02/19/2014

Congestive Heart FailureManuel Fonseca Crescioni MS IIIHospital San Lucas Guayama P.R

Heart Failure

✤ Divided into right and left sided failure

Causes of left-sided failure

✤ Ischemia

✤ Hypertension

✤ Dilated Cardiomyopathy

✤ Myocardial Infarction

✤ Restrictive Cardiomyopathy

Pulmonary Congestion

✤ Pulmonary edema with dyspnea, PND, orthopnea , and crackles

✤ Heart Failure cells

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Decreased forward perfusion

✤ Activation of renin-angiotensin system

✤ Angiotensin II( TPR, Aldosterone)

✤ Mainstay of treatment is ACE inhibitor

Right-sided heart failure is most commonly due to left failure

✤ Other important causes include:

✤ Left-to-right shunt

✤ Chronic lung disease(cor pulmonale)RA LA

RV LV

Clinical features are due to congestion

✤ JVD

✤ Painfull HSM, may lead to cardiac cirrhosis

✤ Dependent pitting edema

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Differential diagnosis

✤ Conditions in which there is circulatory congestion secondary to abnormal salt and water retention but in which there is no disturbance of cardiac structure or function(e.g renal failure)

✤ Non cardiac causas of pulmary edema(eg.ARDS)

✤ CXR usefull, low BNP(helpfull in excluding cardiac cause)

✤ Ankle edema may be due to varicose veins

Factors of poor prognosis

✤ EF < 25%

✤ Low O2 Max uptake

✤ Inability to walk at normal pace for more than 3 min

✤ Low serum Na+

✤ Increased ANP BNP

Rx

✤ Correction of underlying cause

✤ prevention of deterioration of cardiac function(ACE, B-blockers,)

✤ control of CHF state(reduction in Salt retention)

✤ Ace inhibitors, ARB’s, Digoxin, B-blockers Diuretics

References

✤ Harrisons Principles of Internal Medicine 15th Eugene Braunwald

✤ Fundamental of Pathology Husain A. Sattar

✤ Rapid Review Pathology Edward F. Goljan