Congestive heart failure

Background

• Assume valvular problem in new-onset CHF
• Assume valve thrombosis in CHF w/ a prosthetic valve
• Do not give vasodilators in AS, HOCM; yes in MR

NYHA Classes

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

Etiology

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

Diagnosis

1. CBC (r/o anemia)
2. Chem
3. ECG
4. CXR
   1. Cephalization
   2. Interstitial edema
   3. Pulmonary venous congestion
   4. Pleural effusion
   5. Alveolar edema
   6. Cardiomegaly
5. Troponin?
6. BNP?
   1. <100 (Sn 90%, NPV 89%)
   2. > 500 (Sp 87%, PPV 90%)
   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 Emergency
   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. Medication noncompliance
2. Dietary noncompliance
3. Uncontrolled HTN
4. MI
5. Valvular Dysfunction
6. Arrhythmias
7. Infection
8. Inappropriate medications (e.g., negative inotropes)
9. Fluid overload
10. Missed dialysis
11. Thyrotoxicosis
12. Anemia
13. Alcohol Withdrawal

Treatment

Acute Pulmonary Edema and Hypertensive Heart Failure

See Pulmonary Edema

Hypotensive Heart Failure

See Cardiogenic Shock

Heart Failure Without Pulmonary Edema

• UNLOAD+

1. Upright Position
2. Nitrates
   1. start SL 0.4mg delivered over 5 min = 0.15mg/min
   2. IV NTG gtt, start 0.3-0.5mcg/kg/min, but may increase to 3-5mcg/kg/min
      1. Keep BP >95
   3. Consider nitroprusside 0.3 mcg/kg/min if HTN or NTG ineffective
3. Lasix
   1. if no sxs of fluid overload, hold
   2. Give nitrates first
4. Oxygen
   1. CPAP/BiPAP -give early
5. ACEI
   1. Enalaprilat 0.004mg/kg as IVB or 1mg gtt over 2hr
      1. Avoid in pregnancy, hyperK+
6. Digoxin
   1. Indicated for a fib rate control

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

Pulmonary Edema

CHF Meds

Source

EB Medicine, UpToDate, DONALDSON (adapted from Lampe)