This document discusses congestive heart failure, including its causes, physiology, classification, signs and symptoms, diagnostic testing, and treatment. It defines heart failure as the heart's inability to pump enough blood to meet the body's needs. Common causes include heart attacks, ischemia, and valvular diseases. Treatment focuses on reducing preload and afterload, increasing contractility, and addressing any precipitating factors. Goals of admission orders are to stabilize the patient with medications, fluid management, and monitoring.

1. Congestive Heart Failure
Mr. Mahadev prasad,
Inscol Academy,
Lecture

3. Congestive Heart Failure
• Heart failure is the term used when
heart is unable to pump enough blood
to meet the metabolic needs of body
at rest or during exercise even though
filling pressures are adequate.

4. Predisposing Cardiac Diseases
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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
- Dyspnea
- Dec. exercise
tolerance
- Cough
- Orthopnea
- Pink, frothy sputum
Right Heart Failure
- Dec. exercise
tolerance
- Edema
- HJR / JVD
- Hepatomegaly
- Ascites

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

12. Clinical Data
• CXR
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Kerley’s lines : A and B
Pulmonary Edema
Cephalization
Pleural Effusions (bilateral)

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

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

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

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

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
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Infection
Pulm Embolus
Noncompliance
Arrhythmia
Myocardial Infarction
Stress reaction
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Sodium Intake
Medications!!!
Anemia
Thyroid disorders
Endocarditis

23. Admission Orders
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Admit: Telemetry or ICU
EKG STAT, then daily x 3 days
2D Echo
CXR
Labs: BMP, CBC, Coags, LFTs
Pulse ox (ABG)
Oxygen
ASA 325mg 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
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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