Congestive Heart Failure Report

7/28/2019 Congestive Heart Failure Report

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CHF (Christine Dianne Pepito)

CONGESTIVE HEART FAILURE

Heart failure is the inability of the ventricles to deliver adequate blood flow to the metabolizing organs duringnormal activity or at rest.

Why CONGESTIVE? It is a leading cause of mortality and morbidity.

ETIOLOGY

- Coronary artery disease- HPN

- Valvular heart disease

- Infections

- Arrhythmias

- Alcohol--chronic- MI--acute

- Diabeteschronic

- Congenital

- Iatrogenic

Compensatory Mechanisms in CHF

Sympathetic Responses Hormonal Stimulation Concentric cardiac Hypertrophy Frank-Starling Mechanism

Decomposition

: Over time, the compensatory mechanisms become exhausted & increasingly ineffective.Inc. TPR & Afterload

-- FLUID BACK-UP produce signs & symptoms of CHF

Classifications of CHF

Left-sided vs Rightsided Left- pulmonary edema Right-peripheral edema

(LHF: Systolic vs Diastolic ) Systolic- loss of contractility get dec. CO Diastolic- decreased filling or preload

High output- hypermetabolic stateLow output- metabolic demands are normal but heart is unable to meet them

SYMPTOMS

- Shortness of breath- Difficulty sleeping at night due to breathing problems- Increased urination at night- Chronic lack of energy- Swelling of feet & legs- Swollen / tender abdomen with loss of appetite- Cough with frothy sputum- Confusion and/or impaired memory


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Left-side Heart Failure

Signs and symptoms dyspnea orthopnea PND Dry, wheezing cough fatigue & weakness Nocturia Rales, Tachycardia S3 ventricular gallop S4 Atrial gallop

NOTE L FOR LEFT AND L FOR LUNGS

Why does this occur??Diagnostic Test Results (Left-sided HF)

Cardiomegaly LVH Pulmonary congestion Arm-to-tongue circulation prolonged Transudative pleural efflusion (x-ray & aspirated pleural fluid analysis) Cardiomegaly LVH Pulmonary congestion Arm-to-tongue circulation prolonged Transudative pleural efflusion (x-ray & aspirated pleural fluid analysis)

RIGHT-SIDED HEART FAILURE

Signs and Symptoms Tightness & swelling (edema) N&V, anorexia, bloating,wt. gain, inc. abd. Pain Jugular vein distension S3 ventricular & S4 atrial gallop Hepatomegaly +HJR Bilateral Leg Edema

What is present in this extremity, common to right sided HF?o Coughingo Tirednesso Shortness of breatho Pumping action of the heart grows weakero Pulmonary edema (excess fluid in lungs)o Pleural effusion (excess fluid around lungs)o Swelling in abdomen (ascites)o Swelling in ankles and legs

Diagnostic Test Results (Right-sided HF)

Elevated Levels of Hepatic Enzymes (e.g. SGPT) reflecting Hepatic congestion

HEART FAILURE (Diagnostic Studies)

Primary goal- determine underlying cause Hemodynamic assessment-Hemodynamic Monitoring-CVP- (right side) and Swan Ganz (left and right

side)

Echocardiogram-TEE (Transesophageal Echocardiogram) best use sound waves to produce an imageof the heart

Stress testing- exercise or medicine Cardiac catheterization- determine heart pressures ( inc.PAW ) Ejection fraction (EF)


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Goals and drug therapy

Goals

Alleviation of symptoms, improve quality of life Arrest ventricular remodeling Prevent sudden death

Nondrug therapy

Reduce cardiac work; bed rest, Dietary Controls, Low Na+ dietDrug therapy

Chronic heart failure ACE-I, -blockers, ARB, aldosterone antagonists, digoxin, diuretics

Acute heart failure Intravenous diuretics, inotropic agents, PDE inhibitors, vasodilator

Drugs for CHF

Vasodilators (ACE Inhibitors, Nitroprusside, Hydralazine, Prazosin, Nitrates) Diuretics Beta blockers

Digitalis glycosides Other Cardiac Inotropes (Dopamine, Dobutamine, Milrinone)

Angiotensin Converting Enzyme (ACE) Inhibitors :

ACE inhibitors improve mortality, morbidity, exercise tolerance, left ventricular ejection fraction. Captopril, Lisinopril, Enalapril, Ramipril, Quinapril.

Angiotensin Converting Enzyme (ACE) Inhibitors :

Reduction in arterial resistance (afterload) Reduction in venous tension (preload) Reduction in aldosterone secretion Inhibition of cardiac and vascular remodeling

Adverse effects :

Dry irritating persistent cough Hyperkalemia Angioedema Fetal toxicity

Angiotensin Receptor AT-1 blockers (ARB) :

Losartan, Irbesartan, Candesartan

Competitive antagonists of Angiotensin II (AT-1).Vasodilators :

Isosorbide dinitrate and hydralazine also used specially in patients who cannot tolerate ACE inhibitors. Amlodipine and prazosin are other vasodilators can be used in CCF.


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Nitrates in CHF

Diuretics :

These are useful in reducing the symptoms of volume overload by

decreasing the extra cellular volume

decreasing the venous return Loop diuretics like furosemide and bumetanide are the most effective and commonly used. Thiazides are effective in mild cases only.

Adverse effects :

Loop diuretics and thiazides cause hypokalemia. Potassium sparing diuretics help in reducing the hypokalemia due to these diuretics.

Potassium Sparing Diuretics ( Spironolactone)

Aldosterone inhibition minimize potassium loss, prevent sodium and water retention, endothelial dysfunctionand myocardial fibrosis.

Spironolactone : Aldosterone antagonist

Spironolactone can be added to loop diuretics to modestly enhance the diuresis; moreimportantly, improve survival.

Beta blockers for congestive cardiac failure : Acts primarily by inhibiting the sympathetic nervous system. Start at low dose and monitor for bradycardia Carvedilol and Metoprolol are the most commonly used for CHF amongst beta blockers

Cardiac glycosides : Digoxin :

Inhibition of Na/K ATPase pump increase intracellular sodium concentration eventually increase cytosoliccalcium.

Increase the refractoriness of AV node thus decrease ventricular response to atrial rate. Digoxin is used as a first-line drug in patients with congestive heart failure who are in atrial fibrillation.

Digoxin : Adverse effects / Precautions :

Nausea, vomiting, gynecomastia, visual disturbances and psychosis. Ventricular bigeminy, AV block and bradycardia. Amiodarone and verapamil can increase the plasma concentration of digoxin by inhibiting its excretion.

Digoxin toxicity treatment:

Toxicity can be treated with higher than normal doses of potassium. Digoxin antibody (digibind) is used specifically to treat life-threatening digoxin overdose.

Cardiac Inotropes :

Phosphodiesterase III Inhibitors Positive inotropic and vasodilator INO-DILATOR ; Eg., Milrinone Dobutamine is a beta-1 agonist which increase contractility and cardiac output.


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Heart Failure

Classification Systems

New York Heart Association Functional Classification of HF Classes I to IV

ACC/AHA Stages of HF (newer) Stages A to D


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Stage

A

At high risk for developing heart failure. Includes people with:

Hypertension

Diabetes mellitus

CAD (including heart attack)

History of cardiotoxic drug therapy

History of alcohol abuse

History of rheumatic fever

Family history of CMP

Exercise regularly

Quit smoking

Treat hypertension

Treat lipid disorders

Discourage alcohol or illicit drug use

If previous heart attack/ current diabetes mellitus or HTN, use ACE-

Inhibitors

Stage

B

Those diagnosed with systolic heart failure- have neverhad

symptoms of heart failure (usually by f inding an ejection

fraction of less than 40% on echocardiogram

Care measures in Stage A +

Should be on ACE-I

Add beta -blockers

Surgical consultation for coronary artery revascularization and valverepair/replacement (as appropriate

Stage

C

Patients with known heart failure with current or prior

symptoms.

Symptoms include: SOB, fatigue

Reduced exercise intolerance

All care measures from Stage A apply, ACE-I and beta-blockers

should be used + Diuretics, Digoxin,

Dietary sodium restriction

Weight monitoring, Fluid restriction Withdrawal drugs that worsen

condition

Maybe Spironolactone therapy

Stage

D

Presence of advanced symptoms, afterassuring optimized

medical care

All therapies -Stages A, B and C + evaluation for:Cardiac

transplantation, VADs, surgical options, research therapies,

Continuous intravenous inotropic infusions/ End-of-life care

Documents

Congestive Heart Failure Report