CHF

Stage 1 on CXR dilation of upper lobe vessel

CHF---Pulmonary congestion---Exertional dyspnea

Stage II Kerley-B lines

Stage II of CHF is characterized by fluid leakage into the interlobular and interstitium Kerley-B lines : fluid leaks into the interlobular septa (Thickening)

Definition: short horizontal lines perpendicular to the pleural surface at the lung base.

White arrow

When fluid leaks into the interstitium

If you auscultate the lung what is the finding ? Fine vs Corse

Case senario

Orthopnea

Stage III (Alveolar edema)

Continued fluid leakage into the interstitium, -- alveoli (alveolar edema) and to --- the pleural space (pleural effusion).

If you auscultate the lung what is the finding ? Fine vs Corse

All together Exam wise

A - Alveolar Edema (Bat's Wing). B - Kerley B lines. C - Cardiomegaly. D - Dilated prominent upper lobe vessels. E - Pleural Effusion.

Echo

 Ejection fraction (= stroke volume / end diastolic volume ) ( normally > 55 %) Chamber dimension (hypertophy or not)(magm) Presence of global hypokinesia (in cardiomyopathy) or segmental hypokinesia (old MI) Presence of intramural thrombi (due to sluggish circulation) Presence of valvular lesion

 Drugs that show to improve survival in heart failure patient are : ACE inhibitors & ARBs. B-blocker (data available only for Carvedilol, Metoprolol,& Bisoprolol). Aldosterone antagonist.

Revision

 Causes of Decompensated heart failure: (FAILURE):Forgot medication, Arrhythmia/ Anaemia, Ischemia/ Infarction/ Infection, Lifestyle: taken too much salt, Up-regulation of CO: pregnancy, hyperthyroidism, Renal failure, & Embolism: pulmonary.

 left ventricular failure CAUSES Excessive pressure ( increase afterload ) it has to generate in order to overcome resistance to its emptying in case of: Aortic stenosis. Coarctation of the aorta. Systemic Hypertension. Excessive volume ( increase prerload ) it has to pump, in cases of: Aortic incompetence. Mitral incompetence. Ventricular septal defect. Patent ductus arteriosus. Diseases in its myocardium in case of: Myocardial infarction. Myocardititis. Myocarditis Heart muscle disease of unknown cause, i.e. cardiomyopathy. Arrhythmias

Clinical Features Low cardiac output Hand :Rapid small volume pulse. Pale, cold, cyanosed extremities Brain : Chenye-stokes respiration. Kidney: oliguria, oedema Pulmonary congestion : Dyspnea on Paroxysmal nocturnal dyspnea and cardiac asthma Orthopnea Crepitation over lung bases. Important sign Gallop rhythm. Pulsus alternans. Functional mitral incompetence.

 Excessive pressure Pulmonary stenosis pulmonary hypertension. Excessive blood volume Tricuspid incompetence. ASD Disease in its myocardium myocarditis. Arrhythmias commonest cause of right ventricular failure is as a complication of longstanding left ventricular failure

 Clinical Features Low cardiac output Congested neck veins with positive hepato-jugular reflux. Enlarged tender liver. Crepitation over lung bases. Important sign Gallop rhythm. Pulsus alternans. Functional Tricusped incompetence. hepato-jugular reflux ( more than 1 cm increase in JVP for at least 15 second of abdominal pressure). Enlarged Pulsatile liver occurs with tricuspid regurge .

Complications of heart failure

right ventricular failure. Cardiac cirrhosis low cardiac output deep vain thrombosis. pulmonary embolism. Renal failure. Electrolyte disturbance (Medication) Hypokalemia Hyperkalemia Hyponatremia Arrhythmias

INVESTIGATIONS OF Acute HEART FAILURE

Laboratory ECG Imaging

 Ejection fraction (= stroke volume / end diastolic volume ) ( normally > 55 %) Chamber dimension (hypertophy or not)(magm) Presence of global hypokinesia (in cardiomyopathy) or segmental hypokinesia (old MI) Presence of intramural thrombi (due to sluggish circulation) Presence of valvular lesion

ER management
Treatment of Pulmonary Edema (LMNOPP) Lasix 40-500 mg IV Morphine 2-4 mg IV Nitroglycerin Oxygen Positive airway pressure (CPAP/BiPAP) Position If refractory : Dialysis.