Congestive Heart Failure Flashcards
(1) Defined as the hearts inability to pump enough blood throughout the body.
(2) Primarily a disease of aging. 75% of cases in patients over 65 years old.
(3) Normally one way the heart helps to maintain homeostasis is if there is a decrease in cardiac output the body will first signal the Renin- Angiotensin- Aldosterone system to retain fluid in the kidneys. That increase in fluid will increase blood returning to the heart and the restore cardiac output.
(4) Secondly, if the heart starts to slowly fail (decreased ejection fraction) it will trigger to kidneys to retain fluid so that you have more blood coming into the heart and then it causes
increased volume and increased stretch in the LV, which will increase cardiac output (according to the Frank-Starling principle increase stretch will cause increase contractility and thus increased
cardiac output) until a certain point when the stretch
no longer produces a larger CO.
General: Congestive Heart Failure
refers to that ventricle no being able to distend well in order to receive adequate
blood volume from the atrium.
1) This is typically referring to the left ventricle in which there is left ventricular hypertrophy due to uncontrolled HTN.
2) This occurs when the left ventricle becomes thicker and thus leading to more resistance to distending as the left atrium is attempting to contract and fill the LV with more blood.
Diastolic CHF
refers to that ventricle not contracting well leading to decreased cardiac output from that ventricle (this is typically referred to as having a decreased ejection fraction from that ventricle).
1) This is typically due to cardiac ischemia to that ventricle, most commonly the left ventricle.
2) This can also be due to cardiomyopathy, valvular heart disease.
3) This also can be due to extremely high Hypertension which inhibits part of the cardiac output because all the ventricles energy is being used to overcome the Aortic pressure (in the case of the
left ventricle).
Systolic CHF
(1) Heart failure may be right sided or left sided and systolic or diastolic.
(a) Left sided refers to the left ventricle being the problem.
(b) Right sided refers to the right ventricle being the problem.
(c) Systolic refers to that ventricle not contracting well leading to decreased cardiac output from that ventricle (this is typically referred to as having a decreased ejection fraction from that ventricle).
(d) Diastolic refers to that ventricle no being able to distend well in order to receive adequate
blood volume from the atrium.
(e) The most common type of CHF is left ventricular systolic failure.
(f) The most common cause of right heart failure is left heart failure.
Pathophysiology: Congestive Heart Failure
***The pressure is backing up into the lungs so symptoms will be dyspnea, orthopnea, dyspnea on exertion, pulmonary edema, chronic non-productive cough, exercise intolerance, fatigue.
***Examination findings: Crackles in bases of lungs, pleural effusions, expiratory wheezing or rhonchi, Enlarged sustained LV impulse, Decreased S1, murmurs, S3, hypoxemia, displaced apical impulse (if LVH or dilated).
Left sided symptoms: CHF
***The pressure is backing up into the venous system so symptoms will be due to fluid retention, peripheral edema, hepatic congestion, abdominal ascites.
***Examination findings: JVD, elevated JVP, Hepatomegaly, Ascites (fluid wave on abdominal examination), peripheral pitting edema.
Right sided symptoms: CHF
(1) Many patients will have decreased exercise tolerance and dyspnea or fatigue which could be due to AMI, pulmonary disease, PE, Pneumothorax, depression, sleep apnea, or deconditioning.
(2) Fluid retention: Could be due to DVT, venous insufficiency, sodium retention, drug side effects (like CCB), kidney nephrotic syndrome, or liver cirrhosis.
(3) Also could be due to Hypertensive Emergency.
Differential Diagnosis: Congestive Heart Failure
(1) BUN/Creatinine, LFTs, electrolytes.
(2) B type Natriuretic Peptide (BNP) – released from the myocardial tissue in response to increased heart distention which signals the kidneys to start removing more fluid.
(3) CXR: To look for cardiomegaly, pleural effusions, pulmonary edema
(4) EKG: Looking for AMI, arrhythmia, or LVH
(5) Echocardiography to look for LV and RV ejection fraction, looking for valvular disease, looking for how easily the LV relaxes to fill, and looking for LVH.
Labs/Studies/EKG: Congestive Heart Failure
(1) Acute Exacerbation
(a) IV, Oxygen if saturation < 94%, Monitors, Vitals, Foley Catheter
***(c) Diuretics
1) Furosemide (Lasix) 40 mg IV, if inadequate urine output in 30
minutes then repeat the dose.
2) Bumetanide (Bumex) 1 mg IV, if inadequate urine output in 30
minutes then repeat the dose.
*Inhibits loop of Henle (diuretics)
IDC cant do shit on DDG
Treatment: Congestive Heart Failure
(a) Lifestyle changes
(b) Low sodium diet (< 2 grams per day)
(c) Alcohol intake reduction
(d) Smoking Cessation
(e) Exercise
(f) Medications
Chronic Treatment: Congestive Heart Failure
1) ACE Inhibitors – help with myocardial remodeling after AMI
as well as helps protect the kidneys from failing.
2) Diuretics to keep extra fluid from overloading the heart.
3) Nitroglycerine to cause venous vasodilation which decreases
the amount of blood coming to the heart and helps prevent
volume overload.
***Medications: Congestive Heart Failure
(1) ABC’s, Monitor, IV, Oxygen if saturation < 94%, Vitals.
(2) If in pulmonary edema then give Lasix.
(3) EKG to rule out AMI, arrhythmias.
(4) Transfer to higher level of care
Initial Care: Congestive Heart Failure
