Zuhir PBL-II (Heart Failure)
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Transcript of Zuhir PBL-II (Heart Failure)
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PBL-IIZuhir Bodalal
Group A2
Libyan International Medical University
www.limu.edu.ly
http://www.limu.edu.ly/http://www.limu.edu.ly/ -
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Disclaimer The following is a collection of medical
information from multiple sources, both
online and offline. It is to be used for educational purposes only. All materials belong to their respective owners
and the authors claims no rights over them.
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Congestive Heart Failure
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What is CHF?
Definition
Abnormality of cardiac function that leads to theinability of the heart to pump blood to meet thebodys basic metabolic demands or when it cando so only with an elevated filling pressure
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Epidemiology Prevalence
Affects nearly 5 million Americans currently, >500,000 new cases diagnosed each year Cost
Annual direct cost in >10 billion dollars Incidence increased with age
Effects 1-2% of patient from 50-59-years-old and 10% of patient over the age of 75 Frequency
It is the most common inpatient diagnosis in the US for patients over 65 years of age Visits to their family practitioner on average 2-3 times per year
Gender Men> women in those between 40 and 75 years of age The sexes are equal over 75 years of age
5- year survival rates are estimated to be 59% in men and 45% in women.
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Pathiophysiology
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Physical Exam Anxious Pale Clammy Dyspnea Tachypnea Confusion Edema Hypertension Diaphoretic
Rales Ronchi Tachycardia S3 Gallop JVD Pink Frothy Sputum Cyanosis Displaced PMI
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Classification of Heart Failure: ACC/AHA Stage vs NYHA Class
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COPD CHF Pneumonia
Cough Frequent Occasional Frequent
Wheeze Frequent Occasional Frequent
Sputum Thick Thin/white Thick/yellow/ brown
Hemoptysis Occasionally Pink frothy occasionally
PND Sometimes after
a few hours
Often within 1
hour
Rare
Smoking Common Less common Less common
Pedal edema Occasional Common withchronic
none
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COPD CHF Pneumonia
Onset Often URI withcough
Orthopnea atnight
Gradual withfever, cough
Chest Pain pleuritic Substernal,crushing
Pleuritic, oftenlocalized
Clubbing Often Rare Rare
Cyanosis Often and severe Initially mild butprogresses
May be present
Diaphoresis May be present Mild to heavy Dry to moist
Pursed Lips Often Rare Rare unlessCOPD
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Precipitating Causes
Common CAD (70%) Systemic
Hypertension Idiopathic
Less Common
Diabetes Mellitus Valvular Disease
Rare Anemia Connective Tissue Disease Viral Myocarditis Hemochromatosis HIV Hyper/Hypothyroidism Hypertrophic Cardiomyopathy Infiltrative Disease including
amyloidosis and sarcoidosis Mediastinal radiation Peripartum cardiomyopathy Restrictive pericardial disease Tachyarrhythmias Toxins Trypanosomiasis (Chagas
disease)
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Systolic vs. Diastolic
Diastolic dysfunction EF normal or increased Hypertension Due to chronic replacement fibrosis &
ischemia-induced decrease in distensibility Systolic dysfunction
EF < 40% Usually from coronary disease Due to ischemia-induced decrease incontractility
Most common is a combination of both
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Evaluation History: risk factors for ischemic heart disease,
family history
Physical exam: S3, JVD more specific signs ofHF than rales, peripheral edema
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Exam
Major Criteria Paroxysmal nocturnal
dyspnea Neck Vein Distention Rales Cardiomegaly Pulmonary Edema S3 Gallop Hepatojugular Reflex
Minor Criteria Ankle edema Nocturnal Cough Dyspnea on ordinary
exertion Hepatomegaly Pleural Effusion Tachycardia >120bpm
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Confirming the Presence of Heart
FailureCXR-cardiomegaly and pulmonary edema;
Kerleys B Lines
Laboratory Values BNP
Maybe inc by age, female gender, CRI, pulmdisease, hyperthyroid, obesity, steroid use
Electrocardiogram/ECHO Anterior Q waves, LBBB, LVH
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Negative Prognostic Factors Clinical
Increased Age, Diabetes, Smoking Laboratory
Hyponatremia, Elevated neurohormones Hemodynamic
Reduced EF, Increased Pulm Cap Wedge Pressure
Electrophysiological A-fib, A-flutter, Ventricular ectopy, V-tach
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Treatment
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ACE-I
SOLVD-Enalapril20mg/day (41 mo)
2569 Patients with and EF
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Beta-Blockers
34% reduction in all mortality withuse of beta-blockers
Decrease Cardiac Sympathetic Activity Use in stable, chronic disease (start as
early as discharge-IMPACT-HF) Titrate slowly Contraindications-bradycardia, heart
block or hemodynamic instability Mild asthma was not a contraindication Work irrespective of the etiology of the
heart failure
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Initial and Target Doses of beta-
blockers for HFMedicationMedication Starting DoseStarting Dose Target DosageTarget Dosage
BisoprololBisoprolol 1.25mg daily1.25mg daily 10mg daily10mg daily
CarvedilolCarvedilol 3.125mg bid3.125mg bid 25mg bid25mg bid
MetoprololMetoprololCR/XLCR/XL
12.512.5--25mg25mgdailydaily
200mg daily200mg daily
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Aldosterone Antagonists Spironolactone (Aldactone; RALES 1999)
Pts 1,663 Class III/ IV, ACE, Loop,Dig, EF < 35% Decreased all cause mortality of 30%, NNT=10 Hyperkalemia, gynecomastia
Eplerenone (Inspra; EPHESUS 2003 ) Pts 6,642 asym LV dysfunction, DM, or after MI Dec CV mortality of 13%, NNT=43 Newer more selective inhibitor; fewer side effects More pts on beta-blockers
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Hydralazine (Apresoline) and isosorbide
dinitrate (Sorbitrate)HydralazineReduces systemic vascular resistance by preferentially dilatingarterioles
Isosorbide DinitratePreferential Venodilator-reduces ventricular filling pressureand treat pulmonary congestion
Reduces mortality upto 28%Poor tolerability->30% drop out of study
flushing, headaches, gi upset, less frequently can causepositive ANA titers and lupus-like syndrome
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Hydralazine (Apresoline) and isosorbide
dinitrate (Sorbitrate) African-American Heart Failure Trial (A-HeFT)
advanced HF and a fixed dose of isosorbidedinitrate and hydralazine
Added to Standard B-blocker/Ace-I therapy Some survival improvement
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Digoxin May relieve symptoms, does not reduce
mortality
Pts taking digoxin are less likely to behospitalized (25% reduction) More admissions for suspected digoxin
toxicity
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Loop Diuretics Mainstay of symptomatic treatment
Improve fluid retention
Increase exercise tolerance No effects on morbidity or mortality
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CXR Appearance of CHF
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CardiomegalyCardiac width is largerthan half tran s-thoracicdiameter. Cardiothoraccicrar tio >0.5.
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Kerley B Lines
These are short parallel linesat the lun g peripher y. Theselines represent interlobularsepta, which are usually lessthan 1 cm in length andparallel to one another at rightangles to the pleural surface.They may be seen in any zonebut are most frequen tlyobserved at t he lung bases atthe costophrenic angles on the
PA radiograph, and in th esubsternal region on lateralradiographs
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Peri-Bronchial CuffingOccurs when excess fluidor mucus build up in thesmall airway passages of th e lung causing localizedpatches of atelectasis. This
causes the area aroun d thebronchu s to appear moreprom inent on an xray.
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Pulmonary EffusionsFluid accumulation in th epleu ral space. Usually atrasudative effusion in CHF.
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Pulm. Interstitial EdemaClassical bat wing appearanceis visible as b ilateral h ilarhaze. Cardiogenic pulmon aryedema occurs when th epulmonary capillary pressureexceeds 25 mm Hg.
Above th is level, interstitialpulmon ary edema occurswhich man ifests clinicallly asshortness of breath andtachypnoea.
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ECG Appearance of CHF
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Types of Rhythms Associated withCHF