Updated: 3/27/2018

Congestive Heart Failure

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Questions
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Evidence
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Videos
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Snapshot
  • A 70-year-old woman presents to the emergency room for shortness of breath. She has a past medical history of hypertension, type 2 diabetes mellitus, coronary artery disease, and alcohol use disorder. On physical exam, she has jugular venous distention, pulmonary rales, cardiac S3 sound, and pitting edema. Her electrocardiogram shows sinus tachycardia and chest radiograph shows pleural effusions and cardiomegaly. She is immediately given a loop diuretic and oxygen.  
Introduction
  • Clinical definition
    • inability of the heart to pump blood throughout the body, leading to congestion and decreased perfusion
      • systolic dysfunction
        • loss of contractile strength and results in low ejection fraction (< 45%)
      • diastolic dysfunction
        • impairment in filling of the heart and often has a normal ejection fraction
      • high-output heart failure
        • occurs in a minority of patients
        • cardiac output exceeds metabolic demand
      • decompensated heart failure
        • occurs when symptoms are worsened or exacerbated
        • precipitating factors include 
          • infections 
          • arrhythmias
          • excessive salt in the diet (post-holiday heart)
          • uncontrolled hypertension
          • thyrotoxicosis
          • myocardial infarction
  • Epidemiology
    • risk factors 
      • coronary artery disease
      • viral infection
      • alcohol abuse
      • hypertension
      • arrhythmias
      • metabolic syndrome
      • drugs (e.g., doxorubicin)
      • smoking
  • Etiology
    • systolic dysfunction 
      • ischemic heart disease (most common)
      • chronic hypertension
      • dilated cardiomyopathy
      • valvular disease
      • congenital heart disease
    • diastolic dysfunction 
      • hypertension with left ventricular hypertrophy
      • hypertrophic cardiomyopathy
      • amyloidosis
      • sarcoidosis
      • hemochromatosis
      • scleroderma
      • post-operative/radiation fibrosis
    • high output heart failure
      • obesity
      • myeloproliferative disorder
      • arterial-venous fistula
      • thyrotoxicosis
  • Pathogenesis
    • systolic dysfunction
      • ↓ contractility leading to ↓ ejection fraction and ↑ end diastolic volume
      • ↑ systemic vascular resistance
      • most commonly due to dilated cardiomyopathy and ischemic heart disease
    • diastolic dysfunction
      • ↓ compliance leading to problems with relaxation and filling of the heart
      • normal ejection fraction and normal end diastolic volume
      • most commonly due to myocardial hypertrophy
    • right heart failure most commonly results from left heart failure
    • high output heart failure
      • high cardiac output and ↓ systemic vascular resistance
      • often occurs in the setting of existing systolic or diastolic dysfunction
  • Associated conditions
    • obstructive sleep apnea
    • major depression disorder
Presentation
  • Symptoms
    • dyspnea on exertion
    • orthopnea
    • paroxysmal nocturnal dyspnea
    • fatigue
    • pulmonary edema
  • Physical exam 
    • cardiovascular exam
      • pitting lower extremity edema
      • jugular venous distention
      • S3 sound
    • pulmonary exam
      • Cheyne-Stokes respiration
      • shortness of breath
      • rales
        • liquid accumulates in alveoli due to left heart pressure overload
        • alveoli pop open during inhalation, causing rales on exam
    • abdominal exam 
      • ascites
      • hepatojugular reflex
Imaging
  • Chest radiograph
    • findings
      • pulmonary vascular congestion
      • pleural effusion
      • cardiomegaly
      • Kerley-B lines
      • interstitial edema
  • Echocardiogram
    • indications
      • confirms the diagnosis of heart failure
      • classifies whether heart failure is due to systolic or diastolic dysfunction
    • findings
      • assess for low ejection fraction
      • systolic of diastolic dysfunction
      • systolic heart failure is characterized by
        • decreased cardiac index
        • increased systemic vascular resistance
        • increased left ventricular end diastolic pressure
Studies
  • Atrial and B-type (brain) natriuretic peptide (ANP and BNP)
    • released by the ventricles and the atria in response to increased stretch
    • elevated levels are often seen in decompensated CHF
    • normal BNP excludes a diagnosis of CHF
  • Electrocardiogram (ECG)
    • findings
      • sinus tachycardia
      • may also have arrhythmias
      • may show ventricular hypertrophy
  • Making the diagnosis
    • based on clinical presentation and echocardiogram
Differential
  • Acute respiratory distress syndrome
    • distinguishing factors
      • diffuse crackles in the lungs, no S3 heart sound, and increased work of breathing on exam
      • chest radiograph with bilateral alveolar infiltrates
Treatment
  • Management approach
    • mortality is decreased with angiotensin-converting enzyme inhibitors (ACE-inhibitors) or angiotensin II receptor blockers (ARBs), β-blockers, and spironolactone or eplerenone
  • Conservative
    • avoid excessive salt in the diet
      • indication
        • all patients
  • Medical
    • ACE-inhibitors or ARBs
      • indications
        • lowers mortality
        • systolic or diastolic dysfunction
    • hydralazine and nitrates
      • indications
        • systolic dysfunction
        • when ACE-inhibitors or ARBs are contraindicated, such as in those with renal failure
    • β-blockers
      • indications
        • lowers mortality
        • systolic or diastolic dysfunction
      • drugs
        • metoprolol
        • carvedilol
        • bisoprolol
    • spironolactone or eplerenone
      • indication
        • lowers mortality
        • systolic or diastolic dysfunction
      • side effects
        • spironolactone has anti-androgen effects such as erectile dysfunction and gynecomastia in men
        • hyperkalemia
    • diuretics  
      • indications
        • pulmonary edema
        • CHF exacerbations
        • lower extremity edema
        • systolic or diastolic dysfunction
      • drugs  
        • loop diuretics
        • thiazide diuretics
    • digoxin
      • indications
        • severe systolic dysfunction
        • as an inotrope, it does not improve mortality, but it does reduce hospitalizations
Complications
  • CHF exacerbation
  • Cardiac arrhythmias
  • Respiratory failure
 

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Questions (11)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.CV.4754) A 71-year-old male presents to his primary care physician complaining of shortness of breath with exertion. He was previously able to walk one mile without stopping but has recently started to feel short of breath after walking a few blocks. He also complains of a choking sensation when supine that is relieved by sitting up. His medical history is notable for coronary artery disease, diabetes mellitus, and alcohol abuse. Physical examination reveals a diffuse, left-displaced point of maximal impact (PMI). Auscultation demonstrates an early diastolic gallop best heard over the apex with the patient in the left lateral decubitus position. A chest radiograph of the patient is shown (Figure A). Which of the following sets of cardiac parameters would be expected in this patient? Review Topic

QID: 108701
FIGURES:
1

Increased ejection fraction and decreased left ventricular end-diastolic volume

4%

(10/263)

2

Preserved ejection fraction and normal compliance

2%

(4/263)

3

Preserved ejection fraction and decreased compliance

10%

(27/263)

4

Decreased ejection fraction and increased left ventricular end-diastolic volume

68%

(180/263)

5

Decreased ejection fraction and decreased left ventricular end-diastolic volume

13%

(33/263)

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(M1.CV.144) A 36-year-old man with a history of a stab wound to the right upper thigh one year previously presents to the emergency department with complaints of difficulty breathing while lying flat. Physical examination reveals an S3 gallop, hepatomegaly, warm skin and a continuous bruit over the right upper thigh. Which of the following is most likely responsible for his symptoms? Review Topic

QID: 100660
1

Decreased sympathetic output

0%

(0/9)

2

Increased peripheral resistance

11%

(1/9)

3

Increased venous return

67%

(6/9)

4

Decreased contractility

11%

(1/9)

5

Increased pulmonary resistance

0%

(0/9)

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(M1.CV.135) A 65-year-old male with multiple comorbidities presents to your office complaining of difficulty falling asleep. Specifically, he says he has been having trouble breathing while lying flat very shortly after going to bed. He notes it only gets better when he adds several pillows, but that sitting up straight is an uncomfortable position for him in which to fall asleep. What is the most likely etiology of this man's sleeping troubles? Review Topic

QID: 100651
1

Obstructive sleep apnea

0%

(0/4)

2

Amyotrophic lateral sclerosis (ALS)

0%

(0/4)

3

Myasthenia gravis

0%

(0/4)

4

Right-sided heart failure

0%

(0/4)

5

Left-sided heart failure

100%

(4/4)

M1

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(M1.CV.128) A 75-year-old man presents to his primary care physician with worsening breathlessness after walking up the stairs and the need to sleep propped up by an increasing number of pillows. On physical exam, the physician finds an early diastolic decrescendo murmur heard best at the left sternal border and crackles over both lower lung fields. The patient is sent for an echocardiogram with the attached result. Which of the following is the most likely etiology for this patient's symptoms? Review Topic

QID: 100644
FIGURES:
1

Aortic valve regurgitation

64%

(18/28)

2

Aortic valve stenosis

7%

(2/28)

3

Chronic hypertension

4%

(1/28)

4

Mitral Regurgitation

14%

(4/28)

5

Acute myocardial Infarction

7%

(2/28)

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(M1.CV.40) Under what physiologic state is the endogenous human analog of nesiritide produced? Review Topic

QID: 100556
1

Increased external stress

0%

(0/11)

2

Increased ventricular stretch

36%

(4/11)

3

Increased intracranial pressure

36%

(4/11)

4

Increased circulatory volume presenting to the kidneys

9%

(1/11)

5

Decreased circulatory volume presenting to the kidneys

9%

(1/11)

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(M1.CV.32) A 45-year-old African American woman presents to her family physician for a routine examination. Past medical history is positive for amyloidosis and non-rhythm-based cardiac abnormalities secondary to the amyloidosis. Which of the following cardiac parameters would be expected in this patient? Review Topic

QID: 100548
1

Preserved ejection fraction and increased compliance

0%

(0/9)

2

Preserved ejection fraction and decreased compliance

56%

(5/9)

3

Decreased ejection fraction and increased compliance

0%

(0/9)

4

Decreased ejection fraction and decreased compliance

33%

(3/9)

5

Increased ejection fraction and decreased compliance

11%

(1/9)

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(M1.CV.205) A 70-year-old male presents for an annual exam. His past medical history is notable for shortness of breath when he sleeps, and upon exertion. Recently he has experienced dyspnea and lower extremity edema that seems to be worsening. Both of these symptoms have resolved since he was started on several medications and instructed to weigh himself daily. Which of the following is most likely a component of his medical management? Review Topic

QID: 100721
1

Ibutilide

9%

(10/113)

2

Lidocaine

1%

(1/113)

3

Aspirin

9%

(10/113)

4

Carvedilol

47%

(53/113)

5

Verapamil

31%

(35/113)

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(M1.CV.23) A 50-year-old man with congestive heart failure (CHF) was started on an experimental analog of atrial natriuretic peptide. Which of the following would he expect to experience? Review Topic

QID: 100539
1

Increased water reabsorption by the renal collecting ducts

0%

(0/10)

2

Vasoconstriction, increased blood pressure, aldosterone release

30%

(3/10)

3

Increased glomerular filtration rate, restricted aldosterone release, vascular smooth muscle dilation

70%

(7/10)

4

Increased renal absorption of sodium and water

0%

(0/10)

5

Increased plasma calcium and decreased renal reabsorption of phosphate

0%

(0/10)

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