www.medskool.com
 

Google
 
Web www.MedSkool.Net
 
http://www.medskool.net/index.html
http://www.medskool.net/circulatory/index.html
http://www.medskool.net/excretory/index.html
http://www.medskool.net/integumentary/index.html
http://www.medskool.net/reproductive/index.html
http://www.medskool.net/respiratory/index.html
 
 
 
 
 
 
 
 

 

 		  

Congestive Heart Failure: A Clinical Perspective

 

Cardinal symptoms- from lack of perfusion to tissues both from pump dysfunction and other causes

  1. Dyspnea on exertion -
  2. Fatigue

 

Primary symptoms because of volume overloading

  1. orthopena- dyspnea when lying down because of increased pulmonary venous and capillary pressures leading to pulmonary congestion
  2. paroxysmal nocturnal dyspnea-  patients wake up feeling like they are choking in the middle of night and they sit at end of bed and open window to try to get more air. 
  3. pulmonary edema- lungs become flooded with fluids, this is more severe form of fluid overload.

 

Additional symptoms

  1. Peripheral edema-
  2. Palpations
  1. Nocturia- pee in the middle of the night
  2. cerebral- confusion
  3. GI and RUQ abdominal discomfort because of perfusion and distension b/c of volume overload
 
 

Symptomatic classifications based on exercise ability.

 Class I - Ordinary Physical activity does not cause undue fatigue or dyspnea. MVO2=20-25 ml/o2 /kg/min.

Class II - Ordinary physical activity results in fatigue or dyspnea. MVO2 = 15-20 ml/o2/kg/min.

Class III - Less than ordinary physical activity results in fatigue or dyspnea. MVO2 = 10-15 ml/o2/kg/min.

Class IV - Symptoms of fatigue and dyspnea are present at rest. Patients are very ill.  MVO2 = <10 ml/o2/kg/min.

 

Normal peak O2 = 35 but it can be relative because someone like Lance Armstrong would be around 89.

Skip  classification of Heart Failure by American Heart association but read if you want.

 

Physical  Exam findings- (bold are the ones he mentioned)

•          General Appearance  i.e. cachexia, dusky coloration

•          Pulmonary –

•          Rales= crackles, Wheezes / Rhonci Pleural Effusions

•          Increased Jugular Venous Pressure

•          Hepatomegaly and Hepatojugular Reflux

•          Edema

•          Pleural Effusions

•          Cardiac exam

•          Cardiomegaly                                                 

•          Protodiastolic Sounds i.e. the S3 Gallop = early diastolic sound because the ventricles are partially filled already so ventricular filling ends early and valves close early        

•          Pulsus Alternans                                                          

•          Accentuation of P2                                                        

•          Murmurs

•          Cheyne-Stokes Respiration

 

Laboratory abnormalities-

•          Serum Electrolytes:                                                                  

•          Hyponatremia- from free water retention                                                                        

•          Elevated Liver Enzymes (AST, ALT, LDH)                    

•          Hyperbilirubinemia                                                         

•          Prolonged Prothrombin Time      

•          Neurohormones: Increased levels of:                            

•          Angiotensin II                                                                

•          Aldosterone                                                                              

•          Norepinephrine                                                              

•          Endothelin                                                                                

•          Atrial Natriuretic Factor

•          Cytokines levels increased 

•          TNFa

•          Il-6, IL2

•          IFN gamma

 

Diagnostic studies

  • CXR- congestion and cardiomegaly  

•          very white appearance because of volume overload and there are prominent pulmonary arteries.

•          ECG - Infarction, Hypertrophy etc.

•          Echocardiography- see above                                                     

•          Heart Size and Function - Right and Left             

•          Atria and Ventricles

•          Wall motion Abnormalities

•          Valvular Pathology and Function

 

Therapy- need to differentiate between acute, which is treated with hemodynamic stability to prevent myocardial contractility and chronic, where you want to prevent worsening of LV dysfunction.

Chronic Heart Failure Treatment

  1. Treat underlying problems
    1. (HTN, valve disease, restrict Na intake b/c of water retention and increased release of Aldosterone that would hold on to more Na).
  2. ACE inhibitors- to target high levels of Angiotensin II
  3. Aldosterone inhibitors-
  4. Beta blockers- allow ups regulation of beta receptors
  5. Hydralazine /nitrates –for AA pts  but trial is controversial
  6. Diuretics - loop and non-loop to get rid of excess volume but won’t help underlying cause of it
  7. Digitalis glycosides- but does not improve mortality of Heart Failure
  8. Natriuretic factors
  9. Devices
    1. ACID- defibrillators that recognize when in Ventricular tachycardia or V fib. Because about  ½ patients that die of Heart Failure are in V. fib.  Implant gives a shock to get out of v.fib/ v. tach. It is for most patients who have an ejection fraction < 35%
       
    1. Bi-ventricular pacemakers- about 1/3 of systolic Heart Failure patients have ventricular dyssynchrony = Left and right ventricles don’t contract together.  This means that that the interventricular septum is pushed back and forth when each of the ventricles contract alone.  They already have an impaired CO and if the septum not contracting with LV and is over near the RV, there is a further impaired CO.  Can be seen on an EKG by left bundle branch block. 

                                                               i.      This can be seen on a Doppler ECHO where you see the septum and lateral walls of a dilated cardio myopathy heart moving separately.  After the bi-ventricular pacemaker is put in place, you can see the septum and left side of the wall depolarized at the same time to contract together.   (check out his slides if you want to see the ECHOs in motion)


Back to the Circulatory System Index
 
 


Navigation:

MedSkool.Net Home - Circulatory - Excretory - Integumentary - Respiratory
MedSkool.Net Sitemap
 

 

All Content provided on or through MedSkool.Net (i) is provided for informational purposes only, (ii) is not a substitute for professional medical advice, care, diagnosis or treatment, and (iii) is not designed to promote or endorse any medical practice, program or agenda or any medical tests, products or procedures. The Site does not contain information about all diseases, nor does this Site contain all information that may be relevant to a particular medical or health condition. You should not use any Content for diagnosing or treating a medical or health condition. You should carefully read all information provided by the manufacturers of any products advertised or promoted on or through the Site and displayed on or in the associated product packaging and labels before purchasing and/or using such products. If you have or suspect that you have a medical problem, you should contact your professional healthcare provider through appropriate means. You agree that you will not under any circumstances disregard any professional medical advice or delay in seeking such advice in reliance on any Content provided on or through the Site. Reliance on any such Content is solely at your own risk.    Full Disclaimer

Copyright © 2006 www.MedSkool.Net - All Rights Reserved - Trademarks used herein are property of their respective owners