Congestive Heart Failure

Congestive Heart Failure is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • A clinical syndrome in which the heart fails to maintain adequate circulation for metabolic needs, characterized by chronic debility, acute decompensation, and high mortality.
  • Acute Decompensated Heart Failure (ADHF) is a rapidly progressive failure state (hr–days)
    • Common reason for presentation to the ED
    • Usually caused by a precipitating event in which the heart does not have the reserve to compensate for the added burden
  • Chronic HF is a progressive failure state (mo–yr) characterized by cardiac remodeling and neurohormonal changes, with multiple subclasses:
    • Systolic heart failure
      • Impaired contractile or pump function causing decreased ejection fraction
    • Diastolic heart failure
      • Impaired ventricular relaxation resulting in decreased cardiac filling
    • Low-output failure
      • Decreased cardiac output
    • High-output failure:
      • Normal or increased cardiac output, but insufficient to meet metabolic demands
    • Left-sided failure
      • Systolic or diastolic (or both) dysfunction of the left ventricle
      • Resultant pulmonary congestion
    • Right-sided heart failure
      • Due to either intrinsic dysfunction or secondary to left heart failure or pulmonary hypertension (cor pulmonale)
      • Hepatic enlargement, JVD, and dependent edema can occur
  • CHF affects ∼5.8 million Americans.
  • Estimated 2012 cost of CHF is $40 billion
  • ADHF is the leading Medicare diagnosis for hospitalized patients ≥65 yr old.

Etiology

Underlying causes and acute precipitants
  • Decreased myocardial contractility:
    • Myocardial ischemia/infarction
    • Cardiomyopathy (including, alcoholic and pregnancy-related)
    • Myocarditis
    • Dysrhythmias
    • Decreased contractile efficiency:
      • Drug related (negative inotropes)
      • Metabolic disorders
  • Pressure overload states:
    • HTN
    • Valvular abnormalities
    • Arrhythmia
    • Congenital heart disease
    • Pulmonary embolism
    • Primary pulmonary hypertension, sleep apnea syndromes (right heart failure)
  • Restricted cardiac output:
    • Myocardial infiltrative disease
  • Volume overload:
    • Dietary indiscretion (sodium overload)
    • Drugs leading to sodium retention (glucocorticoids, NSAIDs)
    • Overload due to transfusion or IV fluid
  • High demand states:
    • Hyperthyroidism, thyrotoxicosis
    • Pregnancy
    • A-V fistula
    • Beriberi (thiamine deficiency)
    • Paget disease
    • Severe anemia
    • Aortic insufficiency
  • Pediatric etiologies: Volume/pressure overload lesions vs. acquired HD:
    • 1st 6 mo: VSD and PDA
    • Older children: Subvalvular aortic stenosis, coarctation
    • Acquired dysfunction: Nonspecific age of onset, including myocarditis, valvular disease, and cardiomyopathies; cocaine/stimulant abuse in adolescents

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Citation

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TY - ELEC T1 - Congestive Heart Failure ID - 307688 Y1 - 2016 PB - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307688/all/Congestive_Heart_Failure ER -