Congestive heart failure

NYHA Classes

1. No Sx
2. Sx with every day activity
3. Severely limits activity
4. Sx at rest

Work-Up

Key Historical Questions

1. History of heart failure?
2. Have you been taking your meds?
3. Any recent changes in medication?
4. SOB while: lying flat, walking, middle of night?
5. CP?
6. Syncope?

Studies

1. CBC (r/o anemia), chemistry
2. ECG
3. CXR
4. Troponin?
5. BNP?
   1. <100 (90% Sn)
   2. > 500 (87% Sp)
   3. Elevated in:
      1. Elderly, kidney failure, PE
   4. Decreased in:
      1. Obese

DDX

1. Cardiovascular
   1. ACS
   2. Acute valve dysfunction
   3. Aortic Dissection
   4. Dysrhthymia
   5. Endocarditis
   6. Hypertensive crisis
   7. Pericardial tamponade
2. Pulmonary
   1. COPD
   2. PE
   3. PNA
3. Other
   1. Pure volume overload
      1. Renal failure
      2. Post-transfusion
   2. Sepsis

Causes of Decompensation

1. Medical noncompliance
2. Dietary noncompliance
3. ACS
4. Dysrhythmia
5. Uncontrolled HTN
6. Infection
7. Anemia
8. Thyrotoxicosis
9. PE

Underlying Etiology

1. CAD
2. HTN
3. Cardiomyopathy
4. Valvular
5. High-output
6. Post-partum

Treatment

1. UNLOAD+
   1. Upright Position
   2. Nitrates
      1. Consider nitroprusside if NTG ineffective
   3. Lasix
   4. Oxygen
   5. ASA
      1. Digoxin
         1. Indicated for a fib rate control
2. ACEI
   1. Enalaprilat 0.004mg/kg as IVB or 1mg gtt over 2hr
      1. Avoid in pregnancy, hyperK+
3. BiPAP

Disposition

Admission Criteria (AHCPR '00)

1. ACS
2. Pulm edema/resp distress
3. O2 sat < 90% on room air
4. Severe complicating illness
5. CHF refractory to outpt therapy
6. Anasarca
7. Symptomatic hypotension or syncope
8. Arrythmia (e.g. new a. fib)
9. Inadequate outpt support

See Also

Cards: CHF Meds

Source

EB Medicine, UpToDate, DONALDSON (adapted from Lampe)