Congestive Heart Failure

Definition: Abnormality in heart structure or function resulting in (3) Cardiovascular

the inability to adequately perfuse metabolic tissues: (a) Myocardial hypertrophy with valvular
- Heart failure can be systolic or diastolic in origin regurgitation (preload) and HTN
(systolic dysfunction = failure of muscular pumping of ii) Eventual failure of compensatory mechanisms leads to
systole) decreased stroke volume and worsening of
(diastolic dysfunction = failure of relaxation and filling symptomatology
of the heart) 4) Signs
a) General:
1) Epidemiology i) Oliguria
a) 5 million people in the U.S. ii) Tachycardia
b) Incidence is increasing iii) HOTN
c) Prevalence increases with age iv) Decreased peripheral pulses
i) 75% are 65 yrs v) Narrow pulse pressure
d) Gender: men > women vi) Severe: cachexia, cyanotic, clubbing
e) Race: more prevalent in minorities b) Skin:
f) Risk factors i) Pallor
i) CAD: mc cause of HF ii) Cold/clammy extremities
ii) HTN iii) Diaphoresis
iii) DM c) Heart:
iv) Obesity i) Parasternal lift
v) Family hx ii) Enlarged apical impulse
iii) Diminished S1, S3 gallop
2) Etiology d) L:
a) Systolic dysfunction i) Crackles/rales at lung base
i) Ischemic damage: MI, cardiogenic shock ii) Pleural effusion
ii) Chronic pressure overload: HTN iii) S4
iii) Non ischemic - dilated cardiomyopathy e) R:
b) Diastolic dysfunction i) JVD
i) MC cause is systolic dysfunction ii) Abn V waves
ii) Myocardial hypertrophy secondary to HTN iii) Tender or NT hepatic congestion/enlargement
iii) Ischemic fibrosis, deposition Dz iv) Ascites
iv) Restrictive cardiomyopathy v) Pitting edema
c) Mechanical issues: valvular disease, congenital abs
d) arrhythmia 5) Symptoms
e) Pulmonary heart disease a) Left-sided HF
f) High output states (thyrotoxicosis, severe anemia) i) Fatigue
ii) SOB
3) Pathophysiology iii) Syncope
a) Systolic dysfunction from the above leads to impaired iv) Dyspnea at rest, DOE, exercise intolerance
myocardial contractility v) PND (paroxysmal nocturnal dyspnea)
i) EF falls to <40 left-sided HF vi) Orthopnea
b) Diastolic dysfunction from the above leads to increased vii) Chronic non-productive cough
ventricular stiffness or impaired myocardial relaxation viii) Nocturia
i) Preserved ejection fraction c right-sided HF
c) These changes stimulate compensatory responses: b) Right-sided HF possibly all of above sx PLUS
i) Frank-Starling Mechanism Compensatory i) Nausea, anorexia
mechanism leading to increase in preload ii) Peripheral edema (swollen ankles/feet) wt gain
(1) Neurohormonal
6) Diagnosis
(a) Epi /N-epi vasoconstriction
a) Labs
(b) plasma N-epi activates the SNS, causing i) CBC: anemia or hemochromatosis
renal hypoperfusion ii) Electrolytes: hyponatremia, hyperkalemia (unless on
(2) Renal thiazide diuretics, then hypokalemia)
(a) RAAS activation Na and H2O retention iii) LFTs: elevated liver enzymes
BP & vasoconstriction iv) TFTs: may have thyrotoxicosis
(b) Kidney baroreceptors that maintain CV v) RFTs to rule out kidney failure & get a baseline
vi) BNP: inc when ventricular pressures are high
homeostasis become desensitized
vii) Blood glucose and lipid panel
b) EKG: nonspecific findings
i) Arrhythmia, new or old MI, LVH
 c) Imaging (3) If sx continue with ACE-I/ARB and BB
i) CXR (a) Digoxin 0.25mg/d PO
(1) Cardiomegaly
(2) B/L or right-sided pleural effusions e) Surgery
(3) Perivascular/interstitial edema (Kerley B lines) i) ICD (internal cardiodefibrillator) if LVEF < 30%
(4) Cephalization (vascular dilation) more than 40 days post-MI
(5) Alveolar fluid ii) If conduction abnormalities - resynchronization with
ii) Echo with doppler: to assess LV function (EF biventricular pacing abnormal
<40%) iii) If CAD - revascularization
iii) Stress imaging, angiography, or cardiac catheter to iv) Cardiac transplant if end stage disease plus:
assess cause or severity (1) < 70 years
(2) No evidence of:
7) Treatment (a) Permanent end organ dysfunction
a) Correct underlying causes (b) Cancer
b) Recording daily weight (>2 lbs in a day, >5 lbs above (c) Severe pulmonary hypertension
baseline call Dr.) (3) Have good social support and are compliant
c) Non-pharma - diet & exercise, wt. loss, stop smoking
d) Pharmacologic 8) Complications
i) Initial therapy for ALL: diuretic + ACE a) Organ failure kidney, liver
(1) Diuretics b) Ascites
(a) Thiazide diuretic - Hydrochlorothiazide 25- c) Pulmonary edema
100mg/d PO d) Arrhythmias
(b) If GFR < 30: Loop diuretic - Furosemide e) MI
20-320 mg/d PO f) Death 5 yr mortality is 50%
(2) ACE-I: LV remodeling and mortality 20%
(a) Lisinopril 10-40 mg/d PO
ii) Add-ons NYHA Classification
(1) If cough switch ACE-I for ARB I No limitation
(a) Losartan PO 25-100 mg/d II Slight limitation (sxs c moderate activity)
(2) If CAD/HTN/A-fib beta blocker III Marked limitation (sxs c mild activity)
(a) Metoprolol 25mg/d PO IV sxs at rest