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    Congestive Heart Failure

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    sarguss14
    Congestive heart failure occurs when the heart fails to pump an adequate cardiac output due to reduced contractility or stiffness of the ventricles. It can be caused by myocardial ischemia, valve defects, or congenital anomalies. Symptoms include dyspnea, edema, and reduced exercise capacity due to low cardiac output and fluid retention. Diagnosis involves assessing ventricular function with echocardiography and determining the cause. Treatment focuses on removing excess fluid, improving cardiac output, and correcting the underlying cause through medications, surgery, or lifestyle changes.

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    Congestive Heart Failure

    Uploaded by

    sarguss14
    6K views28 pages
    Congestive heart failure occurs when the heart fails to pump an adequate cardiac output due to reduced contractility or stiffness of the ventricles. It can be caused by myocardial ischemia, valve defects, or congenital anomalies. Symptoms include dyspnea, edema, and reduced exercise capacity due to low cardiac output and fluid retention. Diagnosis involves assessing ventricular function with echocardiography and determining the cause. Treatment focuses on removing excess fluid, improving cardiac output, and correcting the underlying cause through medications, surgery, or lifestyle changes.

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    Congestive heart failure occurs when the heart fails to pump an adequate cardiac output due to reduced contractility or stiffness of the ventricles. It can be caused by myocardial ischemia, valve defects, or congenital anomalies. Symptoms include dyspnea, edema, and reduced exercise capacity due to low cardiac output and fluid retention. Diagnosis involves assessing ventricular function with echocardiography and determining the cause. Treatment focuses on removing excess fluid, improving cardiac output, and correcting the underlying cause through medications, surgery, or lifestyle changes.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    6K views28 pages

    Congestive Heart Failure

    Uploaded by

    sarguss14
    Congestive heart failure occurs when the heart fails to pump an adequate cardiac output due to reduced contractility or stiffness of the ventricles. It can be caused by myocardial ischemia, valve defects, or congenital anomalies. Symptoms include dyspnea, edema, and reduced exercise capacity due to low cardiac output and fluid retention. Diagnosis involves assessing ventricular function with echocardiography and determining the cause. Treatment focuses on removing excess fluid, improving cardiac output, and correcting the underlying cause through medications, surgery, or lifestyle changes.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 28

    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 No symptoms or no limitation
    II 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
    cms
    ESV VCF
    LV

    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  Normal
     RVH or dilatation: ex. sternal  None
    pulsation present
     Displaced PMI: no  Yes
     S2: P2 component increased  A2 may be increased
    Right sided S3 present  Left sided S3 present
     Pulmonic and/ or tricuspid  Mitral and /or aortic murmurs
    murmurs maybe present maybe present.
     Crepitant (Fine) rales: no  yes

     Hepatomegaly: maybe present  absent


     Pedal edema: present  absent
    ALGORYTHM
    Dyspnea (Acute or Chronic)

    Signs of cardiac dysfunction


    JVP, S3, abnormal murmur (95% specificity)
    Yes No Respiratory diseases
    Cardiac
    Signs of left Signs of right Pulmonary
    sided failure sided failure hypertension
    Acute causes:
    AcuteCauses: 2.Pulmonary emboli
    Acute MI 2. Endocarditis of
    Arrythmias PV and TV
    Ruptured MV 3. RV infarction
    Endocarditis
    Renal failure Chronic stage:
    Hypertensive Ischemic HD
    crisis Valvular HD
    Congenital HD Cardiomyopthy
    Hypertensive HD etc.
    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
    n Large pulmonary emboli
    n Bacterial endocarditis of the pulmonic/
    tricuspid valve
    n Right ventricular infarction

    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

     Inotropic agents such as Digoxin


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

     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

     Cardiac rehabilitation and exercise program


     Cardiac transplantation for severe refractory CHF

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

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