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/

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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  

 

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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?  

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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  

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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    

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Goal  

•  Review  pathophysiology  •  Evaluate  diagnosEc  findings  

– H&P,  CXR,  BNP,  U/S  •  Evaluate  medical  management    

– Oxygen  delivery,  nitroglycerin,  lasix,  morphine  

7  

Acute  CongesEve  Heart  Failure(CHF)  

•  DefiniEon  

8  

Diagnosis  

•  History  &  Physical  Exam  •  Chest  X-­‐ray  •  Laboratory  tests  •  Ultrasound  

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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  

NT-­‐pro-­‐BNP   BNP  

Myocardial  stretch/stress  

Pro-­‐BNP  

Wapcaplet, Wikimedia Commons

BotanyBRA, Wikimedia Commons

A. Mukkamala

A. Mukkamala 11  

BNP  and  NT  pro-­‐BNP  BNP                      NT  pro-­‐BNP  

AGE   All     <50   50-­‐70   >70  Rule  out   <100   <300   <300     <1200  Sens/Spec   90%/74%   99%/85%   99%/85%   97%/55%  

Rule  in   >400   >450   >900   >4500  Sens/Spec   81%/90%   93%/95%   91%/80%   64%/86%  

References:    Korenstein  BM  Emerg  Med  2007  Jannuzi  et  al  Am  J  Card  2005  Berdague  et  al.,  Am  Heart  J     12  

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%   2%   46%  30%   5%   77%  50%   12%   88%  70%     25%     95%  90%   56%   99%  

Reference:  Korenstein  Et.  al.,BM  Emerg  Med  2007  

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Causes  of  Elevated  BNP  

•  Acute  CHF  •  Renal  Failure  •  Sepsis  •  Pulmonary  Embolism  

14  

BNP  Decreases  LOS  &  Cost  

5.8  hrs  

6.3  hrs   $6,129  

P=0.031   P=0.023  

Reference:  Moe  et.  al.,  Circ  2007  Reference:  Mueller  et.al.,    NEJM   15  

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  

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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  

Ultrasound  B-­‐lines  (Lung  Rockets)  in  CHF  

•  Pros:  – Easy  windows  – 80-­‐90%  sensiEvity  &  specificity  

•  Cons:  – Takes  2-­‐5  minutes  – Limited  data  from  ED    

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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  

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  

Management  of  Acute  CHF  

• Oxygen  •  DiureEcs  • Nitroglycerin  • Morphine  

21  

CPAP/BiPAP  Decreases  Mortality  &  IntubaEon  

45%    mortality*  

0.11  

0.2  

0%  

5%  

10%  

15%  

20%  

25%  

NIPVV   Standard  

42%   IntubaCon*  

0.18  

0.31  

0%  

5%  

10%  

15%  

20%  

25%  

30%  

35%  

NIPVV   Standard  

Reference:  Masip  et  al.  JAMA  2005   Reference:  Masip  et  al.  JAMA  2006  *p<0.001   22  

CPAP  &  BiPAP  Equivalent  

CPAP  =  Bipap  

•  Mortality    •  IntubaEon  rates  •  AMI  

Mortality  

CPAP   BiPAP  

6%   7%  

Reference:  Masip  et  al.  JAMA  2005  23  

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  

No  Difference  NIPPV  vs.  SMC  

•  No  Difference  – Mortality  –  IntubaEon  rates    

•  NIPPV  beser  – ê  Respiratory  distress  

– ê  Metabolic  disturbances  

0.095  

0.029  

0.098  

0.028  

0%  

2%  

4%  

6%  

8%  

10%  

12%  

Moratlity   IntubaEon  

NIPPV  Standard  

Reference:  Gray  et  al.  NEJM  2008   25  

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%  

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Reason  for  Discrepancy  

Change  in  Treatment   Standard  Oxygen  (N=367)  

IntubaEon   3  CPAP   43  NIPPV   13  

Standard  treatment   -­‐-­‐-­‐  Type  treatment  not  noted   6  

65/367  (18%)  PaCents  Crossed  Over  in  Standard  Treatment  Group  

27  

Summary  of  NIPPV  

•  Most  likely:  – Decreases  mortality  – Decreases  intubaEon  rate  – Decreases  respiratory  distress  

•  Use  in  PaEents  with:  – Significant  respiratory  distress  – O2  SaturaEon  <90%  

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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  

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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  

Cardiac  Effects  of  Lasix  

•  Venous  dilataEon  –  Healthy  subjects  – Maximized  @  20  mg  

•  Arterial  constricEon  –  CHF  paEents  –  Predominates  early  

Physiological  Effect  PVR   é  

SVR   é  

MAP   é  

HR   é  

RtAFP   é  

SV??   ê  

Catecholamines   é  31  

Worsening  CreaEnine  and  Acute  CongesEve  Heart  Failure  

 

•  Occurs  in  72%  of  paEents  with  CHF  •  Increased  mortality  •  é LOS  

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Increased  Mortality  Associated  with  Worsening  CreaEnine  

0.89  

1.19  

1.67  

1.91  

2.9  

0  

0.5  

1  

1.5  

2  

2.5  

3  

>0.1   >0.2   >0.3   >0.4   >0.5  

CreaCnine  ElevaCon  

RelaCv

e  Risk  of  D

eath  

 Reference:  GoJlieb  et  al.  J  Card  Fail  2002   33