Updated: 9/27/2020

Congestive Heart Failure

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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
    • milrinone 
      • indications
        • acute cardiogenic shock
        • decompensated heart failure
      • side effects
        • hypokalemia
        • bronchospams
        • tremors
Complications
  • CHF exacerbation
  • Cardiac arrhythmias
  • Respiratory failure
 

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(M1.CV.17.4754) 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? Tested Concept

QID: 108701
FIGURES:
1

Increased ejection fraction and decreased left ventricular end-diastolic volume

3%

(10/318)

2

Preserved ejection fraction and normal compliance

1%

(4/318)

3

Preserved ejection fraction and decreased compliance

10%

(32/318)

4

Decreased ejection fraction and increased left ventricular end-diastolic volume

72%

(229/318)

5

Decreased ejection fraction and decreased left ventricular end-diastolic volume

11%

(34/318)

L 1 B

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(M1.CV.14.144) A 36-year-old man with a history of a stab wound to the right upper thigh 3 months ago presents to the emergency department with complaints of difficulty breathing while lying flat. Physical examination reveals an S3 gallop, warm skin, and a continuous bruit over the right upper thigh. Which of the following is most likely responsible for his symptoms? Tested Concept

QID: 100660
1

Decreased sympathetic output

5%

(4/86)

2

Increased peripheral resistance

20%

(17/86)

3

Increased venous return

40%

(34/86)

4

Decreased contractility

16%

(14/86)

5

Increased pulmonary resistance

15%

(13/86)

L 1 B

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(M1.CV.14.135) 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? Tested Concept

QID: 100651
1

Obstructive sleep apnea

6%

(4/62)

2

Amyotrophic lateral sclerosis (ALS)

0%

(0/62)

3

Myasthenia gravis

0%

(0/62)

4

Right-sided heart failure

11%

(7/62)

5

Left-sided heart failure

82%

(51/62)

L 2 B

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(M1.CV.13.40) Under what physiologic state is the endogenous human analog of nesiritide produced? Tested Concept

QID: 100556
1

Increased external stress

1%

(1/74)

2

Increased ventricular stretch

68%

(50/74)

3

Increased intracranial pressure

11%

(8/74)

4

Increased circulatory volume presenting to the kidneys

8%

(6/74)

5

Decreased circulatory volume presenting to the kidneys

11%

(8/74)

L 1 C

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(M1.CV.13.32) 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? Tested Concept

QID: 100548
1

Preserved ejection fraction and increased compliance

0%

(0/68)

2

Preserved ejection fraction and decreased compliance

69%

(47/68)

3

Decreased ejection fraction and increased compliance

3%

(2/68)

4

Decreased ejection fraction and decreased compliance

25%

(17/68)

5

Increased ejection fraction and decreased compliance

3%

(2/68)

L 1 E

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(M1.CV.12.23) 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? Tested Concept

QID: 100539
1

Increased water reabsorption by the renal collecting ducts

3%

(2/69)

2

Vasoconstriction, increased blood pressure, aldosterone release

9%

(6/69)

3

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

86%

(59/69)

4

Increased renal absorption of sodium and water

0%

(0/69)

5

Increased plasma calcium and decreased renal reabsorption of phosphate

3%

(2/69)

L 3 E

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