Congestive Heart Failure

Definition

Heart failure is a clinical syndrome characterized by systemic perfusion inadequate to meet body metabolic demand Heart ability to fill or to eject the blood is impair.

Prevalence

5 millions American 1 millions american admitted every year 2 HF in US Most common cause heart failure is LV systolic dysfunction Most cases are the result of CAD, idiopathic dilated cardiomyopathy , valvular heart disease, toxic induce cardiomyopathy (doxorubicin) RV failure is usually secondary to left ventricle failure

Pathophysiology
baroreceptor and osmotic stimuli lead to vasopressin release from the hypothalamus, causing reabsorption of water in the renal collecting duct

Worsening of the failing pump

sympathetic nervous system increases heart rate and contractility IN NONESENTIAL VASCULAR BED AND INCREASE RENIN catecholamines aggravate ischemia, potentiate arrhythmias, promote cardiac remodeling, and are directly toxic to myocytes

NYHA

If suspecting CHF
Hx of CAD ? (Most common cause) Current and past use of: ETOH, illicit drugs, alternative drugs, chemotherapy. Hx of recent viral infx (Coxsackie B, influenza, adenovirus

Diagnosis

The diagnosis of heart failure is dependent on a careful assessment of the symptoms and signs complemented by diagnostic testing

Symptoms

Dyspnea(mostly DOE) Orthopnea Paroxysmal nocturnal dyspnea (increases the likelihood of HF, greater than 2fold) Ankle edema Cachexia Gastrointestinal symptoms (Anorexia, nausea, early satiety)

Physical Examination

General appearance (distress, cyanosis) Vital signs (Low BP, tachycardia) JVD (> 8 cmH2O abnormal) Lung crackles S3 gallop (increases the likelihood of HF 11 fold) Abdomen (hepatomegaly, ascites) Extremities (edema, cold or warm to touch

Diagnosis (Lab)

Biomarkers of Myocardial injury r/o ACS causing BNP EKG: Essential diagnostic tool in the evaluation of the patient with HF, provides evidence of: CAD (prior MI or ongoing ischemia), arrythmias, ventricular or atrial enlargement, conduction abnormalities

Diagnosis (Chest Xray)

Diagnosis (echo)

Echocardiogram: The single most useful test in evaluating the etiology of the patient with HF, it can evaluate: Global systolic and diastolic function Regional wall motion abnormalities Valvular function Pericardial disease Hypertrophic or infiltrative cardiomyopathy Distinguish syst from diast HF

Treatment

Diuretics: Used for the management of volume overload Successful use of ACEI and BB contingent upon optimal use of diuretics Effects on morbidity and mortality are not known Do not use alone even if symptoms are controlled (neurohormonal activation) Stop if no congestion and uptitrate other evidence based medicines.

Treatment (ACEi)
Reduce mortality (about 20%) Reduce risk of MI (about 20%) Reduce hospitalizations for HF (about 30 to 40%) Delays the onset of clinical HF in pts with asymptomatic LV dysfunction. Reverse remodeling Contraindications: Hypotension Hx of Angioedema Cr 3 Anuric renal failure K 5.5 Pregnancy B/L renal artery stenosis

Treatment (hydralazine/ nitrate)

For pts who develop hyperkalemia or renal dysfunction with ACEI or ARBs In addition to ACEI and blockers in AfricanAmerican pts who have persistent NYHA class II IV symptoms - Inferior to ACE in improving survival

Treatment (BB)
Routinely administer to stable patients with systolic dysfunction (LVEF 40%) and mild, moderate, severe (NYHA II, III, IV symptoms) who are on standard therapy. Associated with about a 30% reduction in mortality Favor use of Carvedilol, Metoprolol Succinate, Bisoprolol.

Treatment (spironolactone)
Administer to pts receiving standard therapy ACEI and a blocker), in NYHA class III IV - Avoid when Cr is 2.5 or K 5 K monitoring: baseline, within a week, 1 month then every 3 months.

Treatment (digoxin)

Digoxin: Has been shown to reduce hospitalizations but has NOT been shown to affect mortality. Can be started in pts with NYHA class II IV for symptom control.

Thank you