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Congestive Heart Failure for the Prehospital Provider
John Burton, MD- Albany Medical Center-Albany, NY
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62 year old male CC: Difficulty Breathing It’s Midnight….suddenly short of breath! History: CHF, CAD, COPD Drugs: coumadin, digoxin, captopril, Inhalers Allg: None ROS: Negative - no chest pain, etc.. Exam: RR 45, Sat 82%RA, HR 130, BP 190/100 Lungs: bilateral rales Ext: 2+ bilateral edema
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Objectives Discuss core concepts in anatomy and physiology that will enhance your overall understanding of the cardiovascular system Discuss the pathophysiology of CONGESTIVE HEART FAILURE: what it is, what’s it about? Discuss Congestive Heart Failure patient management for the prehospital provider
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Let’s think a little bit about the Left Ventricle
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Acquired or Congenital Cardiomyopathies Affecting the Left Ventricle
Type of Cardiomyopathies Dilated All four chambers are dilated. The most common cause is chronic alcoholism, though some may be the end-stage of remote viral myocarditis. Single ventricle can dilate as well….as in CHF. Hypertrophic The most common form, idiopathic hypertrophic subaortic stenosis (IHSS) results from asymmetric interventricular septal hypertrophy, resulting in left ventricular outflow obstruction. High blood pressure is also a common cause.
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Dilated Cardiomyopathy Hypertrophic Cardiomyopathy
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Dilated Cardiomyopathy Hypertrophic Cardiomyopathy
EITHER WAY…THE HEART DOES NOT FUNCTION AS WELL
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A brief discussion of the works of this thing...
Slide 39
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The Pump: 1. A Mechanical Component 2. An Electrical
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65% 1. A Mechanical Component 2. An Electrical
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Filling….Pumping Problems with Filling... Problems with Pumping...
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PUMPS LESS!!!
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FILLS LESS!!!
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Just how little pumping can one get away with?
Problems with Pumping... Just how little pumping can one get away with?
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Just how little pumping can one get away with?
Normal % No Symptoms % Lethargy, less exercise tolerance % Shortness of breath % Incompatible with life - <15%
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Break
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PREload AFTERload Contractility
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PREload
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AFTERload
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Contractility
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Preload is a passive stretching force exerted on the ventricular muscle at the end of diastole. Preload is caused by the volume of blood in the ventricle at the end of diastole. Afterload is the force resisting the contraction of the cardiac muscle fibers. Afterload can also be considered as the blood pressure exerted on the Atrial Valve during diastole (Diastolic BP). Contractility refers to the ability of cardiac muscle fibers to shorten when stimulated (strength).
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CO = SV x HR Normal - 65% No Symptoms - 40-65%
Lethargy, less exercise tolerance % Shortness of breath % Incompatible with life - <15% CO = SV x HR Where: CO is cardiac output expressed in L/min (normal ~5 L/min) SV is stroke volume per beat
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Both CO and SV are dependent upon
CO = SV x HR Both CO and SV are dependent upon Preload Afterload Contractility
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What have we learned? Cardiac Anatomy
Cardiac physiology and pathophysiology How to think of the above using the concepts of preload, afterload, and contractility
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Filling….Pumping Problems with Filling... Problems with Pumping...
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DEFINITION CHF “The situation when the heart is
incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.” E. Braunwald
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Diagnosis of CHF: Pt with symptoms of heart failure - shortness of breath and leg swelling. Physical exam findings for heart failure - lungs: rales, legs: edema, neck: jvd Chest XRay findings for CHF Findings of systolic or diastolic dysfunction: Echocardiograms: Low ejection fraction/poor contractility (hypocontractility) Maisel A. et al. J Am Coll Cardiol 2001
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Patients with previous history or current HEART DISEASE.
Who gets HEART FAILURE? Risk factors: hypertension, hyperlipidemia, smoking, diabetes, family history of heart disease. Patients with history of acute myocardial infarcation. Patients with previous history or current HEART DISEASE.
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What does Heart Failure do?
“The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.”
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Venous Arterial Legs swell Decreased perfusion…. Neck veins distend
Liver congestion Lung congestion Arterial Decreased perfusion…. Brain Kidneys Everything...
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Venous Legs swell (Pitting Edema) Neck veins distend (JVD)
Liver congestion (HepatoJug Rflx) Lung congestion (Rales)
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LUNG SOUNDS Normal - Clear Asthma - End Expiratory WHEEZES
CHF - Inspiratory RALES
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Heart Failure Approximately 5 million Americans have CHF (male to female ratio 1:1) 550,000 new cases annually Incidence of 10/1000 > 65 years of age Hospital discharges 962,000 Five-year mortality rate as high as 50% Single largest expense for Medicare AHA Heart and Stroke Statistical Update 2002
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HCFA Hospitalization Costs
Billions of $ O’Connell JB. et al. J Heart Lung Transplant 1994;13:S107-12
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Heart Failure Hospitalizations
The number of heart failure hospitalizations is increasing in both men and women AHA Heart and Stroke Statistical Update 2002
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Heart Failure Total Direct and Indirect Costs
Total Direct and Indirect Expenditures = $23.2 billion AHA Heart and Stroke Statistical Update 2002
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Causes of Congestive Heart Failure
Hypertension Ischemia Sustained Arrhythmias Cardiomyopathy EtOH, infiltrative Valvular Heart Disease Pericardial Disease
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CHF: a CLINICAL diagnosis
CHF: Diagnosis CHF: a CLINICAL diagnosis History Physical Exam Chest X Ray Echocardiogram Laboratory testing
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How do you know an EMS patient has Heart Failure?
CHF: a CLINICAL diagnosis History Physical Exam Chest X Ray Echocardiogram Laboratory testing …. Shortness of Breath!!! ; Leg edema; weakness …. Legs: Edema; Lungs: Rales
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How do you know an EMS patient has Heart Failure?
Accuracy of Diagnosis: CHF EMS : % Emergency Doc: % Cardiologist: %
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OR’s for differentiating between patients with and those without CHF
NEJM 02;347:
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IN The Emergency Department: Do a Chest XRay
How do you know an EMS patient has Heart Failure? Ask 3 Questions: 1. History of Congestive Heart Failure? 2. RALES on Lung Examination? 3. EDEMA to Legs? IN The Emergency Department: Do a Chest XRay
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Spectrum of Heart Failure
PND and orthopnea Dyspnea at rest Dyspnea on exertion Pulmonary Edema Moderate Asymptomatic CHF Cardiogenic Shock Severe Mild
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What have we learned: CHF
There’s lots of it….and it’s expensive Diagnosis is tough…mostly shortness of breath and leg edema patients. Ask 3 Questions: 1. History of CHF? 2. Rales to lungs? 3. Leg Edema?
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Goals of Therapy in CHF Relief of symptoms - shortness of breath, leg edema, fatigue Improve hemodynamic compromise Minimize complications - decrease cardiac risk of new events
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Venous Arterial Legs swell Neck veins distend Liver congestion
Lung congestion Arterial Decreased perfusion…. Brain Kidneys Everything... INCREASED PRELOAD INCREASED AFTERLOAD
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Current Treatment of Acute Heart Failure
High Preload High Afterload Poor Contractility Reduce fluid volume Vasodilate Augment Contrac- tility Inotropes -reduce afterload- Diuretics LASIX VasodilatorsNitroglycerin
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CHF: The EMS Approach CHF Patient Traditional Approach Lasix
Top/SL Nitroglycerin Morphine
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Diuretics : Lasix Advantages Disadvantages Alleviate symptoms
Decreases fluid overload Disadvantages Electrolyte imbalance Diuretic resistance Decreases renal perfusion
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Nitroglycerin Advantages Disadvantages Decreases preload at low doses
Higher doses can result in arteriolar dilation (afterload reduction) Disadvantages Tachycardia Tolerance to therapy Overtitration can be problematic Slide 29 Consider relating this back to the patient?
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Increasing dose of nitroglycerin
Arteries VEINS Increasing dose of nitroglycerin
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Morphine Advantages Disadvantages Decreases preload at low doses
Higher doses can result in afterload reduction Disadvantages Sedation Effects on preload are very difficult to titrate and variable from patient to patient Overtitration can be problematic - hypoxemic or sedated? Bad Outcomes in studies Slide 29 Consider relating this back to the patient?
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Am J Emerg Med 99;17: : 181 pts
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Continuous Positive Airway Pressure CPAP
Advantages Increases oxygenation Effects on preload, afterload and contractility are arguable and not completely understood Disadvantages Cooperation Studies are few and unclear…although empiric evidence is stong Slide 29 Consider relating this back to the patient?
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CHF: The Evolving EMS Approach
CHF Patient Traditional Approach Lasix Top/SL Nitroglycerin Morphine Evolving Approach Lasix - smaller doses Nitroglycerin - higher doses Morphine - smaller doses/none Continuous Positive Airway Pressure (CPAP)
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62 year old male CC: Difficulty Breathing It’s Midnight….suddenly short of breath! History: CHF, CAD, COPD Drugs: coumadin, digoxin, captopril, Inhalers Allg: None ROS: Negative - no chest pain, etc.. Exam: RR 45, Sat 82%RA, HR 130, BP 190/100 Lungs: bilateral rales Ext: 2+ bil edema
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Is it CHF or is it COPD?
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CHF COPD Hx COPD Hx CHF Inhalers/O2 Hx Heart Disease
Normotensive +/- Leg edema Sputum Hx CHF Hx Heart Disease Hypertensive Rales Leg edema
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EMS Management 62 yo male Chief complaint: Difficulty breathing
- Face Mask O2 - Lasix - single dose - 40 mg - Nitroglycerin - titrate to symptoms and pressure - CPAP if ya got it
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In the ED.…CHF IV NTG Face mask O2 Lasix
IV/Oral ACE inhibitor (captopril): AFTERLOAD BiPaP/CPAP Intubate if respiratory failure Watch for symptoms to improve….
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Emergency Department
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Current Treatment of Acute Heart Failure
Vasodilators Diuretics Vasodilate Decrease Preload And Afterload Augment Contract- ility Reduce fluid volume Slide 27 Patients with HF frequently present to the hospital with worsened symptoms in a hypervolemic state. Therapy may initially target this excess fluid incorporating diuretics along with vasodilators to help reduce the overloaded state. Current therapies offer symptomatic benefits to patients with HF. Diuretics reduce fluid volume resulting in decreased pulmonary congestion and swelling of extremities. Vasodilators decrease blood vessel constriction, reducing preload and afterload, improving ventricular function and cardiac output. Inotropic agents stimulate the heart muscle, increasing contractility and cardiac output. Lasix Ntg: sl, top, iv MSO4 ACEi BiPAP/CPAP Lasix ACE inhibitor Nitroglycerin
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Patient Follow-up... 62 yo male Chief complaint: Difficulty breathing
In the ED: IV Ntg, Bipap, Captopril.. Got better….admit CICU not intubated Discharged on day 6
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BiPAP or CPAP?? Multiple small case reports of Noninvasive Ventilatory Support (NVS) in patients with varying diagnoses of respiratory failure. No assessment of hemodynamic findings in a controlled fashion. No assessment of neurohormonal effects of NVS.
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BiPAP vs CPAP?? Mehta. Crit Care Med 1997;25:620-628.
One small study raising concern for BiPAP-associated AMI in pulmonary edema patients, compared to CPAP. 27 pts randomized with more rapid improvements in dyspnea and oxygenation associated with BiPAP: BiPAP and CPAP good, BiPAP = MI Kosowsky. Am J Emerg Med 2000;18: Good review of literature to date on Noninvasive Ventilatory Support (NVS).
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