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Snapshot
  • A 68-year-old male presents to his primary care physician 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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