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Congestive Heart Failure Congestive Heart Failure for the Prehospital for the Prehospital
ProviderProvider
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
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
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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...
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The Pump:
1. A Mechanical Component
2. An ElectricalComponent
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1. A Mechanical Component
2. An ElectricalComponent
65%
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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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Pumping
Just how little pumping can one get away with?
Problems with Pumping...
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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%
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Break
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AFTERloadPREload 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
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%
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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 CHFDEFINITION CHF
E. BraunwaldE. Braunwald
“The situation when the heart is incapable of maintaining a cardiacoutput adequate to accommodatemetabolic requirements and the venous return.”
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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
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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?What does Heart Failure do?
“The situation when the heart is incapable of maintaining a cardiacoutput adequate to accommodatemetabolic requirements and the venous return.”
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Venous
Legs swell
Neck veins distend
Liver congestion
Lung congestion
Arterial
Decreased perfusion….
BrainKidneys
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 ExpiratoryWHEEZES
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 2002AHA Heart and Stroke Statistical Update 2002
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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
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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
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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
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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: 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 : 50-65%
Emergency Doc: 65-80%
Cardiologist: 80-85%
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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
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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
AsymptomaticAsymptomaticCHFCHF
Dyspnea Dyspnea on on
exertionexertion
Cardiogenic Cardiogenic ShockShock
Pulmonary Pulmonary EdemaEdema
PND and PND and orthopneorthopne
aa
Dyspnea at Dyspnea at restrest
ModerateModerate
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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
Legs swell
Neck veins distend
Liver congestion
Lung congestion
Arterial
Decreased perfusion….
BrainKidneys
Everything...
INCREASEDPRELOAD
INCREASEDAFTERLOAD
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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
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CHF: The EMS Approach
Traditional Traditional ApproachApproach
LasixLasix
Top/SL Top/SL NitroglycerinNitroglycerin
MorphineMorphine
CHF PatientCHF Patient
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Diuretics : Lasix
Advantages• Alleviate symptoms• Decreases fluid overload
Disadvantages• Electrolyte imbalance• Diuretic resistance• Decreases renal
perfusion
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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
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Increasing dose of nitroglycerin
VEINS
Arteries
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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
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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
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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• Cooperation• Studies are few and
unclear…although empiric evidence is stong
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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
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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 CHF• Hx Heart Disease• Hypertensive• Rales• Leg edema
• Hx COPD• Inhalers/O2• +/- Hx Heart Disease• Normotensive• +/- Leg edema• Sputum
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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
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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….
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Emergency Department
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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
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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
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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;18:91-95. Good review of literature to date on Noninvasive Ventilatory Support (NVS).