Congestive Heart Failure

Congestive heart failure refers to the inability of the heart to pump blood effectively to meet the demands of the body. CHF is unfortunately a common and deadly condition. One estimate places the prevalence of heart failure to 6-10% in adults over the age of 65. The fatality of CHF can be perhaps captured best in this statistic: the risk of death is highest in the first year of diagnosis -- 35%.

Any process that impairs the ability of the heart to adequately pump blood will lead to heart failure. The two general types of heart failure include systolic heart failure and diastolic heart failure. Systolic heart failure refers to systolic dysfunction producing an ejection fraction < 40%. Diastolic heart failure or heart failure with preserved ejection fraction, is exactly that -- the heart is able to contract, but the ability of the ventricles to fill with blood is impaired.

Major causes of heart failure include cardiomyopathies, atrial fibrillation, acute myocardial infarction, medication noncompliance (particularly diuretics), drug toxicities and excessive alcohol use.

The classic presentation of heart failure includes respiratory distress, pink or white sputum, jugular venous distention, hepatomegaly, hepatojugular reflex and bilateral lower extremity edema.

The gold standard for the diagnosis of heart failure is echocardiogram, of which the determination of systolic versus diastolic heart failure can be made.

Other useful studies include:

• CXR: will show evidence of pulmonary edema and possibly cardiomegaly

• EKG: you may see ischemic changes (ST depressions, Twave inversions, ST elevation in the setting of acute MI)

• Labs test: you will often find an elevation in b-type naturietic peptide (BNP). BNP is released by the heart in the setting of excessive stretching of the cardiomyocytes. Patients may also have an elevation in their troponin level due to the strain on the heart.

1. Large bore IVs and connect patient to a monitor.

2. Trial CPAP, then BiPAP and if not, consider endotracheal intubation to maintain patient’s O2 saturation > 88%.

3. Administer sublingual nitroglycerin or nitroglycerin drip as needed for symptom control (titrate to effect). In patients unresponsive to nitroglycerin, consider administration of nitroprusside.

4. Provide 40 to 80mg of lasix intravenously to improve diuresis.

5. Admit these patients to a monitored setting for further ventilatory support and diuresis.

1. Tintinalli’s 7th edition: Chapter 22 -- Congestive heart failure and acute pulmonary edema.

2. Wikipedia: https://en.m.wikipedia.org/wiki/Heart_failure