Congestive Heart Failure Congestive Heart Failure for the Prehospital for the Prehospital

ProviderProvider

John Burton, MD- Albany Medical Center-Albany, NY

burtonj@mail.amc.edu

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

Objectives

1. Discuss core concepts in anatomy and physiology that will enhance your overall understanding of the cardiovascular system

2. Discuss the pathophysiology of CONGESTIVE HEART FAILURE: what it is, what’s it about?

3. Discuss Congestive Heart Failure patient management for the prehospital provider

Let’s think a little bit about the Left Ventricle

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.

Dilated Cardiomyopathy Hypertrophic Cardiomyopathy

Dilated Cardiomyopathy Hypertrophic Cardiomyopathy

EITHER WAY…THE HEART DOES NOT FUNCTION AS WELL

A brief discussion of the works of this thing...

The Pump:

1. A Mechanical Component

2. An ElectricalComponent

1. A Mechanical Component

2. An ElectricalComponent

65%

Filling….Pumping

Problems with Filling...

Problems with Pumping...

PUMPS LESS!!!

FILLS LESS!!!

Pumping

Just how little pumping can one get away with?

Problems with Pumping...

PumpingJust how little

pumping can one get away with?

Normal - 65%No Symptoms - 40-65%Lethargy, less exercise tolerance - 30-45%Shortness of breath - 20 - 30%Incompatible with life - <15%

Break

AFTERloadPREload Contractility

PREload

AFTERload

Contractility

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).

CO = SV x HR

Where:

CO is cardiac output expressed in L/min (normal ~5 L/min)

SV is stroke volume per beat

Normal - 65%No Symptoms - 40-65%Lethargy, less exercise tolerance - 30-45%Shortness of breath - 20 - 30%Incompatible with life - <15%

CO = SV x HR

Both CO and SV are dependent upon

Preload

Afterload

Contractility

What have we learned?

• Cardiac Anatomy

• Cardiac physiology and pathophysiology

• How to think of the above using the concepts of preload, afterload, and contractility

Filling….Pumping

Problems with Filling...

Problems with Pumping...

DEFINITION CHFDEFINITION CHF

E. BraunwaldE. Braunwald

“The situation when the heart is incapable of maintaining a cardiacoutput adequate to accommodatemetabolic requirements and the venous return.”

Diagnosis of CHF: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

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.

What does Heart Failure do?What does Heart Failure do?

“The situation when the heart is incapable of maintaining a cardiacoutput adequate to accommodatemetabolic requirements and the venous return.”

Venous

Legs swell

Neck veins distend

Liver congestion

Lung congestion

Arterial

Decreased perfusion….

BrainKidneys

Everything...

Venous

Legs swell(Pitting Edema)

Neck veins distend(JVD)

Liver congestion(HepatoJug Rflx)

Lung congestion(Rales)

LUNG SOUNDS

Normal - Clear

Asthma - End ExpiratoryWHEEZES

CHF - Inspiratory RALES

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 2002AHA Heart and Stroke Statistical Update 2002

HCFA Hospitalization Costs

0

1

2

3

4

5

6 Heart failureCancerMyocardial infarction

Bil

lion

s of

$

O’Connell JB. et al. J Heart Lung Transplant 1994;13:S107-12

Heart Failure Hospitalizations

0

100,000

200,000

300,000

400,000

500,000

600,000

Dis

char

ges

WomenMen

The number of heart failure hospitalizations is increasing in both men and womenThe number of heart failure hospitalizations is increasing in both men and women

AHA Heart and Stroke Statistical Update 2002AHA Heart and Stroke Statistical Update 2002

Heart Failure Total Direct and

Indirect Costs

66%7%

9%

10%8%

Hospital/NursingHome

Physicians/OtherProfessionals

Drugs/OtherMedical Durables

Home HealthCare

LostProductivity/Mortality

Total Direct and Indirect ExpendituresTotal Direct and Indirect Expenditures= $23.2 billion= $23.2 billion

AHA Heart and Stroke Statistical Update 2002AHA Heart and Stroke Statistical Update 2002

Causes of Congestive Heart Failure

• Hypertension

• Ischemia

• Sustained Arrhythmias

• Cardiomyopathy– EtOH, infiltrative

• Valvular Heart Disease

• Pericardial Disease

CHF: Diagnosis

CHF: a CLINICAL diagnosis• History• Physical Exam• Chest X Ray• Echocardiogram• Laboratory testing

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

How do you know an EMS patient

has Heart Failure?Accuracy of Diagnosis: CHF

EMS : 50-65%

Emergency Doc: 65-80%

Cardiologist: 80-85%

1

11.1

2.72.2

10.7

2.9

1.9

0

2

4

6

8

10

12

OR

Predictor

AgeHx CHFHx MIRalesCeph XREdemaJVD

NEJM 02;347:161-167

OR’s for differentiating between patients with and those without CHFOR’s for differentiating between patients with and those without CHF

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

Spectrum of Heart Failure

AsymptomaticAsymptomaticCHFCHF

Dyspnea Dyspnea on on

exertionexertion

Cardiogenic Cardiogenic ShockShock

Pulmonary Pulmonary EdemaEdema

PND and PND and orthopneorthopne

aa

Dyspnea at Dyspnea at restrest

ModerateModerate

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?

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

Venous

Legs swell

Neck veins distend

Liver congestion

Lung congestion

Arterial

Decreased perfusion….

BrainKidneys

Everything...

INCREASEDPRELOAD

INCREASEDAFTERLOAD

Current Treatment of Acute Heart Failure

DiureticsDiureticsLASIXLASIX

ReduceReducefluidfluid

volumevolume

VasodilateVasodilate

InotropesInotropes-reduce -reduce afterload-afterload-

VasodilatorsVasodilatorsNitroglycerinNitroglycerin

High Preload

High Afterload

Poor Contractility

AugmentAugment Contrac-Contrac- tilitytility

CHF: The EMS Approach

Traditional Traditional ApproachApproach

LasixLasix

Top/SL Top/SL NitroglycerinNitroglycerin

MorphineMorphine

CHF PatientCHF Patient

Diuretics : Lasix

Advantages• Alleviate symptoms• Decreases fluid overload

Disadvantages• Electrolyte imbalance• Diuretic resistance• Decreases renal

perfusion

Nitroglycerin

Advantages• Decreases preload at

low doses• Higher doses can

result in arteriolar dilation (afterload reduction)

Disadvantages• Tachycardia • Tolerance to therapy• Overtitration can be

problematic

Increasing dose of nitroglycerin

VEINS

Arteries

Morphine

Advantages• 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

0

1

2

3

4

5

6

Odds Ratio for Intubation in Heart Failure Patients

MIAgeCaptoprilNTGMSDiuretic

Am J Emerg Med 99;17:571-574: 181 pts

Continuous Positive Airway Pressure CPAP

Advantages• Increases oxygenation• Effects on preload,

afterload and contractility are arguable and not completely understood

Disadvantages• Cooperation• Cooperation• Studies are few and

unclear…although empiric evidence is stong

CHF: The Evolving EMS Approach

Traditional Traditional ApproachApproach

LasixLasix

Top/SL Top/SL NitroglycerinNitroglycerin

MorphineMorphine

CHF PatientCHF Patient

Lasix - smaller dosesLasix - smaller doses

Nitroglycerin - higher dosesNitroglycerin - higher doses

Morphine - smaller doses/noneMorphine - smaller doses/none

Continuous Positive Airway Continuous Positive Airway Pressure (CPAP)Pressure (CPAP)

Evolving ApproachEvolving Approach

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

Is it CHF or is it COPD?

CHF COPD• Hx CHF• Hx Heart Disease• Hypertensive• Rales• Leg edema

• Hx COPD• Inhalers/O2• +/- Hx Heart Disease• Normotensive• +/- Leg edema• Sputum

EMS Management 62 yo male62 yo maleChief complaint: Difficulty breathingChief complaint: Difficulty breathing

- Face Mask O2- Face Mask O2- Lasix - single dose - 40 mg- Lasix - single dose - 40 mg- Nitroglycerin - titrate to symptoms- Nitroglycerin - titrate to symptoms

and pressureand pressure- CPAP if ya got it- CPAP if ya got it

In the ED.…CHF• Face mask O2

• IV NTG• Lasix

• IV/Oral ACE inhibitor (captopril): AFTERLOAD

• BiPaP/CPAP

• Intubate if respiratory failure

• Watch for symptoms to improve….

Emergency Department

Current Treatment of Acute Heart FailureCurrent Treatment of Acute Heart Failure

Diuretics

Reducefluid

volume

Vasodilators

DecreasePreload

AndAfterload

Vasodilate

AugmentContract-

ility

Lasix ACE inhibitor Nitroglycerin

LasixNtg: sl, top, iv

MSO4ACEi

BiPAP/CPAP

Patient Follow-up... 62 yo male62 yo maleChief complaint: Difficulty breathingChief complaint: Difficulty breathing

In the ED: IV Ntg, Bipap, Captopril..In the ED: IV Ntg, Bipap, Captopril.. Got better….admit CICU not intubatedGot better….admit CICU not intubated

Discharged on day 6Discharged on day 6

burtonj@mail.amc.edu

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.

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;18:91-95. Good review of literature to date on Noninvasive Ventilatory Support (NVS).