Diagnosis & Management of Heart Failure. Abena A. Osei-Wusu, M.D. Medical Fiesta

Transcription

1 Diagnosis & Management of Heart Failure Abena A. Osei-Wusu, M.D. Medical Fiesta

2 Learning Objectives: 1) Become familiar with pathogenesis of congestive heart failure. 2) Discuss clinical manifestations and diagnosis of heart failure. 3) Understand the management of acute decompensated congestive heart failure. 4) Discuss issues in the chronic management of heart failure patients.

3 Congestive Heart Failure (CHF) Symptomatology related to elevated cardiac filling pressures, and excess volume Elevated Left-sided filling pressures Pulmonary vascular congestion, interstitial, alveolar edema Elevated Right-sided filling pressures Increased central venous pressure +/- Alteration in cardiac output (CO)

4 CHF Due to systolic dysfunction Impaired ventricular contractility Due to diastolic dysfunction Impaired LV relaxation Due to systolic and diastolic dysfunction Impaired LV contractility and relaxation Due to volume overload (i.e. transfusion etc.) Due to Pressure overload (i.e. aortic stenosis)

5 Causes of CHF Non-Ischemic Hypertension Valvular heart disease Familial Myocarditis Post-partum Chemotherapy Arrhythmia-induced Thyroid disease Nutritional (beriberi) Ischemic Prior myocardial infarction Unrevascularized severe coronary artery disease Pulmonary Disease Cor Pulmonale Infiltrative cardiomyopathies (amyloid, sarcoid) Hypertrophic cardiomyopathy

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7 Pathogenesis

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10 Manifestations CNS: altered mentation (low CO) Pulmonary: dyspnea on exertion, paroxysmal nocturnal dyspnea, effusion Cardiac: chamber enlargement, arrhythmia, syncope, ECG abnormalities, effusion GI: hepatic congestion, gut edema Renal: decreased UOP, altered CrCl Integument: decreased perfusion, cool, clammy skin

11 Clinical Assessment History: duration of symptoms, precipitants, ACS?, drugs?, arrhythmia, Physical Examination: General Appearance Jugular venous distension (JVD) PMI S3 or S4 Rales Hepatic congestion Edema

12 Chest X ray Electrocardiogram Echocardiogram Laboratory testing CBC, chemistries, LFTs, Coags Brain Naturetic Peptide (BNP) Rule out myocardial ischemia

13 Identify Precipitants

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16 Acute Management Assess Respiratory Status Supplemental O2, ABG, assess need for ventilatory support/intubation Continuous ECG Monitoring Diuretic Administration Acutely relieve pulmonary edema Lower filling pressures Improve interstitial edema

17 Diuretics Loop Duretics Furosemide IV/PO Bolus or continuous infusion IV administration acutely mg for naïve x oral dose for chronic patients Electrolyte abnormaliteis common arrhythmia, cramping Thiazide Diuretics Chlorthiazide IV Metolazone, HCTZ Potentiate the effect of loop diuretics Usually daily administration

18 During Diuresis Daily weights Strict I/O monitoring (consider urethral catheter placement) At least daily chemistries Maintain K > 4.0 and Mg > 2.0 Continuous ECG monitoring Closely monitor renal function Watch for hypotension

19 Inotropes Improve myocardial contractility Patients with decreased CO Pro-arrhythmic Atrial fibrillation, flutter, SVT Ventricular tachycardia Dobutamine b1 Selective agonist Vasodilatory at higher doses Initiate 2.5 mcg/kg/min, max dose 20 mcg/kg/min

20 Inotropes cont. Milrinone Phosphodiesterase 3 inhibitor inc camp Improves contractility Vasodilator Pro-arrhythmic 50 mcg/kg over 10 min then mcg/kg/min max dose 0.75 mcg/kg/min

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22 Goals of Acute Hospitalization Determine etiology of CHF if unknown Determine precipitant of exacerbation Assess cardiac structure-echocardiogram Optimize volume status Initiate therapies to reduce hospitalization and mortality

23 Chronic Management

24 Chronic Management Ejection Fraction Re-assess after initiation of therapy. History of ventricular arrhythmia? Assess risk for sudden cardiac death (SCD)

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27 Implantable Defibrillators Primary Prevention Those patients at increased risk of sudden cardiac death, but no history of SCD EF <35% NYHA Class II-II EF <40% post MI, VT on EPS Secondary Prevention Patient s/p cardiac arrest due to ventricular fibrillation or tachycardia

28 Summary Initial Management focuses on stabilization of the patient and acute improvement in respiratory status Precipitants of acute CHF should be identified Imaging of the heart (echocardiogram) is essential to diagnosis and management Diuretics (intravenous) are central to acute management Once volume status is optimized, beta blockers, ACE- I/ARBs, spironolactone, hydralazine/nitrates, digoxin are added to dec mortality and hospitalizations ICDs are used to prevent sudden cardiac death, +/- resynchronization therapy

29 References Zipes et al. Braunwald s Heart Disease Bonow et al. ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Heart Failure. Circulation. 2012;125: Jessup et al Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119: