View source for Congestive heart failure

{{Adult top}} [[congestive heart failure (peds)]]
==Background==
*Assume [[valvular disease|valvular problem]] in new-onset CHF
*Assume valve thrombosis in CHF with a prosthetic valve
*Do not give vasodilators in [[aortic stenosis]], [[HOCM]]; yes in [[mitral regurgitation]]

===Classification===
*Systolic: poor contraction (↓EF) and decreased forward flow
*Diastolic: good contraction (normal EF) but stiff ventricles and poor filling
*Left-sided: LV failure, poor organ perfusion, dyspnea from backup in lung
*Right-sided: peripheral edema, JVD, hepatomegaly
**Most common cause is left-sided failure

===NYHA Classes===
#No symptoms
#Symptoms with every day activity
#Severely limits activity or symptoms with minimal activity
#Symptoms at rest

===Etiology===
*[[Acute coronary syndrome]] (CAD)
*[[Hypertension]]
*[[Cardiomyopathy]]
*[[Valvular emergency]]
*[[High-output heart failure]]
*[[Peripartum cardiomyopathy]]
*[[Cardiac tamponade]]
*[[Dysrhythmias]]

==Clinical Features==
[[File:Elevated JVP.jpg|thumb|Marked jugular venous distension (arrow).]]
[[File:PedalEdema.jpg|thumb|Pitting pedal edema]]
===History & Physical Examination<ref>Peacock W. Chapter 57: Congestive Heart Failure and Acute Pulmonary Edema.  In: Tintinalli J. Tintinalli's Emergency Medicine. A comprehensive study guide. 7th ed. 2011: 405-415.</ref>===
''Different types of presentations:''
#Hypotensive Heart Failure ([[cardiogenic shock]])
#*Least common, worst prognosis
#*[[shortness of breath]], [[pulmonary edema]], narrow pulse pressure, signs of poor end-organ perfusion, [[altered mental status]], cool peripheries, decreased urine output, increased HR, sBP < 90 mmHg
#Normotensive Heart Failure
#*Develops over days to weeks
#*Weight gain, peripheral edema, less shortness of breath, +/- rales
#Hypertensive Heart Failure
#*Most common, presses rapidly
#*sBP > 140 mmHg, preserved LV function, marked shortness of breath, minimal weight gain, rales, increased HR, pulmonary edema on CXR
#Acute (Flash) Pulmonary Edema
#*Severe respiratory distress, relative hypertension, cool dipahoretic skin, +/- rales, JVD (94% specific, 39% sensitive), +/- peripheral edema, S3 (99% specific)

==Differential Diagnosis==
{{CHF}}

===Causes of CHF Decompensation===
*Medication noncompliance
*Dietary noncompliance
*Uncontrolled [[hypertension]]
*[[MI]]
*[[Valvular Dysfunction]]
*[[Arrhythmias]]
*Infection
*Inappropriate medications (e.g., negative inotropes)
*Fluid overload
*[[Missed dialysis]]
*[[Thyrotoxicosis]]
*[[Anemia]]
*[[Alcohol Withdrawal]] or [[alcohol intoxication]]
*[[Sympathomimetic]] excess
*Acute [[hypoxia]] or other respiratory problems
*[[Myocarditis]]
*[[Pulmonary embolism]]
*Excessive exertion or trauma

{{Elevated BNP}}

==Evaluation==
[[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]]
[[File:Kerley-B-Linien.jpg|thumb|Kerley B lines in acute cardiac decompensation. The short, horizontal lines can be found everywhere in the right lung.]]
*CBC (rule out anemia)
*Chemistry
*[[ECG]]
*[[Digoxin]] level
*[[CXR]]
**Cephalization
**Kerley B lines (thick and horizontal)
**Interstitial edema
**Pulmonary venous congestion
**Pleural effusion
**Alveolar edema 
**Cardiomegaly
*[[Troponin]]/CK
*[[Ultrasound]]
**Bedside to assess [[Cardiac ultrasound|global function]], [[Ultrasound: lungs|B lines]], [[IVC ultrasound|assessment of IVC]]
**Formal TTE/TEE

{{BNP value}}

{{Lung ultrasound pulmonary edema}}

==Management==
===Acute Pulmonary Edema and Hypertensive Heart Failure===
See [[Pulmonary Edema]] or [[Sympathetic crashing acute pulmonary edema (SCAPE)]]

===Hypotensive Heart Failure===
See [[Cardiogenic Shock]]

'''Inotropic Agents'''
*[[Dobutamine]] generally first line
*[[Milrinone]] if patient on beta-blockers
*Consider in severe LV dysfunction and low output syndrome
**Diminished peripheral perfusion and end organ damage
*Vasodilatory treatment inadequate response or limited by symptomatic hypotension
*Must have obvious evidence of elevated filling pressures
**JVD, noncollapsing IVC, etc
*Inotropes are not indicated in setting of preserved systolic function

===Heart Failure Without Pulmonary Edema===
[[File:Starling.jpg|thumbnail|Goal in heart failure management is to reduce preload (EDV), to reach higher SV on Frank Starling curve.]]
'''UNLOAD+'''
#Upright Position
#[[Nitrates]]
#*Do not use with [[sildenafil]], severe AS, or if right-sided MI
#*Start sublingual [[nitroglycerin]] 0.4mg delivered over 4 min = 0.10mg/min
#*If no improvement IV [[nitroglycerin]] drip, start 0.3-0.5mcg/kg/min, but may increase to 3-5mcg/kg/min
#**Keep BP >95 
#*Consider [[nitroprusside]] 0.3 mcg/kg/min if hypertension or [[nitroglycerin]] ineffective
#[[Lasix]]
#*Hold if no symptoms of fluid overload
#*Give nitrates first
#*Give double home dose, or up to 2.5x dose.
#**If lasix 40mg po QD, then lasix 40-100mg IV
#[[Oxygen]]
#*[[CPAP]]/[[BiPAP]]
#**Increases intrathoracic pressure and thus reduces preload
#[[ACEI]]
#*Afterload reduction
#*[[Enalaprilat]] at 0.004mg/kg as IVB or 1mg drip over 2hr
#**Avoid in pregnancy, hyperK+, angioedema
#[[Digoxin]]
#*[[Pulmonary edema|Decompensated HF]]
#**[[Digoxin]] and [[Amiodarone]] are the only medications indicated for use in decompensated HF for rate control if needed<ref>January CT, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: Executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014; 64(21):2246-2280.</ref>
#**Evidence suggests that treating rate in acutely ill patients including CHF leads to worse outcomes<ref>Scheuermeyer FX, et al. Emergency department patients with atrial fibrillation or flutter and an acute underlying medical illness may not benefit from attempts to control rate or rhythm. Ann Emerg Med. 2015; 65(5):511-522.e2.</ref>
#*Compensated HF (not acutely symptomatic from failure)
#**May benefit from a fib rate control, but calcium-channel blockers and beta-blockers first line, goal of < 85 bpm per RACE II trial
#**[[Diltiazem]] low and slow at 5mg/hr
#***AVOID in severe heart failure, preexcitation syndrome
#***AVOID in significant hypotension
#**[[Metoprolol]] 2.5 - 5.0mg over 2 min, then q5 as needed to max of 15mg
#**[[Esmolol]] 0.5mg/kg bolus over 1 min, then 50 mcg/kg/min, may increase q30 min by 50 mcg/kg/min

===Medications to Avoid===
*Anti-dysrhythmics other than [[digoxin]] and [[amiodarone]]
*[[Calcium-channel blockers]] - worsen HF
*[[NSAIDs]] - sodium retention, worsen toxicity of diuretics and ACE-I
*[[Thiazolidinediones]] - worsen HF
*[[Morphine]] - chart reviews show increased morbidity in ADHF patients<ref>Peacock WF, Hollander JE, Diercks DB, Lopatin M, Fonarow G, Emerman CL. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008 Apr;25(4):205-9.</ref><ref>Ellingsrud C, Agewall S. Morphine in the treatment of acute pulmonary oedema--Why? Int J Cardiol. 2016 Jan 1;202:870-3.</ref>

==Disposition==

===Admission Criteria===
'''CCORT - Emergent Heart Failure Mortality Risk Grade Calculator'''
*7 day mortality risk score calculator for patients presenting to the ED with decompensated HF  
*https://ehmrg.ices.on.ca

'''AHCPR '00'''
*ACS
*Pulmonary edema/respiratory distress
*O2 sat < 90% on room air
*Severe complicating illness
*[[CHF]] refractory to outpatient therapy
*Anasarca
*Symptomatic hypotension or syncope
*Arrhythmia (e.g. new a. fib)
*Inadequate outpatient support

===CHF Drug Target Doses===
*[[ACE inhibitor]]
**[[Lisinopril]] 5mg QD start; 20mg QD goal
**[[Captopril]] 25mg tid start; 100mg tid goal
**[[Benazepril]] 10mg QD start; 40mg QD goal
*[[ARB]]
**[[Losartan]] 25mg BID start; 50mg BID goal
**[[Valsartan]] 80mg QD start; 160mg QD goal
*[[Beta-blocker]]
**[[Carvedilol]] 3.125mg BID start; 25mg BID goal (50mg BID goal if weight > 85 kg)
**[[Metoprolol]] ER 12.5mg QD start; 190mg QD goal
*Others
**[[Hydralazine]]/[[isosorbid]] dinitrate 10-20mg (1 tab) tid start; 100-80mg (5 tabs) goal for black patients with NYHA III-IV already on BB and ACEi
**[[Spironolactone]] 25mg QD start; 50mg QD goal for indications:
***LVEF < 30% with NYHA II
***LVEF < 35% with NYHA III-IV
***LVEF < 40% post-MI, goal ACE-I, symptomatic CHF, or DM

==See Also==
*[[Pulmonary Edema]]
*[[CHF Meds]]

==External Links==
*[http://www.mdcalc.com/emergency-heart-failure-mortality-risk-grade-ehmrg/ MDCalc - Emergency Heart Failure Mortality Risk Grade (EHMRG)]
*[http://www.emdocs.net/ed-management-heart-failure-pearls-pitfalls/ emDocs - ED Management of Heart Failure: Pearls and Pitfalls]

==References==
<references/>

[[Category:Cardiology]]