CONGESTIVE HEART

FAILURE AND ACUTE

PULMONARY EDEMA

TINTINALLIS CHAPTER 53
MARK SERRA
EPIDEMOLOGY
 550,000 NEW CASES PER YEAR
 LEADING CAUSE OF
HOSPITALIZATION IN PEOPLE
OLDER THAN 65
 OVERALL COST IS ROUGHLY
DOUBLE OF ANY CANCER
DIAGNOSIS
PROGNOSIS
 2 YEAR MORTALITY RATE 35% IF
SYMPTOMATIC
 INCREASES TO 80% (MALES) AND
65% (FEMALES) WITHIN 6 YEARS
 PATIENTS DEVELOPING
PULMONARY EDEMA SURVIVAL
RATE 1 YEAR
 85% OF PATIENTS IN
CARDIOGENIC SHOCK DIE
WITHIN 1 WEEK
TYPES OF PATHOLOGY
 HIGH-OUTPUT,
LOW-OUTPUT
 SYSTOLIC,
DIASTOLIC
 RIGHT SIDED,
LEFT SIDED
 COMBINATION OF
TYPES
PATHOPHYISIOLOGY
 INABILITY OF THE HEART TO SUPPLY BLOOD
TO ADEQUATLY MEET THE METABOLIC NEEDS
OF BODILY TISSUES
 MAY DEVELOP OVER LIFETIME OR PRESENT
ACUTELY
 3 MECHANISMS UTILIZED TO COMPENSATE
– FRANK-STARLING LAW: INCREASING PRELOAD
RESULTS IN INCREASED CONTRACTILITY
– MYOCARDIAL STRUCTURAL CHANGES:
HYPERTROPHY OF MYOCYTES (INCREASED MASS)
– NEUROHORMONAL : RENIN-ANGIOTENSIN-
ALDOSTERONE SYSTEM, RELEASE OF
NOREPINEHRINE, NATRIURETIC PEPTIDES AND
ENDOTHELIEN RELEASE
PATHOPHISIOLOGY
 HIGH-OUTPUT: CARDIAC FUNTION IS
MAINTAINED, BUT INADEQUQTE TO
MEET EXCESSIVE DEMANDS OF
TISSUES
– ETIOLOGY: ANEMIA, BERIBERI,
THYROTOXICOSIS, PAGET’S DISEASE,
ARTERIOVENOUS SHUNTS
 LOW-OUTPUT: DECREASE IN
MYOCARDIAL CONTRACTION FROM
INHERENT OR AQUIRED ETIOLOGIES
– MANY CAUSES: ISCHEMIA, HYPERTENSION
MOST COMMON
SYSTOLIC VS
DIASTOLIC
 SYSTOLIC DYSFUNCTION DEFINED AS
EJECTION FRACTION <40% (AFTERLOAD
SENSITIVE)
– CAUSES AN INCREASE IN PULMONARY VASCULAR
PRESSURES, PULMONARY CONGESTION AND
EDEMA

 DIASTOLIC DYSFUNCTION: IMPAIRED

VENTRICULAR RELAXATION WITH PRESEVED
CONTRACTILITY (PRELOAD SENSITIVE)
– EXCESSIVE DIURESIS MAY EXACERBATE
CONDITION

 DISTINCTION MADE BY ECHOCARDIOGRAM

RIGHT SIDED VS LEFT
SIDED
 LEFT SIDED: INCREASING PRESSURES
IN PULMONARY VASCULATURE
– MANIFESTS AS PERIVASCULAR AND
INTERSTITIAL TRANSUDATE
– ALVEOLAR SEPTAL WIDENING
– ACUMMULATION OF TRANSUDATE IN
ALVEOLI
 ETIOLOGY: HTN, ISCHEMIA, VALVULAR
DISEASES
LEFT SIDED
KERLY B LINES
-SIDEROPHAGES
RIGHT SIDED
 ISOLATED RIGHT SIDED HF RARE
– CHRONIC PULMONARY HYPERTENSION
MOST COMMON CAUSE (COR
PULMONALE)
 LEFT SIDED HEART FAILUSE MOST
COMMON CAUSE OF RIGHT SIDED
FAILURE
 MANIFESTS AS: PERIPHERAL EDEMA,
JVD, RUQ PAIN,
HEPATOSPLEENOMEGALY
RIGHT SIDED
DIAGNOSIS
 CLINICAL FINDINGS: RESPIRATORY DISTRESS
ORTHOPNEA, JVD, HTN, DIAPHORESIS,
PERIPHERAL EDEMA, ELEVATED PCWP
 Chest X-RAY: VASCULAR REDISTRIBUTION,
CARDIOMEGALY (CARDIOTHORACIC RATIO >
0.6 PA), INTERSTITIAL EDEMA, KERLY B
LINES, PLEURAL EFFUSIONS
 CLINICAL SYMPTOMS MAY PRECEDE IMAGING
EVIDENCE BY UP TO 6 HOURS, DONOT
WITHHOLD THERAPY
 ECHOCARDIOGRAPHY GOLD STANDARD
CLINICAL DIAGNOSIS
DIAGNOSIS
 ELEVATED BNP LEVELS
 NON HF PATIENTS LEVELS AVG 38
pg/ml
 HF PATIENT AVG 1076 pg/ml
 BNP INCREASED IN ELDERLY,
RENAL FAILURE, WOMEN,
CIRRHOSIS
 BNP LEVELS 100-250 pg/ml
CONSIDER OTHER DIAGNOSIS
TREATMENT
 AIRWAY MANAGEMENT:
 CADIAC MONITORING, PULSE
OXIMETRY, ECG, IV ACSESS
 CARDIAC ENZYMES (14% HAVE
POSITIVE SERUM MARKERS)
 CBC,BMP,BNP, CHEST XRAY,
LIVER ENZYMES, DIGOXIN LEVEL
TREATMENT
PHARMACOLOGY
 REDUCTION OF AFTERLOAD
– SUBLINGUAL NITROGLYCERIN: 0.4 mg REPEAT 1-5
MIN
– IV NITROGLYCERIN: 10-30 micg/min TITRATE TO
200 micg/min
– IV NITROPRUSSIDE: 2.5 micg/kg/min TITRATE
– NESIRITIDE: ANTAGONIST TO RENIN- ANGIOTENSIN
AXSIS, 2 micg/kg BOLUS, IV DRIP 0.01 micg/kg/min

 VASODIALATORS NOT RECOMMENED FOR

HYPOTENSIVE PATIENTS, PATIENTS WITH
CARDIOGENIC SHOCK
CONTRAINDICATIONS
TO VASODIALATORS
 PRELOAD DEPENDENT STATES
– RIGHT VENTRICULAR INFARCTION
– AORTIC STENOSIS
– VOLUME DEPLETION
– HYPERTROPHIC CARDIOMYOPATHY
 REDUCTION OF HEART RATE AND
CONTRACTILITY WITH IV BETA
BLOCKERS IS THERAPY OF
CHOICE
TREATMENT
PHARMACOLOGY
 FUROSEMIDE:
– NO PRIOR USE: 40 mg IVP
– PRIOR USE: DOUBLE LAST 24 HOUR
USAGE: 80-180 mg
– NO RESPONSE IN 20-30 MIN RE-DOUBLE
DOSE
 BUMETANIDE:
– 1-3 MG DIURESIS BEGINS WITHIN 10 MIN
 MONITORING OF ELECTROLYTES
ESSENTIAL
TREATMENT
PHARMACOLOGY
 ACE INHIBITORS
– DECREASE MORTALITY AND HOSPITALIZATIONS
– ALL HF PATIENTS SHOULD BE DISCHARGED WITH
ACEI (DECREASES MORTALITY IN CLASS 4 HF BY
31%)

 BETA BLOCKERS
– DECREASE MYOCARDIAL HYPERTROPHY,
AFTERLOAD AND MYOCARDIAL OXYGEN DEMAND
– METOPROLOL DECREASES 1 YEAR MORTALITY IN
CLASS II-III BY 34%
CLASSIFICATION OF HF
PHARMACOLOGY
 DRUGS CONTRAINDICATED IN HF
 CALCIUM CHANNEL BLOCKERS
 NSAIDS: INHIBIT EFFECTS OF
DIURETICS AND ACEI
 ANTIARRHYTHMICS:
PROPHYLACTIC USE IS NOT
EFFECTIVE, AND MAY INCREASE
MORTALITY
DISPOSITION
 MOST PATIENTS WITH ACUTE
PULMONARY EDEMA REQUIRE ICU
ADMISSION
 PATIENTS WITH RESOLVED
HYPERTENSION AND DYSPNEA MAY BE
ADMITTED TO MONITORED NON-ICU
BED
 FOLLOW ENTRY PROTOCOL
GUIDELINES FOR OBSERVATION,
ACUTE CARE OR SHORT-STAY UNIT
ADMISSION
LONG TERM
MANAGEMENT
 OUTPATIENT FOLLOW-UP BY PHYSCIAN
TRAINED IN HF MANAGEMENT

 SOCIAL SERVICE EVALUATION

– MEDICATION COMPLIANCE
– DIETARY EDUCATION
– SMOKING CESSATION (REDUCES
MORTALITY AS EFFECTIVLY AS BEST
MEDICATION)