و و و و و 

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Deusuriay ‏رل‎ Orwvws Pressure 

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bub @udlysis ia Weart Puure ° 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. Fib, and hypothyroidism can results in HF. © Iron studies * To screen for hereditary hemochromatosis as cause of heart failure. ° ANA * To evaluate for possible lupus © Viral studies © If viral mycocarditis suspected 

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© BNP © With chronic heart failure, 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. 

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Chest X-ray fo Wem Puhure 9 © Cephalization of the pulmonary vessels © Kerley B-lines © Pleural effusions 

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a (Puihure (ukoocury (Edexwu due to “I 

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(ertey © fines 

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‎Destiny io Wet Pure‏ لسو) ‎© Electrocardiogram: ۶ 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 ‎ 

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(Ruther Curciaz Destiog io Weot (Pure © Exercise Testing © Should be part of initial evaluation of all patients with CHF. © Coronary arteriography © Should be performed in patients presenting with heart failure who have angina or significani ischemia Reasonable in patients who have chest pain that may or may not be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina. * Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure. 

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CRunther testo ic Weort (Poiture © Endomyocardial biopsy © Not frequently used © Really only useful in cases such as viral- induced cardiomyopathy 

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ChossFicaiod oP Wet Puttin © 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 

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ChossFicatiod oP Wet Pune (cost.) © ACC/AHA Guidelines © Stage A - High risk of HF, 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 

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‎Gypstolic Wewt‏ اه امه سومان ‎Putas‏ ‎© 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) ‎ 

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و وه ‎Order‏ 1. Loop diuretics 2. ACE inhibitor (or ARB if not tolerated) Beta blockers Digoxin Hydralazine, Nitrate Potassium sparing diuretcs ga Ew 

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Oiuretics © Loop diuretics ° Furosemide, buteminide © For Fluid control, and to help relieve symptoms © Potassium-sparing diuretics © Spironolactone, eplerenone © Help enhance diuresis © Maintain potassium © Shown to improve survival in CHF 

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له" 0۵۶) © Improve survival in patients with all severities of heart failure. © Begin therapy low and titrate up as possible: © Enalapril - 2.5 mg po BID © Captopril - 6.25 mg po TID © Lisinopril - 5 mg po QDaily © If cannot tolerate, may try ARB 

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eta locker therapy © Certain Beta blockers (carvedilol, metoprolol, bisoprolol) can improve overall and event free survival in NYHA class II to Ill HF, probably in class IV. © Contraindicated: © Heart rate <60 bpm © Symptomatic bradycardia ® Signs of peripheral hypoperfusion * COPD, asthma © PR interval > 0.24 sec, 2™ or 3 degree block 

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له ۳() دم اهر © Dosing: © Hydralazine © Started at 25 mg po TID, titrated up to 100 mg po TID © Isosorbide dinitrate © Started at 40 mg po TID/QID © Decreased mortality, lower rates of hospitalization, and improvement in quality of life. 

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

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حصاه<() سصاا ود دص ام ‎Obker‏ ‎Gratias‏ -- © Statin therapy is recommended in CHF for the secondary prevention of cardiovascular disease. © Some studies have shown a possible benefit specifically in HF with statin therapy © Improved LVEF © Reversal of ventricular remodeling © Reduction in inflammatory markers (CRP, IL-6, TNF-alphall) 

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Oeds ty BOO10 ia heat Puture © NSAIDS * Can cause worsening of preexisting HF © Thiazolidinediones © Include rosiglitazone (Avandia), and pioglitazone (Actos) © Cause fluid retention that can exacerbate HF © Metformin ۶ People with HF who take it are at increased risk of potentially lethic lactic acidosis 

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Aspphoctable Curdioventer-DePibrilatrs Por و 2 We © Sustained ventricular ۱ tachycardia is associated with sudden cardiac death in HF. © About one-third of mortality in HF is due to sudden cardiac death. © Patients with ischemic or nonischemic cardiomyopathy, NYHA class II to Ill HF, and LVEF = 35% have a significant survival benefit from an implantable cardioverter- defibrillator (ICD) for the primary prevention of SCD. 

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QOuacageweu oF (RePractory Wew Pure © Inotropic drugs: * Dobutamine, dopamine, milrinone, nitroprusside, nitroglycerin © Mechanical circulatory support: © Intraaortic balloon pump © Left ventricular assist device (LVAD) © Cardiac Transplantation * Ahistory of multiple hospitalizations for HF * Escalation in the intensity of medical therapy © Areproducable peak oxygen consumption with maximal exercise (Wo2max) of <14 mL/kg per min. (normal is 20 mUkg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication. 

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عصاه<) ‎Orvowpeusuted Wem‏ طح © Cardiogenic pulmonary edema is a common and sometimes fatal cause of acute respiratory distress. © 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. 

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@rvute Orvowpeuscoted Wen (Pure )7( © Causes: ° Acute MI © Rupture of chordae tendinae/acute mitral valve insufficiency ° Volume Overload ° Transfusions, IV fluids © Non-compliance with diuretics, diet (high salt intake) ° Worsening valvular defect ° Aortic stenosis 

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© Symptoms © Severe dyspnea * Cough © Clinical Findings ° Tachypnea © Tachycardia © Hypertension/Hypotension © Crackles on lung exam ° Increased JVD * 53, 54 or new murmur 

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bubs/Gtudies i Brute Orvowpeusuted Weert Puttin © Chemistry, CBC © EKG © Chest X-ray © May consider cardiac enzymes © 2D-Echo 

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صى ]نه ) ‎Wewt‏ لجادجوج م ۱6۱ ° Treatment © Strict I’s and O’s, daily weights © Oxygen, mechanical ventilation if needed © Loop diuretics (Lasix!) © Morphine ° Vasodilator therapy (nitroglycerin) © Nesiritide (BNP) - can help in acute setting, for short term therapy 

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

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Oven kA tena) © PMH: ۶ CAD - MI and CABG in 2002 © Hypertension © Diabetes Mellitus © Hypothyroidism © Allergies: * NKDA © Outpatient Meds: © Synthroid * Metformin * Norvasc 

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Oven kA tena) © Physical Exam: ۶ 97.6, 168/72, 99, 28, 93% on RA © Gen: Alert and oriented x 3, breathing rapidly © CV: RRR, no murmurs; mod. JVD © Resp: Crackles throughout lungs ° Abd.: soft, nontender, NABS © Ext: 2 + pitting edema bilaterally 

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Oven kA tena) © Labs: ۶ ‏:0و۲‎ 5 © Trop. |- 0.01 ° WBC: 8 © CPK: 120 © Platelets: 240 * Sodium: 139 ۶ Potassium: 3.8 © BUN: 18 © Cr: 0.8 

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Cue #1 

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Cuse # (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? 

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

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Cur #O © On examination her heart rate is 75/min and her blood pressure is 185/93 mm Hg. BMI is 32.9. Jugular venous pressure is mildly elevated. Lung examination reveals a few bibasilar crackles. Cardiac examination reveals regular rhythm, normal S1 and S2 and the presence of an S3. There is mild peripheral edema. An echocardiogram is significant for left ventricular hypertrophy and severely decreased systolic function (left ventricular ejection fraction, 20%) An electrocardiogram shows a previous anteroseptal MI. 

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Cur #S © Which of the following is the most appropriate next diagnostic test? (a) Measurement of plasma BNP (8) Serum Protein Electrophoresis (c) Cardiac Stress Test ‎Cardiac catheterization‏ (ه) ‎(ce) Endomyocardial biopsy ‎