GEMC- Acute Congestive Heart Failure- for Residents
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This is a lecture by Rashmi U. Kothari from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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GEMC- Acute Congestive Heart Failure- for Residents
- 1. Project: Ghana Emergency Medicine Collaborative Document Title: Acute Congestive Heart Failure Author(s): Rashmi U. Kothari (Michigan State University), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
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- 3. 68 y.o. Female with Severe Shortness of Breath P=130 RR=32 BP=220/120 P.Oxm=86%è90% DifferenEal Diagnosis • • • • • • PE CHF/Pulmonary edema Pneumonia COPD Pneumothorax Pericardial effusion 3
- 4. 68 y.o. Female with Severe Shortness of Breath • History – Onset (gradual or sudden) – Cough, fever, unilateral leg swelling – Orthopnea, PND, DOE, Swelling – PMH: CAD, CHF, PE/DVT, ESRD – Same it past? 4
- 5. 68 y.o. Female with Severe Shortness of Breath • Physical Exam – VS: (T/RR/HR/BP/Pulse Oxm) – Neck: JVD – Chest: ê BS, rales, wheezing, rhonchi – Heart: Afib, bradycardia, distant HS, S3 – ExtremiEes: edema, unilateral swelling, cord, tenderness 5
- 6. 68 y.o. Female with Severe Shortness of Breath • HPI: 3-‐4 days, cough, ééworse this am • PMH: COPD, CHF, CAD, & HTN • PE: Obese, severe resp. distress – T=36.6 P=130 RR=32 BP=220/120 NRB=89-‐91% • Chest: ê BS, ?rales, ?wheezing • Cardiac: RRR no Murmur • ExtremiEes: 2+ bilateral edema 6
- 7. Goal • Review pathophysiology • Evaluate diagnosEc findings – H&P, CXR, BNP, U/S • Evaluate medical management – Oxygen delivery, nitroglycerin, lasix, morphine 7
- 8. Acute CongesEve Heart Failure (CHF) • DefiniEon 8
- 9. Diagnosis • • • • History & Physical Exam Chest X-‐ray Laboratory tests Ultrasound 9
- 10. Diagnosing CHF • • • • • Increased Likelihood Hx CHF LR=5.8 PND LR=2.6 S3 LR=11 + CXR LR=12 Afib LR=3.8 • • • • • Decreased Likelihood No hx CHF LR=.45 No DOE LR=.48 No rales LR=.51 -‐Cardiomegaly LR=.51 EKG WNL LR=.64 Wang et al. JAMA 2005 10
- 11. Wapcaplet, Wikimedia Commons Myocardial stretch/stress Pro-‐BNP A. Mukkamala NT-‐pro-‐BNP BNP A. Mukkamala 11 BotanyBRA, Wikimedia Commons
- 12. BNP and NT pro-‐BNP AGE Rule out Sens/Spec All <100 90%/74% BNP NT pro-‐BNP <50 50-‐70 >70 <300 <300 <1200 99%/85% 99%/85% 97%/55% Rule in Sens/Spec >400 81%/90% >450 93%/95% References: Korenstein BM Emerg Med 2007 Jannuzi et al Am J Card 2005 Berdague et al., Am Heart J >900 91%/80% >4500 64%/86% 12
- 13. Impact of High & Low BNP on Pre-‐ Test ProbabiliEes Pre-‐test Probability Post-‐test Probability for BNP<105 pg/ml Post-‐test Probability for BNP >300 pg/ml 10% 30% 50% 70% 90% 2% 5% 12% 25% 56% 46% 77% 88% 95% 99% Reference: Korenstein Et. al.,BM Emerg Med 2007 13
- 14. Causes of Elevated BNP • • • • Acute CHF Renal Failure Sepsis Pulmonary Embolism 14
- 15. BNP Decreases LOS & Cost 6.3 hrs $6,129 5.8 hrs P=0.031 Reference: Mueller et.al., NEJM P=0.023 Reference: Moe et. al., Circ 2007 15
- 16. Summary of BNP • Combining clinical judgment & BNP may improve accuracy of diagnosis • Most helpful when diagnosis unclear (e.g. COPD) • Can be elevated in ARF, sepsis or PE 16
- 17. Diagnosing CHF by Ultrasound • Extravascular lung fluid – Look for “comet tails” • Elevated Rt heart filling pressures – Examine IVC within 2 cm of Rt atrium 17
- 18. Ultrasound B-‐lines (Lung Rockets) in CHF • Pros: – Easy windows – 80-‐90% sensiEvity & specificity • Cons: – Takes 2-‐5 minutes – Limited data from ED 18
- 19. Lung Ultrasound for B-‐Lines (Lung Rockets) • Use a 3-‐5 MHz Probe • PosiEon 1: anterior chest view • PosiEon 2: lateral chest views Drickey, Wikimedia Commons 19
- 20. Measuring IVC by Ultrasound in AHF • Pros: – Rapid – 69%PPV & 91% NPV – Accuracy 83% for é Atrial Pressures • Cons: – CorrelaEon é Atrial Pressures to AHF – Technically challenging Reference: Blair JE, et al: Am J Card 2009 20
- 21. Management of Acute CHF • Oxygen • DiureEcs • Nitroglycerin • Morphine 21
- 22. CPAP/BiPAP Decreases Mortality & IntubaEon 45% mortality* 25% IntubaCon* 35% 0.2 20% 0.31 30% 25% 15% 20% 0.11 0.18 15% 10% 10% 5% 5% 0% 0% NIPVV *p<0.001 42% Standard Reference: Masip et al. JAMA 2005 NIPVV Standard Reference: Masip et al. JAMA 2006 22
- 23. CPAP & BiPAP Equivalent CPAP = Bipap • Mortality • IntubaEon rates • AMI Mortality CPAP BiPAP 6% 7% Reference: Masip et al. JAMA 2005 23
- 24. ED Study of NIPPV vs. Standard Medical Care (SMC) • 1069 ED • Randomized for 2 hrs of treatment – CPAP – BiPAP – Oxygen by NC or FM Gray et al. NEJM 2008 24
- 25. No Difference NIPPV vs. SMC • No Difference – Mortality – IntubaEon rates • NIPPV beser – ê Respiratory distress – ê Metabolic disturbances 12% 0.095 NIPPV Standard 0.098 10% 8% 6% 4% 0.029 0.028 2% 0% Moratlity IntubaEon Reference: Gray et al. NEJM 2008 25
- 26. Why Discrepancy Between Studies? Study Mortality IntubaCon Rate Gray et al. NEJM 16.5%??? 2.8% Masip et al JAMA 20% 31% Cochrane 20% 30% 26
- 27. Reason for Discrepancy Change in Treatment Standard Oxygen (N=367) IntubaEon CPAP NIPPV Standard treatment Type treatment not noted 3 43 13 -‐-‐-‐ 6 65/367 (18%) PaCents Crossed Over in Standard Treatment Group 27
- 28. Summary of NIPPV • Most likely: – Decreases mortality – Decreases intubaEon rate – Decreases respiratory distress • Use in PaEents with: – Significant respiratory distress – O2 SaturaEon <90% 28
- 29. 68 y.o. Female in Severe CHF. Home Meds 80 mg Lasix • How much IV Lasix should you give her? – None – 40 mg – 80 mg – 160 mg 29
- 30. Decreased EffecEveness of Loop DiureEcs in CHF • Delayed onset of acEon – 15-‐30 minutes normal paEents – 45-‐120 minutes in CHF • Drug resistance in chronic users 30
- 31. Cardiac Effects of Lasix Physiological Effect • Venous dilataEon – Healthy subjects – Maximized @ 20 mg • Arterial constricEon – CHF paEents – Predominates early PVR é SVR é MAP é HR é RtAFP é SV?? ê Catecholamines é 31
- 32. Worsening CreaEnine and Acute CongesEve Heart Failure • Occurs in 72% of paEents with CHF • Increased mortality • é LOS 32
- 33. Increased Mortality Associated with Worsening CreaEnine RelaCve Risk of Death 3 2.9 2.5 2 1.91 1.67 1.5 1 1.19 0.89 0.5 0 >0.1 >0.2 >0.3 >0.4 >0.5 CreaCnine ElevaCon Reference: GoJlieb et al. J Card Fail 2002 33