Congestive Heart Failure Patient Profile. Patient Identity - Mr. Douglas - 72 year old man - No drugs, smokes, moderate social alcohol consumption

Transcription

1 Congestive Heart Failure Patient Profile Patient Identity - Mr. Douglas - 72 year old man - No drugs, smokes, moderate social alcohol consumption Chief Complaint - SOB - When asked: Increasing difficulty breathing upon activities like gardening and lawn mowing Patient Signs and Symptoms - Recently felt lightheaded, as if I were about to faint, but felt better after resting - SOB specially upon sleeping Exam Findings - Heart rate: 110 bpm, Blood pressure: 130/92 mmhg, 32 breaths per minute, distended neck veins, inspiratory crackles on lung auscultation, S4 present at apex, carotid pulse diminished - Jugular venous pressure (JVP) is elevated 3 cm above normal. - HTN, hyperlipidemia (treated with thiazides and statins) - Diabetes, Coronary artery disease, Family history of heart failure - His ECG shows sinus tachycardia, and a transthoracic echocardiogram (TTE) performed in the emergency department reveals impaired systolic function, with an ejection fraction of 20%. - Sympathetic symptoms of compensation Lab Findings - Elevated B-type natriuretic peptide, diminished ejection fraction Differential Diagnosis - Cardiomyopathies, MI, arrhythmias Diagnosis - Congestive Heart Failure Many patients remain asymptomatic for extended time periods because mild impairment in cardiac function is balanced by compensatory mechanisms. Often, clinical manifestations occur only in the presence of precipitating factors that increase the cardiac workload and tip the balanced state into one of decompensation. Thus, the first symptoms and signs may be those of the underlying precipitating condition. Definition:

2 Cardiac or heart failure Inability of the heart to pump blood forward at a sufficient rate to meet the metabolic demands of the body (forward failure), or Ability to do so only if the cardiac filling pressures are abnormally high (backward failure), or Both Congestive heart failure (CHF) Clinical syndrome with signs and symptoms including dyspnea, increased fatigability and edema Is cardiac failure + abnormal circulatory congestion, due to systemic compensatory responses to failing pump (sympathetic nervous activity, renal vasoconstriction and activation of the renin-angiotensin system) Etiologies: Increased preload (volume of blood ) Fluid overload, renal failure Valvular regurgitation Shunts Decreased preload: obstructed, restricted filling Restrictive cardiomyopathy, tamponnade Valvular stenosis (aortic, mitral) Decreased contractility Infarcts, dilated cardiomyopathy Negative inotropic drugs, ETOH Increased afterload Valvular stenosis, e.g., aortic, pulmonic Systemic hypertension Pulmonary embolism RV afterload failure Electrophysiological abnormalities Arrhythmias, conduction problems

3 Slow or too rapid heart rate Aggravating factors Hypermetabolic states (fever, pregnancy, hyperthyroidism ) Anemia (increase demand to pump more blood) Compensation + effects: As the heart fails, compensatory mechanisms are brought into play including the Frank Starling mechanism, sympathetic activation, the renin-angiotensin-aldosterone system, hypertrophy and dilatation, but each may decompensate The effects of heart failure on other organs are due to elevation in venous pressure, reduced perfusion or both Respiratory-symptoms-from:

4 Questions: Previous MI/ HTN/ Cardiac history/ cardiac symptoms/ family history (+ age)/ Fatigue and exercise intolerance (NYHA Score)/ palpitation (can ask to tap the heart beat he feels)/ ask about risk factors/

5 LHF: Dyspnea, orthopnea (pillows), no elevation in venous P, pulmonary edema, position (to increase breathing) (not being able to hyperventilate enough) Orthopnea: lay down = heart comes back to heart and lungs, overwhlemed, increased P, more pulmonary edema. Paroxysmal Nocturnal Dyspnea (PND) Severe breathlessness which awakens pt 2-3 hours after falling asleep Results from gradual reabsorption into circulation of lower extremity interstitial edema after lying down (expanded intravascular volume)

6 Nocturnal cough Hemoptysis (less common) Rupture of engorged bronchial veins Manifestations of low forward cardiac output Dulled mental status Impaired urine output Fatigue and Weakness RHF: most common cause is LHF, cyanosis, engorgement of jugular veins, hepatomegaly, ascites, dependant edema, elevated VP, position, Peripheral edema Esp. ankles and feet Reflects increased hydrostatic venous pressures Worse with patient upright (gravity) Improves after lying supine at night more swollen at end of the day than in morning Weight gain Abdominal discomfort Engorged liver with stretching of the its capsule (covering) Anorexia and nausea Edema of GI tract PE: (Pulse /Blood pressure/ Respiratory rate/ Temperature/ O 2 saturation) Tachypnea Cheyne-Stokes respiration Pattern of breathing characterized by periods of hyperventilation separated by intervals of apnea Sinus tachycardia

7 Increased sympathetic activity Pulsus alternans (not always) Alternating strong and weak contractions detected in the peripheral pulse Sign of advanced ventricular dysfunction Cachexia (frail, wasted appearance) Poor appetite Metabolic demands of increased work of breathing Diaphoresis Sweating from increased sympathetic nervous activity LHF more specifics: Pulmonary rales or crackles Popping open of small airways during inspiration that had been closed off by edema fluid Abnormalities of the cardiac apex Diffuse in dilated cardiomyopathy (vs. focal) Sustained in pressure overload states (Sustained= more than 2/3 of systole) E.g. Aortic stenosis, HTN Lifting in volume overload states Mitral regurgitation Auscultation: S 3 Early diastolic sound (after S2)-- volume overload best heard at apex in lateral decubitus position Can be normal in young people, but not in elderly Due to rapid early filling of the dilated ventricle from elevated filling pressures S 4 Late diastolic sound (before S1) P overload--best heard at apex in lateral decubitus position Atrial contraction into stiff, non-compliant ventricle

8 Murmur of mitral regurgitation Caused by dilatation of the mitral annulus causing mal-coaptation of the leaflets RH more specifics: Palpable parasternal right ventricular heave Represents RV enlargement Distention of the jugular veins (elevation) Hepatic enlargement with abdominal tenderness Edema in dependent portions of the body Murmur of tricuspid regurgitation (Pulsatile liver) Right-sided S 3 and S 4 gallops R or L : Pleural Effusions (chest pain, dyspnea, dry cough) May develop in left or right sided HF On exam: Dullness to percussion over the posterior lung bases

9 Compensated for a long time until precipitating factor (increasing workload on the heart), now decompensated. **Do not give B blocker to decompensated HF