High output heart failure:
Increase in CO because of increased peripheral oxygen demands
Systolic dysfunction;
Impaired contractility; Decreased EF
Systolic dysfunction: Causes
Ischemia, HTN –> Cardiomyopathy,
valvular heart disease,
myocarditis,
Alcohol,
radiation,
hemochromatosis,
thyroid disease
Diastolic dysfunction:
Impaired filling; Impaired relaxation or increased stiffness of ventricle or both
Diastolic dysfunction: Causes
- HTN –> myocardial hypertrophy,
- aortic stenosis,
- mitral stenosis,
- aortic regurg,
- restrictive cardiomyopathy
PND:
Waking after 1-2 hours of sleep due to SOB
Pathologic S3:
rapid filling into non-compliant left ventricular chamber
S4 gallop:
Atrial systole as blood is ejected into non-compliant, stiff, left ventricular chamber; heard best at left sternal border
New York heart association classification
- Symptoms with vigorous activity
- Symptoms with mild activity
- Symptoms with regular daily activity
- Symptoms at rest. incapacitating
Tests to order for CHF:
CXR, ECG, Cardiac enzymes, CBC, ECHO
CHF: CXR findings
- Cardiomegaly,
- Kerley B lines (pulmonary congestion; secondary to dilation of pulmonary lymphatic vessels),
- Prominent interstitial markings
Systolic dysfunction: Treatment options
(Diuretics, spirono, ACEi, B-blocker, Digitalis, Hydralazine)
- Lifestyle modifications,
- Diuretics (symptomatic relief)
- Initial treatment for symptoms
- Spironolactone
- Effective in NYHA class 3/4
- ACE inhibitor
- Given to all Systolic heart failure pts
- Beta-Blockers
- Given to stable patients
- Digitalis
- EF <40 who have symptoms despite optimum treatment with all above
- Hydralazine / isosorbide dinitrates
- pts who cant tolerate ACEi
CHF: ACE inhibitors
Venous / Arterial dilation
Decrease Preload / afterload
Reduction in mortality
Alleviate symptoms
CHF: Spironolactone
prolong survival in NYHA 3/4;
monitor renal function and K+
CHF: beta blockers
- Decrease mortality in pts post MI Heart failure
- Slow progression of heart failure (inhibit tissue remodelling)
- Improve symptoms
- Anti-arrythmic and Antischemic effect
- Carvedilol > metoprolol, bisoprolol >>>> all others
CHF: Digitalis
- Short term symptomatic releif
- No change in mortality
*
CHF: Hydralazine
Reduce mortality (in place of ACEi)
CHF: Digitalis - signs of toxicity
- GI: N/V
- Cardiac:
- ectopic ventricular beats,
- AV block,
- AFib
- CNS:
- Visual disturbances,
- Disorientation
CHF: Systolic dysfunction - contraindications
- Metformin: potentiallly lethal lactic acidosis
- Thiazolidinediones: fluid retention
- NSAIDS: increased risk of exacerbation
- Antiarrythmics with negative ionotropic effects
Systolic dysfunction: Devices that reduce mortality
- ICD: Prevent SCD
- Indication:
- 40 days post MI
- EF <35
- Class 2/3 symptoms
- Indication:
- Cardiac resynchronization therapy
- Biventricular pacemaker
- Indications:
- Same + QRS >120
CHF: Diastolic dysfunction - treatment
- Beta blockers: clear benefit
- Diuretics for symptoms
- ACEi and ARBs possibly
CHF: Diastolic dysfxn - contraindications
Digoxin/spironolactone
General principles of CHF treatment: NYHA classification
NYHA1
- Loop if volume overload / pulm congestion
- ACEi
NYHA 2/3
- Add beta blocker
NYHA 3/4
- Add Digoxin (can be added at any time)
- possibly add spironoactone
Acute Decompensated heart failure
Acute dyspnea associated with elevated left sided filling pressures, with or without pulmonary edema
