Congestive Heart Failure

Congestive Heart Failure Bernardo D. Morantte Jr. M.D. Dept. of Medicine College of Medicine Pamantasan Ng Lungsod Maynila

Congestive Heart Failure  It is a condition when the heart fails to pump

the expected cardiac output due to reduced myocardial contractility. This is known as systolic heart failure.  When it is due to stiffness of the ventricle it is known as diastolic heart failure.  It can occur in myocardial ischemia or mechanical abnormalities such as valve defects and congenital anomalies.

Pathophysiology:  The symptoms and physical examination

findings in congestive heart failure are due to:  1. low cardiac output  2. water retention  General Causes of CHF:  1. myocardial diseases  2. mechanical causes ex. Valvular defects  3. pericardial diseases

Key Symptoms of Congestive Heart Failure (CHF)  Dyspnea/ orthopnea and PND  Reduced physical capabality  Weight gain and water retention

Goals of History Taking 1. determine whether the symptoms are acute or chronic 2. establish the degree of functional impairment 3. determine the cause

New York Heart Functional Class I II

No symptoms or no limitation Mild restriction or symptoms only on moderate to extreme physical exertion III Symptoms on slight physical exertion or moderate physical restriction IV Symptoms at rest or severe physical restriction

Key Features on Physical Examination  Abnormal vital signs  Abnormal physical appearance  Abnormal cardiac findings  Pulmonary congestion  Signs of water retention

Abnormal Vital Signs and Physical Appearance  Restlessness  Cyanosis  Pallor and sweating  Hypertension or hypotension  Tachycardia and abnormal rhythm  Tachypnea and use of accessory muscles for

respiration.

Abnormal Cardiac Findings  Jugular venous engorgement  Cardiomegaly  Tachycardia and abnormal cardiac rhythm  Presence of heart murmurs  Presence S3, S4 or summation gallops

Signs of Pulmonary Congestion Decreased breath sounds Dullness on percussion Auscultation: Crepitant (fine) or subcrepitant rales on both lungs Expiratory wheezing Peripheral Cyanosis

Signs of Water Retention  Weight gain  Dependent edema_ pedal or sacral  Ascites  Hepatomegaly  Anasarca  Jugular venous distention

Ancillary and Diagnostic Laboratory Examination  Chest x-ray  Echocardiography and doppler (most

important)  Bedside hemodynamic monitoring  BNP > 500 pcg/ ml  EKG  Cardiac enzymes  Azotemia and uremia

Chest x-ray  Cardiomegaly  Pulmonary venous engorgement  Kerley B lines  Pleural effusion  Pulmonary edema

EKG  You do not make a diagnosis of CHF based

on the EKG  But there are EKG abnormalities associated with CHF.  EKG abnormalities may give clues to the cause or diagnosis

EKG ABNORMALITIES Presence of atrial or ventricular hypertrophy Presence of cardiac arrhythmias LBBB Acute changes consistent with acute MI Electrical alternans

Bedside Hemodynamic Monitoring  Urine output  Swan Ganz catheter insertion (invasive)  Measurement of cardiac outputs  Measurement of arterial O2 saturations  Measurement of pulmonary venous O2

saturations  BP monitoring

Echocardiography  Abnormal parameters of systolic function

Reduced Ejection fraction (EF) Reduced velocity of circumferential fiber shortening (VCF) Increased end systolic volume (ESV) Segmental wall motion abnormalities Abnormal diastolic function presence of ventricular hypertrophy abnormal mitral valve diastolic flow by doppler

M-mode Echocardiogram Diagrammatic representation  Ejection fraction = EDV- ESV / EDV  Velocity of circumferential shortening (VCF) Anterior wall RV Septum EDV LV

cms

ESV

VCF

Posterior wall

1 sec.

Assessment Goal  Determine the degree of congestive heart

failure  ? Acute or chronic  ? Right sided or left sided ventricular failure or both  ? Low output ( common) or high output cardiac failure  Systolic or diastolic failure  Arrive at the cause or the diagnosis

PHYSICAL EXAM in CHF RIGHT SIDED

LEFT SIDED

 JVP: increased  RVH or dilatation: ex. sternal

 Normal  None

   

pulsation present Displaced PMI: no S2: P2 component increased Right sided S3 present Pulmonic and/ or tricuspid murmurs maybe present Crepitant (Fine) rales: no

 Hepatomegaly: maybe present  Pedal edema: present

 Yes  A2 may be increased  Left sided S3 present  Mitral and /or aortic murmurs

maybe present.  yes  absent  absent

ALGORYTHM Dyspnea (Acute or Chronic) Signs of cardiac dysfunction JVP, S3, abnormal murmur (95% specificity) Yes No Respiratory diseases Cardiac Signs of left sided failure AcuteCauses: Acute MI Arrythmias Ruptured MV Endocarditis Renal failure Hypertensive crisis Congenital HD

Signs of right sided failure

Chronic stage: Ischemic HD Valvular HD Cardiomyopthy Hypertensive HD etc.

Pulmonary hypertension Acute causes: 2.Pulmonary emboli 2. Endocarditis of PV and TV 3. RV infarction

Criteria for diagnosis of CHF I.

Framingham criteria

III. Evidence based medicine: CHF  Sensitivity Specificity JVP <50-68%  S3 gallop 69-89% 95%  cardiomegaly 53-87% 90%  abnormal  murmurs 80-95% 80-100% Suggested criteria: 3 out of 4

Causes of Acute Left Sided HF  Acute Myocardial infarction  Tachy and brady arrhythmias  Valvular heart disease especially acute events such    

as ruptured papillary muscle, ruptured chordae Ruptured Ventricular septum Hypertensive Crisis Bacterial endocarditis/ fulminating myocarditis Acute renal failure

Goal of Therapy in CHF  1. remove the excess water  2. improve cardiac output  3. correct the underlying cause

Therapy in Acute CHF Remove excess water by:  Fluid restriction  IV diuretics with loop diuretics Improve cardiac output:  BP support with IV inotropic agents  Afterload reducing agents and antihypertensive therapy  Correct cardiac arrhythmias Supportive care: Make patient comfortable  Oxygen supplement  Mechanical ventilator support if indicated Correct the underlying cause:  Management of Acute MI  Hemodialysis for acute renal failure  Correct other underlying causes

Causes of Acute Right Sided HF Large pulmonary emboli n Bacterial endocarditis of the pulmonic/ tricuspid valve n Right ventricular infarction n

n

Therapy: depends on the cause plus the management of CHF in general

Causes of Chronic CHF  All cardiac diseases will eventually lead to

CHF  Renal failure  Pulmonary diseases (right sided failure)

Therapy in Chronic CHF   

Dietary restriction on salt_ 1 gm/ day Fluid restrictions Use of Diuretics_ loop diuretics, Thiazides, K sparing

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Inotropic agents such as Digoxin After load reducing agents such as ACE I inhibitors, ARB Cautious use of beta blockers for diastolic heart failure

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Correction of the underlying cause such as by cardiac valve surgery, PTCA and stents, CABG, repair of congenital anomalies Treatment of associated illness such as anemia, thyrotoxicosis, chronic lung disease Cardiac resynchronization therapy (CRT) for bundle branch block

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Cardiac rehabilitation and exercise program Cardiac transplantation for severe refractory CHF

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Preventive measures Treatment of risk factors for Coronary artery disease (CAD) SBE prophylaxis for valvular disease

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