Congestive heart failure

2016-02-26T13:55:40Z

Geigerha: /* Hypotensive Heart Failure */

==Background==
*Assume 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]]

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

===Etiology===
*CAD
*[[HTN]]
*[[Cardiomyopathy]]
*[[Valvular Emergency]]
*High-output
*[[Peripartum Cardiomyopathy]]
*[[Cardiac Tamponade]]
*[[Dysrhythmias]]

==Clinical Features==
===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
#* Least common, worst prognosis
#* SOB, pulmonary edema, narrow pulse pressure, signs of end-organ perfusion, altered mental status, cool peripheries, decreased urine output, increased HR, sBP < 90 mmHg
# Hypertensive Heart Failure
#* Most common, presses rapidly
#* sBP > 140 mmHg, preserved LV function, makred SOB, minimal weight gain, rales, increased HR, pulmonary edema on CXR
# Normotensive Heart Failure
#* Develops over days to weeks
#* Weight gain, peripheral edema, less SOB, +/- rales
# Acute Pulmonary Edema
#* Severe respiratory distress, relative hypertension, cool dipahoretic skin, +/- rales, JVD (94% specific, 39% sensitive), +/- peripheral edema, S3 (99% specific)

==Differential Diagnosis==
*Cardiovascular
**[[ACS]]
**[[Acute Valve Dysfunction]]
**[[Aortic Dissection]]
**[[Dysrhthymia]]
**[[Endocarditis]]
**[[Hypertensive Emergency]]
**[[Pericardial Tamponade]]
*Pulmonary
**[[COPD]]
**[[PE]]
**[[PNA]]
*Other
**Pure volume overload
***[[Renal Failure]]
***Post-[[Transfusion]]
**[[Sepsis]]

===Causes of Decompensation===
*Medication noncompliance
*Dietary noncompliance
*Uncontrolled [[HTN]]
*[[MI]]
*[[Valvular Dysfunction]]
*[[Arrhythmias]]
*Infection
*Inappropriate medications (e.g., negative inotropes)
*Fluid overload
*Missed dialysis
*[[Thyrotoxicosis]]
*[[Anemia]]
*[[Alcohol Withdrawal]]

==Diagnosis==
[[File:PedalEdema.jpg|thumb|Pitting pedal edema]]
[[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]]
*CBC (r/o anemia)
*Chem
*ECG
*CXR
**Cephalization
**Interstitial edema
**Pulmonary venous congestion
**Pleural effusion
**Alveolar edema
**Cardiomegaly
*Troponin/CK
*[[Ultrasound]]
**Bedside to assess [[Ultrasound: Cardiac|global function]], [[Ultrasound: lungs|B lines]], [[Ultrasound: IVC|assessment of IVC]]
**Formal TTE/TEE

{{BNP value}}

==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 pt 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===
'''UNLOAD+'''
#Upright Position
#Nitrates - ask about sildenafil
#*Start SL 0.4mg delivered over 5 min = 0.15mg/min
#*If no improvment IV NTG gtt, 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 HTN or NTG ineffective
#[[Lasix]]
#*Hold if no sxs 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]] -give early
#[[ACEI]]
#*[[Enalaprilat]] at 0.004mg/kg as IVB or 1mg gtt 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 CCBs and BBs first line, goal of < 85 bpm per RACE II trial
#**Diltiazem low and slow at 5 mg/hr
#***AVOID in severe heart failure, preexcitation syndrome
#***AVOID in significant hypotension
#**Metoprolol 2.5 - 5.0 mg over 2 min, then q5 as needed to max of 15 mg
#**Esmolol 0.5 mg/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
*CCBs - worsen HF
*NSAIDs - sodium retention, worsen toxicity of diuretics and ACE-I
*Thiazolidinediones - worsen HF

==Disposition==

===Admission Criteria===
'''CCORT'''
*7 day mortality risk score calculator for pts presenting to the ED with decompensated HF
*http://www.ccort.ca/calculator.aspx

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

===CHF Drug Target Doses===
*[[ACE inhibitor]]
**[[Lisinoprol]] 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 (50 mg 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 pts with NYHA III-IV already on BB and ACEi
**[[Spironolactone]] 25 mg qd start; 50 mg 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

==External Links==
*[http://www.mdcalc.com/emergency-heart-failure-mortality-risk-grade-ehmrg/ MDCalc - Emergency Heart Failure Mortality Risk Grade (EHMRG)]

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

==References==

[[Category:Cards]]

<references/>

WikEM - User contributions [en]

Congestive heart failure