questions 10

Congestive Heart Failure

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Topic updated on 07/06/17 12:15pm

Snapshot
  • A 68-year-old male presents to his primary care physiciaDilated cardiomyopathyn with dyspnea on exertion and swollen ankles. He has a long history of coronary artery disease and alcohol abuse. 
Introduction
  • Congestive heart failure (CHF)
    •  inability of the heart to meet the demands of the body
  • Iatrogenic volume overload is the most common cause of CHF
    • the major etiologic categories include
      • systolic dysfunction
        • or weakened pumping function of the heart via
          • ischemic heart disease 
          • chronic hypertension
          • cardiomyopathy (viral or idiopathic) in younger patients
      • diastolic dysfunction
        • or the inability of the heart to relax/fill via
          • hypertension with LVH
          • hypertrophic cardiomyopathy
          • amyloidosis
          • sarcoidosis
          • hemochromatosis
          • scleroderma
          • post-operative/raditation fibrosis
      • valvular dysfunction
      • arrhythmias
  • Precipitating factors
    • acute MI
    • long-standing HTN
    • chronic anemia
    • acute and/or recurrent pulmonary embolism
    • chronic endocarditis
    • post-partum females
    • and thyrotoxicosis
  • Risk factors
    • CAD
    • family history of hypertrophic cardiomyopathy
    • HTN
    • valvular heart disease
    • ETOH abuse
    • myocarditis 
    • drug side effects (i.e. doxorubicin )
    • smoking
  • CHF exacerbation can be induced by (FAILURE)
    • forgetting medication
    • arrhythmia
    • ischemia
    • lifestyle (salt and obesity)
    • upregulation (pregnancy and hyperthyroidism)
    • renal failure
    • embolus (pulmonary)
Presentation
  • Symptoms
    • patients suffering from CHF can present with a wide range of symptoms that help identify the affected side of the heart as follows
      • left-sided failure
        • lower extremity swelling
          • left-sided failure results in right-sided failure, producing ankle-swelling
        • abdominal fullness
        • exertional dyspnea
        • orthopnea
        • paroxysmal nocturnal dyspnea
        • persistent coughing
      • right-sided failure presents with
        • abdominal fullness
        • exertional dyspnea
        • ankle-swelling
      • 3rd heart sound is first sign of left or right failure
  • Physical exam 
    • left-sided failure
      • bibasilar crackles
      • diffuse, left-displaced PMI
      • S3 (systolic) or S4 (diastolic) gallop
    • right-sided failure
      • atrial fibrillation
      • JVD
      • hepatojugular reflex
      • hepatomegaly
      • lower-extremity edema
Evaluation
  • Echocardiogram
    • echocardiogram and clinical picture provide definitive diagnosis
    • shows impaired cardiac function
      • decreased EF in left-sided heart failure
      • normal-to-elevated EF in right-sided heart failure
    • Systolic heart failure is characterized by: 1) decreased cardiac index, 2) increased systemic vascular resistance, and 3) increased left ventricular end diastolic pressure 
  • CXR may show
    • cephalization of pulmonary vessels
    • cardiomegaly
    • and pleural effusions
  • Cardiac biopsy
    • indicated if infiltrative or viral myocarditis is suspected
  • BNP and NT-proBNP 
  •  

    New York Heart Association Functional Classification of Heart Failure

    Class

    Limitations of Physical Activity

    Heart Failure Symptoms

    I

    • None
    • None

    II

    • Mild
    • Symptoms with significant exertion; comfortable at rest or mild activity

    III

    • Marked limitation
    • Symptoms with mild exertion; only comfortable at rest

    IV

    • Discomfort with any activity
    • Symptoms occur at rest
Differential
  • Deconditioning, chronic lung disease, MI, angina, pericarditis, renal failure, cirrhosis, or other causes of lower-extremity edema (venous insufficiency, hypoproteinemia, nephrosis, etc)
Treatment
  • Acute cases
    • if the patient has worsening dyspnea and other symptoms then
      • diurese aggressively
      • use ACE inhibitors in all patients who can tolerate them
      • dobutamine ("dobutamine holiday") for inotropy
      • nitroprusside for afterload reduction.
  • Chronic cases
    • lifestyle modifications
      • limit dietary sodium intake
    • pharmacologic
      • ACE inhibitors are first-line have been shown to improve survival 
        • Renin-angiotensin-aldosterone system and ADH is upregulated in these patients 
      • digitalis and diuretics improve symptoms but not proven to improve survival
      • warfarin indicated with
        • severe dilated cardiomyopathy
        • atrial fibrillation
        • previous embolic episode
      • maintenance medications include
        • B-blockers
        • afterload reduction via ACEi/ARB
        • spironolactone if K level is not high
        • hydralazine and long-acting nitrates in African-Americans
      • arrythmia medications
        • treat arrhythmia as they arise
    • operative 
      • AICDs should be used
        • indicated when EF < 35% 
        • shown to decrease mortality from VT/VF
  • Exacerbations (in Chronic Patients)
    • treat with loop diuretics such as furosemide when patient is volume-overloaded
  • Treat/control underlying etiologies if identified and possible
    • such as thyrotoxicosis, anemia, CAD, HTN, etc
    • *avoid overdiuresis
Prognosis, Prevention, and Complications
  • Manage underlying etiologies such as
    • thryoid dysfunction
    • long-standing hypertension
  • Reverse alcoholic dilated cardiomyopathy
    • by abstaining from EtOH
  • Reverse tachycardia-induced cardiomyopathy
    • via medication or treating afibrillation/other arrythmias
  • If left untreated
    • almost certainly will lead to death
      • via dry drowning/oxygen deprevation or pneumonia (sepsis)


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Qbank (5 Questions)

TAG
(M3.CV.1) A 65-year-old man with a history of ischemic cardiomyopathy, congestive heart failure, diabetes mellitus, and chronic kidney disease presents to the emergency room with progressive dyspnea on exertion and weight gain for 8 days. Vitals signs are T 99.0, HR 110, BP 130/90, RR 24, SpO2 94% on room air. Physical examination reveals an S3 gallop, 2+ peripheral pitting edema, and marked jugular venous distention. Laboratory results show a serum creatinine of 1.2 mg/dL compared with the patient's normal baseline value of 1.1 mg/dL. The patient's chest radiograph is shown in Image A. A serum troponin is drawn and found to be 0.04 ng/mL. Which of the following medications is indicated first in the care of this patient? Topic Review Topic
FIGURES: A          

1. Enalapril
2. Furosemide
3. Dobutamine
4. Hydralazine
5. Dopamine

PREFERRED RESPONSE ▶
TAG
(M3.CV.14) A 60-year-old Caucasion male presents to your office complaining of shortness of breath on exertion. He undergoes an echocardiogram and is found to have an ejection fraction of 35%. Which of the following classes of drugs would improve mortality in this patient? Topic Review Topic

1. Cardiac glycosides
2. Calcium channel blockers
3. Thiazide diuretics
4. ACE inhibitors
5. Nitrates

PREFERRED RESPONSE ▶
TAG
(M2.CV.57) A 68-year-old male suffered a myocardial infarction two weeks ago. Since this incident, he has reported increased shortness of breath with both activity as well as when lying flat; he has also noted increased swelling in his ankles. Physical exam is significant for an S3 gallop on cardiac auscultation, bibasilar crackles on lung auscultation, and 2+ edema of the bilateral ankles. Which of the following sets of cardiac parameters would most likely be associated with this patient's current condition? (Cardiac index = CI; Systemic vascular resistance = SVR; Left ventricular end diastolic pressure = LVEDP) Topic Review Topic

1. Decreased CI, decreased SVR, increased LVEDP
2. Decreased CI, increased SVR, decreased LVEDP
3. Decreased CI, increased SVR, increased LVEDP
4. Increased CI, decreased SVR, increased LVEDP
5. Increased CI, increased SVR, decreased LVEDP

PREFERRED RESPONSE ▶
TAG
(M2.CV.120) A 69-year-old is hospitalized for worsening dyspnea at rest. Physical examination is notable for crackles at both lung bases and 2+ edema at the ankles bilaterally. Current medications include losartan, metoprolol, furosemide and spironolactone. An EKG and echocardiography are ordered. Which of the following results would serve as the best indication for placement of an implantable cardioverter defibrillator (ICD) in this patient? Topic Review Topic

1. Supraventricular tachycardia on EKG
2. Atrial fibrillation on EKG
3. Reduced diameter of aortic valve on echocardiography
4. Reduced left ventricular ejection fraction on echocardiography
5. Left ventricular hypertrophy on echocardiography

PREFERRED RESPONSE ▶
TAG
(M2.CV.4754) A 69-year-old male presents to the emergency department with shortness of breath. The patient has presented three times this past month with similar complaints. The patient sees no primary care physician and is currently not taking any medications. The patient states his shortness of breath started when he was walking from his car to a local restaurant. His temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 130/90 mmHg, respirations are 18/min, and oxygen saturation is 96% on room air. On physical exam you note a fatigued appearing gentleman. Cardiovascular exam reveals an additional heart sound after S2. Pulmonary exam is notable for bilateral crackles. Abdominal exam reveals an obese abdomen without pain in any of the quadrants. Lower extremity pitting edema is noted bilaterally. Which of the following sets of lab values most likely corresponds to this patient's presentation? Topic Review Topic

1. High BNP, high ADH, high sodium, high potassium
2. High BNP, low ADH, normal sodium, low potassium
3. High BNP, high ADH, low sodium, low potassium
4. Low BNP, high ADH, low sodium, low potassium
5. Low BNP, low ADH, normal sodium, normal potassium

PREFERRED RESPONSE ▶
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