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Congestive Heart Failure. ADOPTED FROM: Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series. Congestive Heart Failure. Clinical presentation of disease NOT a diagnosis in and of itself Differential includes Underlying cardiovascular disease Precipitating factors.

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Congestive Heart Failure


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    1. Congestive Heart Failure ADOPTED FROM: Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series

    2. Congestive Heart Failure • Clinical presentation of disease • NOT a diagnosis in and of itself • Differential includes • Underlying cardiovascular disease • Precipitating factors

    3. Predisposing Cardiac Diseases • Myocardial infarction • Chronic ischemia • Cardiomyopathy • Arrhythmias • Diastolic dysfunction • Valvular diseases • Aortic Stenosis • Mitral Stenosis • Mitral Regurgitation

    4. Cardiac Physiology(remember this?) • CO = SV x HR • HR: parasympathetic and sympathetic tone • SV: preload, afterload, contractility

    5. Preload • Def: Passive stretch of muscle prior to contraction • Measurement: Swan-Ganz • LVEDP • Really a function of LVEDV • Affected by compliance • Low compliance = higher LVEDP @ lower LVEDV • False high estimate of preload • Frank-Starling right?

    6. Afterload • Def: Force opposing/stretching muscle after contraction begins • Measurement: SVR • Really a function of: • SVR • Chamber radius (dilated cardiomyopathies) • Wall thickness (hypertrophy)

    7. Contractility • Def: Normal ability of the muscle to contract at a given force for a given stretch, independent of preload or afterload forces • In other words: • How healthy is your heart muscle? • Ischemia, Hypertrophy (?), Muscle loss

    8. Classifying Heart Failure • Anatomically • Left versus Right • Physiologically • Systolic versus Diastolic • Functionally • How symptomatic is your patient?

    9. Left Heart Failure - Dyspnea - Dec. exercise tolerance - Cough - Orthopnea - Pink, frothy sputum Right Heart Failure - Dec. exercise tolerance - Edema - HJR / JVD - Hepatomegaly - Ascites Left versus Right Failure

    10. Systolic– “can’t pump” Aortic Stenosis HTN Aortic Insufficiency Mitral Regurgitation Muscle Loss Ischemia Fibrosis Infiltration Diastolic- “can’t fill” Mitral Stenosis Tamponade Hypertrophy Infiltration Fibrosis Systolic versus Diastolic

    11. no distress at rest, except for feeling uncomfortable when lying flat for more than a few minutes Decreased pulse pressure cool peripheral extremities and cyanosis of the lips and nail beds Increased jugular venous pressure Rales Hepatomegaly Peripheral edema Physical Exam

    12. Clinical Data • CXR • Kerley’s lines : A and B • Pulmonary Edema • Cephalization • Pleural Effusions (bilateral) • EKG • Left atrial enlargement • Arrhythmias • Hypertrophy (left or right)

    13. Pulmonary Edema Cardiomyopathy

    14. Clinical Data • HEART SOUNDS!!! • Systolic Murmurs • Mitral Regurg • Aortic Stenosis • Diastolic Murmurs • Mitral Stenosis • Aortic Insufficiency • S3: Rapid filling of a diseased ventricle

    15. Clinical Data • Laboratory Data • Chemistry • Renal Function: Be Wary • BNP • Used in ER departments the world over • Good negative correlation • Need baseline for positivity • Pulmonary versus cardiac dyspnea

    16. Treatment of CHF • Treat Precipitating Factor(s)!!!! • Adjust Heart Rate • Decrease Preload • Decrease Afterload • Increase Contractility • Increase Oxygenation

    17. Treatment of CHF • Oxygen – nasal, BiPAP, intubation • Morphine • Preload Reduction • Loop diuretics • Nitrates • ACEi / ARB • Morphine

    18. Treatment of CHF • Afterload Reduction • IV NTG, Nitroprusside • Hydralazine • ACEi / ARB • Ionotropic Support • Dopamine / Dobutamine • Amrinone / Milrinone • Digoxin (chronic) • Mechanical (ABP)

    19. Treatment of CHF • Beta-Blockers • Chronic > Acute • Carvedilol (Coreg), Metoprolol (Toprol XL) • Fluid Balance • Restrict fluid / salt intake • Monitor I/Os and daily weight • Dialysis if needed • Aspirin

    20. Infection Pulm Embolus Noncompliance Arrhythmia Myocardial Infarction Stress reaction Sodium Intake Medications!!! Anemia Thyroid disorders Endocarditis Precipitating Factors

    21. Admission Orders • Admit: Telemetry or ICU • EKG STAT, then daily x 3 days • 2D Echo • CXR • Labs: BMP, CBC, CE x 3, Coags, LFTs, UA • Pulse ox (ABG) • Oxygen • ASA 325mg PO daily

    22. Admission Orders • Nitroglycerin • Paste: 1” ACW TID – Holding parameters • IV: 50mg in 250cc D5W – Titrate • Morphine 1-5mg IV q10-20 min prn • Lasix 20-200mg IV (q 6-8 hours) • ACEi • Captopril 6.25-50mg PO q8h • Enalapril 2.5-20mg PO BID (0.625-2.5mg IV q6h) • Hydralazine 10-100mg PO q6-8 h

    23. Admission Orders • Beta Blocker • Probably not acutely • Start Coreg or Toprol XL prior to discharge • Fluid Restrict 1000ml daily • Low salt diet • Daily patient weights • Daily I/Os

    24. Admission Orders • Dobutamine 500mg in 250cc D5W • 3-10ug/kg/min • Digoxin • Probably not acutely • Titrate to effective dose prior to discharge • IABP • Cardiogenic shock unresponsive to above tx • Dialysis • Critical renal failure patients