Congestive Heart Failure

Bernardo D. Morantte Jr. M.D.

Dept. of Medicine
College of Medicine
Pamantasan Ng Lungsod Maynila
Congestive Heart Failure
 It is a condition when the heart fails to pump
the expected cardiac output due to reduced
myocardial contractility. This is known as
systolic heart failure.
 When it is due to stiffness of the ventricle it is
known as diastolic heart failure.
 It can occur in myocardial ischemia or
mechanical abnormalities such as valve
defects and congenital anomalies.
Pathophysiology:
 The symptoms and physical examination
findings in congestive heart failure are due to:
 1. low cardiac output
 2. water retention

 General Causes of CHF:

 1. myocardial diseases
 2. mechanical causes ex. Valvular defects
 3. pericardial diseases
Key Symptoms of Congestive Heart Failure
(CHF)

 Dyspnea/ orthopnea and PND

 Reduced physical capabality
 Weight gain and water retention
Goals of History Taking
1. determine whether the symptoms are
acute or chronic
2. establish the degree of functional
impairment
3. determine the cause
New York Heart Functional Class
I No symptoms or no limitation
II Mild restriction or symptoms only on
moderate to extreme physical exertion
III Symptoms on slight physical exertion or
moderate physical restriction
IV Symptoms at rest or severe physical
restriction
Key Features on Physical Examination
 Abnormal vital signs
 Abnormal physical appearance
 Abnormal cardiac findings
 Pulmonary congestion
 Signs of water retention
Abnormal Vital Signs and Physical
Appearance
 Restlessness
 Cyanosis
 Pallor and sweating
 Hypertension or hypotension
 Tachycardia and abnormal rhythm
 Tachypnea and use of accessory muscles for
respiration.
Abnormal Cardiac Findings
 Jugular venous engorgement
 Cardiomegaly
 Tachycardia and abnormal cardiac rhythm
 Presence of heart murmurs
 Presence S3, S4 or summation gallops
Signs of Pulmonary Congestion

Decreased breath sounds

Dullness on percussion
Auscultation: Crepitant (fine) or subcrepitant
rales on both lungs
Expiratory wheezing
Peripheral Cyanosis
Signs of Water Retention
 Weight gain
 Dependent edema_ pedal or sacral
 Ascites
 Hepatomegaly
 Anasarca
 Jugular venous distention
Ancillary and Diagnostic Laboratory
Examination
 Chest x-ray
 Echocardiography and doppler (most
important)
 Bedside hemodynamic monitoring

 BNP > 500 pcg/ ml

 EKG
 Cardiac enzymes
 Azotemia and uremia
Chest x-ray
 Cardiomegaly
 Pulmonary venous engorgement
 Kerley B lines
 Pleural effusion
 Pulmonary edema
EKG
 You do not make a diagnosis of CHF based
on the EKG
 But there are EKG abnormalities associated
with CHF.
 EKG abnormalities may give clues to the
cause or diagnosis
EKG ABNORMALITIES
Presence of atrial or ventricular hypertrophy
Presence of cardiac arrhythmias
LBBB
Acute changes consistent with acute MI
Electrical alternans
Bedside Hemodynamic Monitoring
 Urine output
 Swan Ganz catheter insertion (invasive)
 Measurement of cardiac outputs
 Measurement of arterial O2 saturations
 Measurement of pulmonary venous O2
saturations
 BP monitoring
Echocardiography
 Abnormal parameters of systolic function
Reduced Ejection fraction (EF)
Reduced velocity of circumferential
fiber shortening (VCF)
Increased end systolic volume (ESV)
Segmental wall motion abnormalities
Abnormal diastolic function
presence of ventricular hypertrophy
abnormal mitral valve diastolic flow by
doppler
M-mode Echocardiogram
Diagrammatic representation
 Ejection fraction = EDV- ESV / EDV
 Velocity of circumferential shortening (VCF)
Anterior wall

RV

Septum
EDV
cms
ESV VCF
LV

Posterior wall

1 sec.
Assessment Goal
 Determine the degree of congestive heart
failure
 ? Acute or chronic
 ? Right sided or left sided ventricular failure
or both
 ? Low output ( common) or high output
cardiac failure
 Systolic or diastolic failure
 Arrive at the cause or the diagnosis
PHYSICAL EXAM in CHF
RIGHT SIDED LEFT SIDED
 JVP: increased  Normal
 RVH or dilatation: ex. sternal  None
pulsation present
 Displaced PMI: no  Yes
 S2: P2 component increased  A2 may be increased
Right sided S3 present  Left sided S3 present
 Pulmonic and/ or tricuspid  Mitral and /or aortic murmurs
murmurs maybe present maybe present.
 Crepitant (Fine) rales: no  yes

 Hepatomegaly: maybe present  absent

 Pedal edema: present  absent
 ALGORYTHM
Dyspnea (Acute or Chronic)

Signs of cardiac dysfunction

JVP, S3, abnormal murmur (95% specificity)
Yes No Respiratory diseases
Cardiac
Signs of left Signs of right Pulmonary
sided failure sided failure hypertension
Acute causes:
AcuteCauses: 2.Pulmonary emboli
Acute MI 2. Endocarditis of
Arrythmias PV and TV
Ruptured MV 3. RV infarction
Endocarditis
Renal failure Chronic stage:
Hypertensive Ischemic HD
crisis Valvular HD
Congenital HD Cardiomyopthy
Hypertensive HD etc.
Criteria for diagnosis of CHF
I. Framingham criteria

III. Evidence based medicine: CHF

 Sensitivity Specificity
JVP <50-68%
 S3 gallop 69-89% 95%
 cardiomegaly 53-87% 90%
 abnormal
 murmurs 80-95% 80-100%
Suggested criteria: 3 out of 4
Causes of Acute Left Sided HF
 Acute Myocardial infarction
 Tachy and brady arrhythmias
 Valvular heart disease especially acute events such
as ruptured papillary muscle, ruptured chordae
 Ruptured Ventricular septum
 Hypertensive Crisis
 Bacterial endocarditis/ fulminating myocarditis
 Acute renal failure
Goal of Therapy in CHF

 1. remove the excess water

 2. improve cardiac output
 3. correct the underlying cause
Therapy in Acute CHF
Remove excess water by:
 Fluid restriction
 IV diuretics with loop diuretics
Improve cardiac output:
 BP support with IV inotropic agents
 Afterload reducing agents and antihypertensive therapy
 Correct cardiac arrhythmias
Supportive care:
Make patient comfortable
 Oxygen supplement
 Mechanical ventilator support if indicated
Correct the underlying cause:
 Management of Acute MI
 Hemodialysis for acute renal failure
 Correct other underlying causes
Causes of Acute Right Sided HF
n Large pulmonary emboli
n Bacterial endocarditis of the pulmonic/
tricuspid valve
n Right ventricular infarction

n Therapy: depends on the cause plus the

management of CHF in general
Causes of Chronic CHF

 All cardiac diseases will eventually lead to

CHF
 Renal failure
 Pulmonary diseases (right sided failure)
Therapy in Chronic CHF
 Dietary restriction on salt_ 1 gm/ day
 Fluid restrictions
 Use of Diuretics_ loop diuretics, Thiazides, K sparing

 Inotropic agents such as Digoxin

 After load reducing agents such as ACE I inhibitors, ARB
 Cautious use of beta blockers for diastolic heart failure

 Correction of the underlying cause such as by cardiac valve surgery, PTCA and
stents, CABG, repair of congenital anomalies
 Treatment of associated illness such as anemia, thyrotoxicosis, chronic lung
disease
 Cardiac resynchronization therapy (CRT) for bundle branch block

 Cardiac rehabilitation and exercise program

 Cardiac transplantation for severe refractory CHF

 Preventive measures
Treatment of risk factors for Coronary artery disease (CAD)
SBE prophylaxis for valvular disease