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CONGESTIVE HEART FAILURE see RMC Pre-Printed Orders for CHF

Def: structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood causing signs and symptoms of intravascular and interstitial volume overload

Systolic dysfunction: inability of the myofibrils to shorten against a load (decreased EF)

Causes: CAD, HTN, cardiomyopathy, (idiopathic dilated CM, hypertrophic CM, alcohol, DM, Viral, infiltrative, toxin-induced, metabolic D/O, aging), valvular disease, pericardial disease, tachyarrhythmias, high output states (hyperthyroidism, AV fistula, anemia)

Diastolic dysfunction: impaired/stiff LV filling (decreased LVEDV reduces CO)

Causes: HTN, ischemic heart disease, hypertrophic obstructive CM, restrictive CM.

Non-systolic/non-diastolic causes: obesity, lung disease, MI

|2007 UpToDate® | |

|Modified Framingham clinical criteria for the diagnosis of heart failure |

|Major |

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|Paroxysmal nocturnal dyspnea, Orthopnea, Elevated jugular venous pressure, Pulmonary rales, S3, Cardiomegaly or Pulmonary edema on CXR, Wt |

|loss [pic]4.5 kg in 5 days in response to treatment of presumed heart failure |

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|Minor |

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|Bilateral leg edema, Nocturnal cough, Dyspnea on ordinary exertion, Hepatomegaly, Pleural effusion, Tachycardia (heart rate [pic]120 |

|beats/min), Weight loss [pic]4.5 kg in five days |

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|Diagnosis |

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|The diagnosis of heart failure requires that 2 major or 1 major and 2 minor criteria be present and cannot be attributed to another medical |

|condition. |

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NYHA Classification of severity—quantify the functional limitation imposed by HF:

Class I – symptoms of HF only at activity levels that would limit normal individuals

Class II – symptoms of HF with ordinary exertion

Class III – symptoms of HF with less than ordinary exertion

Class IV – symptoms of HF at rest

Workup: CBC (anemia), CMP (hepatic congestion and renal fxn), UA (renal fxn), BNP, cardiac enzymes, consider PT/PTT, TSH, ESR, lipid panel

Studies: CXR (pulm edema, cardiomegaly, effusion), EKG (LVH, BBB, A Fib/Flutter), Echo, Cardiolite

Mgmt: salt restriction (2gm/day), daily weights, strict I/O (heplock IV), fluid restriction, smoking cessation, cardiac rehab, monitor BP, ASA, diuretics, ACEI, B-B when acute CHF resolved

Medication Management

Diastolic Dysfunction: prevent ischemia, control HTN, preserve normal sinus rhythm

ACEI/ARB, diuretics, BB, AVOID digoxin and nitrates (stiff LV is susceptible to excessive preload reduction, which can lead to under-filling of LV, decreased CO, and hypotension)

Systolic Dysfunction: increase cardiac contractility, limit volume overload

ACEI/ARB, diuretics, BB (Coreg or metoprolol), consider digoxin, spironolactone, BiDil

Severe Class IV pts may require consideration of pacemaker/defibrillator, heart transplant

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