Snapshot A 68-year-old male presents to his primary care physician with dyspnea on exertion and swollen ankles. He has a long history of coronary artery disease and alcohol abuse. Introduction Congestive heart failure (CHF) inability of the heart to meet the demands of the body Iatrogenic volume overload is the most common cause of CHF the major etiologic categories include systolic dysfunction or weakened pumping function of the heart via ischemic heart disease chronic hypertension cardiomyopathy (viral or idiopathic) in younger patients diastolic dysfunction or the inability of the heart to relax/fill via hypertension with LVH hypertrophic cardiomyopathy amyloidosis sarcoidosis hemochromatosis scleroderma post-operative/raditation fibrosis valvular dysfunction arrhythmias Precipitating factors acute MI long-standing HTN chronic anemia acute and/or recurrent pulmonary embolism chronic endocarditis post-partum females and thyrotoxicosis Risk factors CAD family history of hypertrophic cardiomyopathy HTN valvular heart disease ETOH abuse myocarditis drug side effects (i.e. doxorubicin ) smoking CHF exacerbation can be induced by (FAILURE) forgetting medication arrhythmia ischemia lifestyle (salt and obesity) upregulation (pregnancy and hyperthyroidism) renal failure embolus (pulmonary) Presentation Symptoms patients suffering from CHF can present with a wide range of symptoms that help identify the affected side of the heart as follows left-sided failure lower extremity swelling left-sided failure results in right-sided failure, producing ankle-swelling abdominal fullness exertional dyspnea orthopnea paroxysmal nocturnal dyspnea persistent coughing right-sided failure presents with abdominal fullness exertional dyspnea ankle-swelling 3rd heart sound is first sign of left or right failure Physical exam left-sided failure bibasilar crackles diffuse, left-displaced PMI S3 (systolic) or S4 (diastolic) gallop right-sided failure atrial fibrillation JVD hepatojugular reflex hepatomegaly lower-extremity edema Evaluation Echocardiogram echocardiogram and clinical picture provide definitive diagnosis shows impaired cardiac function decreased EF in left-sided heart failure normal-to-elevated EF in right-sided heart failure Systolic heart failure is characterized by: 1) decreased cardiac index, 2) increased systemic vascular resistance, and 3) increased left ventricular end diastolic pressure CXR may show cephalization of pulmonary vessels cardiomegaly and pleural effusions Cardiac biopsy indicated if infiltrative or viral myocarditis is suspected BNP and NT-proBNP New York Heart Association Functional Classification of Heart Failure Class Limitations of Physical Activity Heart Failure Symptoms I None None II Mild Symptoms with significant exertion; comfortable at rest or mild activity III Marked limitation Symptoms with mild exertion; only comfortable at rest IV Discomfort with any activity Symptoms occur at rest Differential Deconditioning, chronic lung disease, MI, angina, pericarditis, renal failure, cirrhosis, or other causes of lower-extremity edema (venous insufficiency, hypoproteinemia, nephrosis, etc) Treatment Acute cases if the patient has worsening dyspnea and other symptoms then diurese aggressively use ACE inhibitors in all patients who can tolerate them dobutamine ("dobutamine holiday") for inotropy nitroprusside for afterload reduction. Chronic cases lifestyle modifications limit dietary sodium intake pharmacologic ACE inhibitors are first-line have been shown to improve survival Renin-angiotensin-aldosterone system and ADH is upregulated in these patients digitalis and diuretics improve symptoms but not proven to improve survival warfarin indicated with severe dilated cardiomyopathy atrial fibrillation previous embolic episode maintenance medications include B-blockers afterload reduction via ACEi/ARB spironolactone if K level is not high hydralazine and long-acting nitrates in African-Americans arrythmia medications treat arrhythmia as they arise operative AICDs should be used indicated when EF < 35% shown to decrease mortality from VT/VF Exacerbations (in Chronic Patients) treat with loop diuretics such as furosemide when patient is volume-overloaded Treat/control underlying etiologies if identified and possible such as thyrotoxicosis, anemia, CAD, HTN, etc *avoid overdiuresis Prognosis, Prevention, and Complications Manage underlying etiologies such as thryoid dysfunction long-standing hypertension Reverse alcoholic dilated cardiomyopathy by abstaining from EtOH Reverse tachycardia-induced cardiomyopathy via medication or treating afibrillation/other arrythmias If left untreated almost certainly will lead to death via dry drowning/oxygen deprevation or pneumonia (sepsis)