Congestive heart failure

Background

NYHA Classes

1. No Sx
2. Sx with every day activity
3. Severely limits activity
4. Sx at rest

Diagnosis

Key Historical Questions

1. History of heart failure?
2. Have you been taking your meds?
3. Any recent changes in medication?
4. SOB while: lying flat, walking, middle of night?
5. CP?
6. Syncope?

Studies

1. CBC (r/o anemia), chemistry
2. ECG
3. CXR
4. Troponin?
5. BNP?
   1. <100 (90% Sn)
   2. > 500 (87% Sp)
   3. Elevated in:
      1. Elderly, kidney failure, PE
   4. Decreased in:
      1. Obese

DDX

1. Cardiovascular
   1. ACS
   2. Acute valve dysfunction
   3. Aortic Dissection
   4. Dysrhthymia
   5. Endocarditis
   6. Hypertensive crisis
   7. Pericardial tamponade
2. Pulmonary
   1. COPD
   2. PE
   3. PNA
3. Other
   1. Pure volume overload
      1. Renal failure
      2. Post-transfusion
   2. Sepsis

Causes of Decompensation

1. Medical noncompliance
2. Dietary noncompliance
3. ACS
4. Dysrhythmia
5. Uncontrolled HTN
6. Infection
7. Anemia
8. Thyrotoxicosis
9. PE

Underlying Etiology

1. CAD
2. HTN
3. Cardiomyopathy
4. Valvular
5. High-output
6. Post-partum

Treatment

UNLOAD+

1. Upright Position
2. Nitrates
   1. Consider nitroprusside if NTG ineffective
3. Lasix
4. Oxygen
5. ACEI
   1. Enalaprilat 0.004mg/kg as IVB or 1mg gtt over 2hr
      1. Avoid in pregnancy, hyperK+
6. Digoxin
   1. Indicated for a fib rate control
7. BiPAP

Disposition

Admission Criteria (AHCPR '00)

1. ACS
2. Pulm edema/resp distress
3. O2 sat < 90% on room air
4. Severe complicating illness
5. CHF refractory to outpt therapy
6. Anasarca
7. Symptomatic hypotension or syncope
8. Arrythmia (e.g. new a. fib)
9. Inadequate outpt support

See Also

Cards: CHF Meds

Source

EB Medicine, UpToDate, DONALDSON (adapted from Lampe)