TOC | Cardiology   

Ref:  Systolic Heart Failure 2010  

*CONGESTIVE HEART FAILURE - Left sided       Causes  |  Rx                
[See also  Right sided CHF ]

REF:  CHF Rx Guidlines 2006.pdf  (Heart Failure Society of America)

DX of CHF:

  1. History & Physical Exam
  2. Lab: BNP (B-type Natriuretic Peptide) blood test, O2 saturation, Arterial blood gases, etc.
  3. Imaging:  Chest x-ray, ECG, Echocardiogram, MUGA cardiac scan, Cardiac catherization

CAUSES of CHF:

A. Reduced Inotropy

  1. Coronary Artery Disease - myocardial ischemia or infarction
  2. Cardiomyopathy
  3. Myocarditis
  4. Misc: Drugs, Acidosis, etc

B. Pressure Overload

  1. Aortic Stenosis
  2. Hypertension
  3. Idiopathic Hypertrophic Subaortic Stenosis/Asymmetric Septal Hypertrophy
  4. Coarctation of the Aorta

C. Volume Overload

  1. Aortic Regurgitation
  2. Mitral Regurgitation
  3. Left to Right Shunts

D. Reduced Diastolic Relaxation

  1. Poor Compliance: Ischemic Heart Disease, Restrictive Cardiomyopathy, Hypertrophied Muscle
  2. Constrictive Disorder: Pericardial Tamponade, Constrictive Pericarditis, Restrictive Cardiomyopathy

E. Obstruction of Left Atrial Emptying

  1. Mitral Stenosis
  2. Left Atrial Myxoma
  3. Left Atrial Thrombus
  4. Cor Triatriatum

Precipitating Causes of heart failure:

  1. Poor medication or dietary compliance;  Physical, fluid, environmental, & emotional excesses
  2. Systemic hypertension
  3. Myocardial infarction
  4. Arrhythmias
  5. Pulmonary Embolism
  6. Infection
  7. Anemia
  8. Thyrotoxicosis
  9. Pregnancy
  10. Rheumatic & other myocarditis
  11. Infective endocarditis

     

RX of Heart Failure:
Removal of the precipitating cause, & Correction of the underlying cause
Dietary salt & fluid restriction & Hypertension control  (keep BP low if tolerated)

Medication Rx for CHF:

  1. Diuretics if there is fluid retention or worsening of CHF, as
    Lasix 40-100 mg (Max 400 mg/d) or Bumetanide 1 mg IV or PO 0.5-1 mg 1-2x/d (Max 10 mg/d).
  2. ACE Inhibitors - Angiotensin Converting Enzyme Inhibitor  (first line of Rx)
    Benazepril/Lotensin 5 10 20 40 mg tablets Start 10 mg/d; usual dose 20 40 mg/d once daily.
    Captopril/Capoten     12.5 25 50 100 mg tab 6.25-50 mg 2- 3x/day; (Max: 50 mg tid)
    Enalapril/Vasotec 2.5 5 10 20 mg tablets 2.5- 20 mg bid (Max 10-20 mg bid).
    Fosinopril/Monopril 10 mg tablet Start 5-10 mg once/d; (Max 40 mg/d)
    Lisinopril/Zestril/Prinivil 5 10 20 40 mg tablets Start 2.5-10 mg/d; usual dose 20-40 mg/d (Max)
    Quinapril/Accupril 10 20 40 mg tab usually 10 bid, (Max 40 mg bid)
    Ramipril/Altace 1.25 2.5 5 10 mg cap Start with 1.25-2.5 mg once daily; (Max 10-20 mg/d)
    Perindopril/Acceon 4-8 mg once daily

    ARB - Angiotensin II receptor blockers
    Losartan/Cozaar 25-100 mg/day;  Hyzaar (Cozaar 50 mg + Hctz 12.5 mg)
    ValsartanDiovan 40-160 mg bid

    Avapro/Irbesartan 150-300 mg
    Atacand/Candesartan 16-32 mg 1/day
    Micardis/Telmisartan 40-80 mg tab once daily
    Teveten/Eprosartan 400-800 mg tab once daily

    Other Vasodilators:
    Hydralazine, minoxidil, prazosin - in hypertensive pts
    Nitroglycerin, isosorbide, nitroprusside - in ischemic pts
    Enhancement of myocardial contractility:
  3. Aldosterone/Spironolactone or Eplerenone  (Aldosterone receptor antagonist)
    - should be used in al patients with severe heart failure with LV EF <40%,
    unless the drugs are contraindicated because of hyperkalemia  (K > 5.0 mmol/L) or renal dysfunction (GFR <30 mL/min).  
    - are not advisable for inferior or non-ST-segment elevation MI without signs of heart failure or systolic LV dysfunction.
    (REF: Cleveland Clinic J of Med,  March 2006; Vol 73: 257)

  4. Digoxin 0.125 - 0.25 mg/day - esp. in atrial fibrillation pts or in severe CHF
    Dopamine, Dobutamine, Amrinone
  5. Beta-blockers as:
    Carvedilol (nonselective B-blocker with alpha1 blocking & antioxidant properties)
    Coreg (Carvedilol) 3.125 - 6.25 - 12.5 - 25 mg bid PO   for CHF or Hypertension.
  6. Natrecor (Nesiritide) 2 ug/kg IV bolus, then 0.01 ug/kg/min infusion.
      * New IV B-type natriuretic peptide  
    When added to standard care in patients hospitalized with acutely decompensated CHF, nesiritide improves hemodynamic function and some self-reported symptoms more effectively than intravenous nitroglycerin or placebo.  JAMA. March 27, 2002;287:1531-1540    Editorial  
  7. Biventricular Pacing / Cardiac transplantation
    Cardiac resynchronization reduces mortality from progressive heart failure in patients with symptomatic left ventricular dysfunction. This finding suggests that cardiac resynchronization may have a substantial impact on the most common mechanism of death among patients with advanced heart failure. Cardiac resynchronization also reduces heart failure hospitalization and shows a trend toward reducing all-cause mortality.
    JAMA. Feb. 12, 2003;289:730-740

REF: Progress in Cardiovascular diseases, Vol.41, No.1 Suppl. 1 (July/Aug), 1998 - Marvin Konstam

     

The 2006 Comprehensive Heart Failure Practice Guidelines of the HFSA address diuretic resistance in patients hospitalized for ADHF as follows1:

When congestion fails to improve in response to [loop] diuretic therapy, the following options should be considered:

• Sodium and fluid restriction

• Increasing doses of loop diuretics

• Continuous infusion of a loop diuretic

• Addition of a second type of diuretic orally (metolazone or spironolactone) or intravenously (chlorothiazide)

• Ultrafiltration may be considered

RX of Acute Pulmonary Edema:

  1. Sitting up position
  2. O2 supplement
  3. Morphine 2-5 mg IV (Have Naloxone available prn resp. depression)
  4. Lasix 40-100 mg or Bumetanide 1 mg IV
  5. Nitroprusside IV 20-30 ug/min if systolic BP >100 mmHg.
  6. Digoxin IV; Dopamine, Dobutamine, or Amrinone if needed.
  7. Aminophylline 240-480 mg IV for bronchospasm.
  8. Rotating tourniquets to the extremities if needed. ? Phlebotomies?
  9. Dialysis in renal failure pts.

     

SYSTOLIC HEART FAILURE
("Squeeze" dysfunction, Decreased Ejection Fraction & LV contractility)
The inability of the ventricle to contract normally and expel sufficient blood.

SX: low cardiac output Sx of weakness, fatigue, reduced exercise tolerance,cool skin, mental obtundation, & other Sx of hypoperfusion. JVD, rales, S3, cardiomegaly, edema.

Tests: CXR, ECG, Echocardiogram, MUGA scan, Cardiac cath.

RX: Positive inotropic agent; digoxin, Dopamine, Dobutamine, Amrinone, Diet & Diuretics, ACE Inhibitors: enalapril, captopril, etc. Vasodilators: prazosin, hydralazine, isosorbide.

DIASTOLIC HEART FAILURE
("Dilate" dysfunction, Normal Ejection Fraction, Stiff LV)
The inability of the ventricle to relax and fill normally.

Sx: related to an elevation of filling pressures, as dyspnea, pulm congestion, edema.

Causes of Diastolic Heart Failure:
Constrictive pericarditis, restrictive, hypertensive, & hypertrophic cardiomyopathy, acute myocardial ischemia, myocardial fibrosis & infiltration.

RX: B-blockers, Ca-blockers, Antihypertensive drugs, ?ACE inhibitors?

(REF: JAMA 4-27-94, 271:1276 Gaasch)

     

2010