Transcript Advances in the Management of Acute Heart Failure in the

Congestive Heart
Failure for the
Prehospital Provider
John Burton, MD- Albany Medical Center-Albany, NY
[email protected]
62 year old male
CC: Difficulty Breathing
It’s Midnight….suddenly short of breath!
History: CHF, CAD, COPD
Drugs: coumadin, digoxin, captopril, Inhalers
Allg: None
ROS: Negative - no chest pain, etc..
Exam: RR 45, Sat 82%RA, HR 130, BP 190/100
Lungs: bilateral rales
Ext: 2+ bilateral edema
Objectives
1. Discuss core concepts in anatomy and physiology that
will enhance your overall understanding of the
cardiovascular system
2. Discuss the pathophysiology of CONGESTIVE
HEART FAILURE: what it is, what’s it about?
3. Discuss Congestive Heart Failure patient management
for the prehospital provider
Let’s think a little bit
about the Left Ventricle
Acquired or Congenital Cardiomyopathies
Affecting the Left Ventricle
Type of Cardiomyopathies
Dilated
All four chambers are dilated. The most common cause is
chronic alcoholism, though some may be the end-stage of remote
viral myocarditis. Single ventricle can dilate as well….as in CHF.
Hypertrophic
The most common form, idiopathic hypertrophic
subaortic stenosis (IHSS) results from asymmetric
interventricular septal hypertrophy, resulting in left ventricular
outflow obstruction. High blood pressure is also a common cause.
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
EITHER WAY…THE HEART DOES NOT FUNCTION AS WELL
A brief
discussion of
the works of
this thing...
The Pump:
1. A Mechanical
Component
2. An Electrical
Component
65%
1. A Mechanical
Component
2. An Electrical
Component
Filling….Pumping
Problems with
Filling...
Problems with
Pumping...
PUMPS LESS!!!
FILLS LESS!!!
Pumping
Problems with
Pumping...
Just how little
pumping can one
get away with?
Pumping
Just how little
pumping can one
get away with?
Normal No Symptoms Lethargy, less exercise tolerance Shortness of breath Incompatible with life -
65%
40-65%
30-45%
20 - 30%
<15%
Break
PREload AFTERload Contractility
PREload
AFTERload
Contractility
Preload is a passive stretching force exerted on the ventricular
muscle at the end of diastole. Preload is caused by the volume of
blood in the ventricle at the end of diastole.
Afterload is the force resisting the contraction of the cardiac muscle
fibers. Afterload can also be considered as the blood pressure
exerted on the Atrial Valve during diastole (Diastolic BP).
Contractility refers to the ability of cardiac muscle fibers to shorten
when stimulated (strength).
Normal No Symptoms Lethargy, less exercise tolerance Shortness of breath Incompatible with life -
65%
40-65%
30-45%
20 - 30%
<15%
CO = SV x HR
Where:
CO is cardiac output expressed in L/min (normal ~5 L/min)
SV is stroke volume per beat
CO = SV x HR
Both CO and SV are dependent upon
Preload
Afterload
Contractility
What have we learned?
•
Cardiac Anatomy
•
Cardiac physiology and pathophysiology
•
How to think of the above using the concepts of
preload, afterload, and contractility
Filling….Pumping
Problems with
Filling...
Problems with
Pumping...
DEFINITION CHF
“The situation when the heart is
incapable of maintaining a cardiac
output adequate to accommodate
metabolic requirements and the
venous return.”
E. Braunwald
Diagnosis of CHF:
• Pt with symptoms of heart failure - shortness of
breath and leg swelling.
• Physical exam findings for heart failure - lungs:
rales, legs: edema, neck: jvd
• Chest XRay findings for CHF
• Findings of systolic or diastolic dysfunction:
Echocardiograms: Low ejection fraction/poor
contractility (hypocontractility)
Maisel A. et al. J Am Coll Cardiol 2001
Who gets HEART FAILURE?
• Risk factors: hypertension, hyperlipidemia,
smoking, diabetes, family history of heart
disease.
• Patients with history of acute myocardial
infarcation.
• Patients with previous history or current
HEART DISEASE.
What does Heart Failure do?
“The situation when the heart is
incapable of maintaining a cardiac
output adequate to accommodate
metabolic requirements and the
venous return.”
Venous
Arterial
Legs swell
Decreased
perfusion….
Neck veins distend
Liver congestion
Brain
Kidneys
Lung congestion
Everything...
Venous
Legs swell
(Pitting Edema)
Neck veins distend
(JVD)
Liver congestion
(HepatoJug Rflx)
Lung congestion
(Rales)
LUNG SOUNDS
Normal - Clear
Asthma - End Expiratory
WHEEZES
CHF - Inspiratory RALES
Heart Failure
• Approximately 5 million Americans have CHF
(male to female ratio 1:1)
• 550,000 new cases annually
• Incidence of 10/1000 > 65 years of age
• Hospital discharges 962,000
• Five-year mortality rate as high as 50%
• Single largest expense for Medicare
AHA Heart and Stroke Statistical Update 2002
HCFA Hospitalization Costs
6
Billions of $
5
4
3
2
1
0
O’Connell JB. et al. J Heart Lung Transplant 1994;13:S107-12
Heart failure
Cancer
Myocardial infarction
Heart Failure Hospitalizations
The number of heart failure hospitalizations is increasing in both men and women
600,000
Discharges
500,000
400,000
300,000
200,000
Women
Men
100,000
AHA Heart and Stroke Statistical Update 2002
7
'9
5
'9
3
'9
1
'9
9
'8
7
'8
5
'8
3
'8
1
'8
'7
9
0
Heart Failure Total Direct and
Indirect Costs
Hospital/Nursing
Home
8%
10%
Physicians/Other
Professionals
9%
Drugs/Other
Medical Durables
7%
Total Direct and Indirect Expenditures
= $23.2 billion
AHA Heart and Stroke Statistical Update 2002
66%
Home Health
Care
Lost
Productivity/Mort
ality
Causes of Congestive Heart Failure
• Hypertension
• Ischemia
• Sustained
Arrhythmias
• Cardiomyopathy
– EtOH, infiltrative
• Valvular Heart
Disease
• Pericardial Disease
CHF: Diagnosis
CHF: a CLINICAL diagnosis
• History
• Physical Exam
• Chest X Ray
• Echocardiogram
• Laboratory testing
How do you know
an EMS patient
has Heart Failure?
CHF: a CLINICAL diagnosis
• History…. Shortness of Breath!!! ; Leg edema; weakness
• Physical Exam …. Legs: Edema; Lungs: Rales
• Chest X Ray
• Echocardiogram
• Laboratory testing
How do you know
an EMS patient
has Heart Failure?
Accuracy of Diagnosis: CHF
EMS :
50-65%
Emergency Doc: 65-80%
Cardiologist:
80-85%
OR’s for differentiating between patients with and those without CHF
12
11.1
10.7
10
8
Age
Hx CHF
Hx MI
Rales
Ceph XR
Edema
JVD
OR 6
4
2.9
2.7
2.2
2
1
0
NEJM 02;347:161-167
Predictor
1.9
How do you know
an EMS patient
has Heart Failure?
Ask 3 Questions:
1. History of Congestive Heart Failure?
2. RALES on Lung Examination?
3. EDEMA to Legs?
IN The Emergency Department: Do a Chest XRay
Spectrum of Heart Failure
Dyspnea at rest
PND and
orthopnea
Dyspnea
on
exertion
Asymptomatic
CHF
Pulmonary
Edema
Moderate
Cardiogenic
Shock
What have we learned: CHF
•
There’s lots of it….and it’s expensive
•
Diagnosis is tough…mostly shortness of breath and
leg edema patients.
•
–
–
–
Ask 3 Questions:
1. History of CHF?
2. Rales to lungs?
3. Leg Edema?
Goals of Therapy in CHF
• Relief of symptoms - shortness of breath,
leg edema, fatigue
• Improve hemodynamic compromise
• Minimize complications - decrease cardiac
risk of new events
Venous
Arterial
Legs swell
Decreased
perfusion….
Neck veins distend
Liver congestion
Brain
Kidneys
Lung congestion
Everything...
INCREASED
PRELOAD
INCREASED
AFTERLOAD
Current Treatment of Acute Heart Failure
High
Preload
Reduce
fluid
volume
Diuretics
LASIX
High
Afterload
Poor
Contractility
Vasodilate
Augment
Contractility
Vasodilators
Nitroglycerin
Inotropes
-reduce
afterload-
CHF: The EMS Approach
CHF Patient
Traditional
Approach
Lasix
Top/SL
Nitroglycerin
Morphine
Diuretics : Lasix
Advantages
• Alleviate symptoms
• Decreases fluid overload
Disadvantages
• Electrolyte imbalance
• Diuretic resistance
• Decreases renal
perfusion
Nitroglycerin
Advantages
• Decreases preload at
low doses
• Higher doses can
result in arteriolar
dilation (afterload
reduction)
Disadvantages
• Tachycardia
• Tolerance to therapy
• Overtitration can be
problematic
Arteries
VEINS
Increasing dose of nitroglycerin
Morphine
Advantages
• Decreases preload at
low doses
• Higher doses can
result in afterload
reduction
Disadvantages
• Sedation
• Effects on preload are
very difficult to titrate
and variable from
patient to patient
• Overtitration can be
problematic hypoxemic or sedated?
• Bad Outcomes in
studies
Odds Ratio for Intubation in Heart Failure Patients
6
5
4
3
2
1
0
Am J Emerg Med 99;17:571-574: 181 pts
MI
Age
Captopril
NTG
MS
Diuretic
Continuous Positive Airway
Pressure CPAP
Advantages
• Increases oxygenation
• Effects on preload,
afterload and
contractility are
arguable and not
completely understood
Disadvantages
• Cooperation
• Cooperation
• Studies are few and
unclear…although
empiric evidence is
stong
CHF: The Evolving EMS Approach
CHF Patient
Traditional
Approach
Evolving Approach
Lasix
Lasix - smaller doses
Top/SL
Nitroglycerin
Nitroglycerin - higher doses
Morphine
Morphine - smaller doses/none
Continuous Positive Airway
Pressure (CPAP)
62 year old male
CC: Difficulty Breathing
It’s Midnight….suddenly short of breath!
History: CHF, CAD, COPD
Drugs: coumadin, digoxin, captopril, Inhalers
Allg: None
ROS: Negative - no chest pain, etc..
Exam: RR 45, Sat 82%RA, HR 130, BP 190/100
Lungs: bilateral rales
Ext: 2+ bil edema
Is it CHF or is it
COPD?
CHF
•
•
•
•
•
Hx CHF
Hx Heart Disease
Hypertensive
Rales
Leg edema
COPD
•
•
•
•
•
•
Hx COPD
Inhalers/O2
+/- Hx Heart Disease
Normotensive
+/- Leg edema
Sputum
EMS Management
62 yo male
Chief complaint: Difficulty breathing
- Face Mask O2
- Lasix - single dose - 40 mg
- Nitroglycerin - titrate to symptoms
and pressure
- CPAP if ya got it
In the ED.…CHF
• Face mask O2
• IV NTG
•
•
•
•
•
Lasix
IV/Oral ACE inhibitor (captopril): AFTERLOAD
BiPaP/CPAP
Intubate if respiratory failure
Watch for symptoms to improve….
Emergency Department
Current Treatment of Acute Heart Failure
Vasodilators
Diuretics
Reduce
fluid
volume
Lasix
Decrease
Preload
And
Afterload
Lasix
Ntg: sl, top, iv
MSO4
ACEi
BiPAP/CPAP
Vasodilate
Augment
Contractility
ACE inhibitor
Nitroglycerin
Patient Follow-up...
62 yo male
Chief complaint: Difficulty breathing
In the ED: IV Ntg, Bipap, Captopril..
Got better….admit CICU not intubated
Discharged on day 6
[email protected]
BiPAP or CPAP??
• Multiple small case reports of Noninvasive
Ventilatory Support (NVS) in patients with
varying diagnoses of respiratory failure.
• No assessment of hemodynamic findings in
a controlled fashion.
• No assessment of neurohormonal effects of
NVS.
BiPAP vs CPAP??
• Mehta. Crit Care Med 1997;25:620-628.
One small study raising concern for BiPAP-associated
AMI in pulmonary edema patients, compared to CPAP. 27
pts randomized with more rapid improvements in dyspnea
and oxygenation associated with BiPAP: BiPAP and CPAP
good, BiPAP = MI
• Kosowsky. Am J Emerg Med 2000;18:91-95. Good review
of literature to date on Noninvasive Ventilatory Support
(NVS).