CHF in the ED

Bryce C Inman, MDLoma Linda University Medical Center

Congestive Heart Failure

• Congestive heart failure is an imbalance in pump function in which the heart is unable to maintain adequate forward blood flow.

• 10% of those > 80 years old• Most common cause of death is progressive

heart failure

CHF: 2 types

Systolic• EF < 40%• Impaired ventricular

contraction• Most commonly from

ischemic heart disease

Diastolic• EF > 60%• Impaired ventricular

relaxation• Most commonly from

chronic HTN and LVH

Prognosis

• Heart failure has an overall poor prognosis• Symptoms predict outcome– 5-10% mortality per year in moderate CHF – 30-40% mortality per year in severe CHF

Diagnosis: History

• Dyspnea at rest• Dyspnea upon exertion• Orthopnea• Cough: Frothy pink sputum highly predictive

of CHF• Nonspecifics: weakness, dizziness, malaise,

etc.

Diagnosis: Exam

• Acute pulmonary edema: Severe respiratory distress , relative hypertension, diaphoretic skin. Bilateral crackles can typically be heard

• An S3 has 99 percent specificity for an elevated capillary wedge pressure (but 20% sensitivity)

• JVD has 94 percent specificity for elevated capillary wedge pressure (but 39% sensitivity)

Imaging

• 1/5 CHF patients admitted to the hospital lacked signs on CXR

• Congestive signs on CXR are unreliable in chronic CHF

• Sensitivity for CHF with a portable CXR is poor. • CXR findings often lag behind clinical

manifestions by several hoursHowever, a CXR is useful to exclude other

processes (e.g., pneumothorax)

Pleural effusion

Pulmonary Edema

What about labs and EKG?

• Lack sensitivity and specificity– Occasionally you might see an elevated AST/ALT

or prerenal azotemia– EKG may show ischemia or previous MI,

dysrhythmias, etc.

Natriuretic peptides

• 70 y/o M presents with respiratory distress. His 02 saturations are in the 70’s, he has mild retractions, and breath sounds are difficult to auscultate.– Is this CHF or COPD?

• A BNP of <100 almost entirely excludes CHF

What else looks like acute CHF?

TREAT!

70 y/o M presents with respiratory distress. His 02 saturations are in the 70’s, he has mild retractions, and breath sounds are difficult to auscultate.

Airway Management

• Airway management supercedes all other priorities in these patients, particularly those who are critically ill.

• Hypoxia is a greater risk than hypercarbia so CO2 retention is not an immediate concern

o What is the best way to manage the airway?

Intubation vs NIPPV

Intubation• Typically for those in severe

distress or those who are non-cooperative.

BiPAP/CPAP• May decrease the need for

intubations, but no significant change in mortality

Pressure Control• Systolic pressure acceptable?– Start nitroglycerin (0.4 mg PO q2-3 min) – Nitrospray: Single spray (0.4 mg) up to a max of 1.2 mg

Ointment: Apply 1-2 inches of nitropaste to chest wallIV: Start at 20 mcg/min IV and rate to effect in 5-10 mcg increments q3-5min

• The failing heart is sensitive to increases in afterload; these measures alleviate the pulmonary edema from CHF.

Don’t venodilate when….

• Preload dependent states exist such as;– Right ventricular infarct– Critical aortic stenosis– Volume depletion

Most require only oxygen, blood pressure control, and diuresis

-Vasoconstricted patients require vasodilators.-Congested patients required diuretics

★Diastolic HF patients respond better to BP management than diuresis

Diuresis

• First line therapy is a diuretic such as furosemide.– 10-20 mg IV for symptomatic CHF and diuretic naïve.

40-80 mg IV for patients already using diuretics80-120 mg IV for patients whose symptoms are refractory to the initial dose after 1 h of its administration

• Metolazone, a thiazide diuretic, can be added for effect.

If hypotensive…

• Inotropes including dobutamine and dopamine are used primarily– Dopamine starts at 5 mcg/kg/min IV and increase

at 5 mcg/kg/min increments to a 20 mcg/kg/min dose

– Dobutamine starts at 2.5 mcg/kg/min IV; generally therapeutic in the range of 10-40 mcg/kg/min

Admit or go home?

• With few exceptions, most patients presenting with symptoms of CHF require admission. Those who respond well to initial interventions may require only basic ward admission with telemetry.

• Those who had a gradual onset dyspnea, rapid response to therapy, good oxygen saturations, and ACS/MI unlikely as the inciting event may be stable for discharge

In conclusion

• Airway management is goal– IF NIPPV easily available, begin immediately and

monitor for progress or decline• Control Pressure– Use nitroglycerin and titrate to effect– If known diastolic CHF, attempt to reduce

afterload• Pressor support if hypotensive– Dobutamine/dopamine