– Dr. J. Satish Kumar, MD, Department of Basic & Medical Sciences, AUST General Medicine CVS Name:________________________________________ Congestive Heart Failure Definition –Abnormality of cardiac function that leads to the inability of the heart to pump blood to meet the body’s basic metabolic demands or when it can do so only with an elevated filling pressure

Predisposing Cardiac Diseases Myocardial infarction Chronic ischemia Cardiomyopathy Arrhythmias Valvular diseases – Aortic Stenosis – Mitral Stenosis – Mitral Regurgitation

Cardiac Physiology CO = Stroke Volume x HR HR: parasympathetic and sympathetic tone SV: preload, afterload, contractility

–Heart failure is a complex of signs and symptoms that occurs when the heart fails to pump an adequate cardiac output. –Starling’s Curve for normal and falling heart

Preload Def: Passive stretch of muscle prior to contraction Measurement: Swan-Ganz – LVEDP Really a function of LVEDV Affected by compliance – Low compliance

Afterload Def: Force opposing/stretching muscle after contraction begins Really a function of: – Chamber radius (dilated cardiomyopathies) – Wall thickness (hypertrophy)

Contractility Def: Normal ability of the muscle to contract at a given force for a given stretch, independent of preload or afterload forces In other words: – How healthy is your heart muscle? Ischemia, Hypertrophy (?), Muscle loss

Classifying Heart Failure Anatomically – Left versus Right Physiologically – Systolic versus Diastolic Functionally – How symptomatic is your patient?

Left versus Right Failure Left Heart Failure - Dyspnea - Dec. exercise tolerance - Cough - Orthopnea - Pink, frothy sputum Right Heart Failure - Dec. exercise tolerance - Edema - Hepatomegaly - Ascites

Systolic versus Diastolic Systolic– “can’t pump” – Aortic Stenosis – HTN – Aortic Insufficiency – Mitral Regurgitation – Muscle Loss Ischemia Fibrosis Infiltration Diastolic- “can’t fill” – Mitral Stenosis – Tamponade – Hypertrophy – Infiltration – Fibrosis

–Heart Failure: Pumping and Filling Problems

Clinical Data CXR – Pulmonary Edema – Pleural Effusions (bilateral) ECG – Left atrial enlargement – Arrhythmias – Hypertrophy (left or right)

Cardiomyopathy Pulmonary Edema

Clinical Data HEART SOUNDS!!! Systolic Murmurs – Mitral Regurg – Aortic Stenosis Diastolic Murmurs – Mitral Stenosis – Aortic Insufficiency S3: Rapid filling of a diseased ventricle

Treatment of CHF Treat Precipitating Factor(s) Adjust Heart Rate Decrease Preload Decrease Afterload Increase Contractility Increase Oxygenation

Precipitating Factors Infection Pulm Embolus Noncompliance Arrhythmia Myocardial Infarction Stress reaction Sodium Intake Medications!!! Anemia Thyroid disorders Endocarditis

Treatment of CHF 4 D Digoxin, Diuretics, Decubitus, Diet Oxygen – nasal, intubation Preload Reduction – Loop diuretics – Nitrates – ACEi

Treatment of CHF Afterload Reduction – IV NTG, Nitroprusside – Hydralazine – ACEi / ARB Ionotropic Support – Dopamine / Dobutamine – Amrinone / Milrinone – Digoxin (chronic) – Mechanical (ABP)

Treatment of CHF Beta-Blockers – Chronic > Acute – Metoprolol Fluid Balance – Restrict fluid / salt intake – Monitor I/Os and daily weight – Dialysis if needed Aspirin

Key Management Points Beta Blocker Fluid Restriction to 1000ml daily Low salt diet Daily patient weight chart Daily I/Os