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, PAGETS 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)