Congestive Heart Failure, Emergency Medicine

Basics

Description

A clinical syndrome in which the heart fails to maintain adequate circulation for metabolic needs, characterized by chronic debility, acute decompensation, and high mortality.
Acute Decompensated Heart Failure (ADHF) is a rapidly progressive failure state (hr-days)
- Common reason for presentation to the ED
- Usually caused by a precipitating event in which the heart does not have the reserve to compensate for the added burden
Chronic HF is a progressive failure state (mo-yr) characterized by cardiac remodeling and neurohormonal changes, with multiple subclasses:
- Systolic heart failure
  - Impaired contractile or pump function causing decreased ejection fraction
- Diastolic heart failure
  - Impaired ventricular relaxation resulting in decreased cardiac filling
- Low-output failure
  - Decreased cardiac output
- High-output failure:
  - Normal or increased cardiac output, but insufficient to meet metabolic demands
- Left-sided failure
  - Systolic or diastolic (or both) dysfunction of the left ventricle
  - Resultant pulmonary congestion
- Right-sided heart failure
  - Due to either intrinsic dysfunction or secondary to left heart failure or pulmonary hypertension (cor pulmonale)
  - Hepatic enlargement, JVD, and dependent edema can occur
CHF affects ~5.8 million Americans.
Estimated 2012 cost of CHF is $40 billion
ADHF is the leading Medicare diagnosis for hospitalized patients ≥65 yr old.

Etiology

Underlying causes and acute precipitants

Decreased myocardial contractility:
- Myocardial ischemia/infarction
- Cardiomyopathy (including, alcoholic and pregnancy-related)
- Myocarditis
- Dysrhythmias
- Decreased contractile efficiency:
  - Drug related (negative inotropes)
  - Metabolic disorders
Pressure overload states:
- HTN
- Valvular abnormalities
- Arrhythmia
- Congenital heart disease
- Pulmonary embolism
- Primary pulmonary hypertension, sleep apnea syndromes (right heart failure)
Restricted cardiac output:
- Myocardial infiltrative disease
Volume overload:
- Dietary indiscretion (sodium overload)
- Drugs leading to sodium retention (glucocorticoids, NSAIDs)
- Overload due to transfusion or IV fluid
High demand states:
- Hyperthyroidism, thyrotoxicosis
- Pregnancy
- A-V fistula
- Beriberi (thiamine deficiency)
- Paget disease
- Severe anemia
- Aortic insufficiency
Pediatric etiologies: Volume/pressure overload lesions vs. acquired HD:
- 1st 6 mo: VSD and PDA
- Older children: Subvalvular aortic stenosis, coarctation
- Acquired dysfunction: Nonspecific age of onset, including myocarditis, valvular disease, and cardiomyopathies; cocaine/stimulant abuse in adolescents

Diagnosis

Signs and Symptoms

Poor perfusion:
- Fatigue, somnolence, lightheadedness
- Palpitations, or irregular pulse
- Shortness of breath
- Cool extremities
- Worsening renal function
Congestion
- Dyspnea, cough
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Evidence of sleep disordered breathing
- Decreased exercise tolerance
- Elevated JVD or abdominojugular reflex
- Dependent edema (poor sensitivity and specifity)
- Rales and/or wheezing, (absent in 80% with chronically elevated filling pressure due to compensatory lymphatic drainage)
- Pleural effusion, dullness at lung bases
- S3 gallop and/or S4.
- Laterally displaced apical impulse
- Hepatic enlargement/tenderness
- Nausea
- Ascites
ADHF with hemodynamic instability:
- Confusion, anxiety, syncope
- Tachypnea
- Tachycardia
- Hypotension
- Cool, pale or cyanotic extremities
- Narrow pulse pressure or pulsus alternans
- Cheyne-Stokes respirations

Essential Workup

The CXR is important in confirming the diagnosis and assessing severity.
12-hr radiographic lag from onset of symptoms may occur.
Radiographic findings may persist for several days despite clinical improvement.

Diagnosis Tests & Interpretation

Lab

Chemistry/electrolytes:
- Establish baseline renal function when initiating diuretics, or ACE inhibitors
- Hyperkalemia possible with low output
- Hyponatremia associated with poor prognosis
CBC:
- Anemia can cause or exacerbate failure
- Infection can cause or exacerbate failure
Liver function tests:
- Increase suggests hepatic congestion, or ischemia.
Thyroid function tests:
- Specifically in patients >65 yr old or in a-fib
Cardiac enzymes:
- Evaluate for ischemia or infarction
ANA and rheumatoid factor: Suspected lupus
Viral panel: Suspected myocarditis
BNP:
- Useful for distinguishing cardiac vs. pulmonary cause of dyspnea
  - BNP >500 pg/mL, HF likely (ppv 90%)
  - BNP <100 pg/mL, HF unlikely, (npv 90%)
  - BNP 100-500 pg/mL, consider PE, cor pulmonale, renal failure, or stable underlying HF.
- REDHOT II Study: BNP levels are better than physicians at predicting which patients are more likely to have bad outcomes
  - EPs were blinded to BNP values. 78% of patients discharged from ED had BNP >400.
  - Of those discharged with a BNP >400, 90-day mortality was 9%
- BNP levels rise with age and are affected by gender, comorbidity, and drug therapy and should not be used in isolation
- BNP levels may be low in acute pulmonary edema (<1-2 hr) and obesity (BMI >30).
NT-proBNP: Cleavage product of prohormone.
- NT-proBNP >1,000 pg/mL predictive of HF
- NT-proBNP <300 pg/mL unlikely to be HF

Imaging

CXR:
- Cardiomegaly (sensitive)
- Specific signs of CHF:
  - Cephalization (vascular prominence in the upper lungs due to fluid overload)
  - Interstitial edema/Kerley B lines
  - Alveolar edema
- Effusions (usually right sided)
- Bilateral confluent perihilar infiltrates leading to classic butterfly pattern:
  - May be asymmetric and mistaken for pneumonia
EKG:
- Underlying cardiac ischemia
- Presence of dysrhythmias
- Left-ventricular hypertrophy
- Heart block
- Normal EKG has high negative predictive value for systolic dysfunction.
2-D Cardiac Echo:
- Ejection fraction
- Acute valvular pathology
- Pericardial tamponade
- Pericardial thickening in constrictive pericarditis
- Ventricle dilation, or hypertrophy
- Regional wall motion abnormalities

Differential Diagnosis

Left-sided CHF:
- Acute exacerbation of COPD
- Asthma exacerbation
- Acute respiratory distress syndrome
- Pneumonia, bronchitis
- Constrictive pericarditis
- Anemia, malnutrition
- Pericardial tamponade
- Coarctation of aorta
Right-sided HF:
- Nephrotic syndrome, chronic renal failure
- Cirrhosis
- Left-side heart failure
- Pulmonary embolism
- Sleep disordered breathing
- Venous stasis

Treatment

Pre-Hospital

IV access
Supplemental oxygen
Cardiac monitor and pulse oximetry
EKG
Sublingual nitrates for active chest pain without hypotension
Furosemide
Endotracheal intubation may be required.

Initial Stabilization/Therapy

IV access
Supplemental oxygen
Cardiac monitor and pulse oximetry
EKG
Elevate head of bed to reduce venous return.
Control airway as needed:
- Noninvasive positive pressure ventilation
  - CPAP vs. BiPAP
  - Reduce work of breathing, improve oxygenation, decrease need for intubation, possible mortality benefit
  - Some studies report higher incidence of MI with BiPAP over CPAP in acute CHF; studies not conclusive
- Intubation for impending respiratory failure

Ed Treatment/Procedures

General: Oxygenate, ventilate, treat underlying condition when possible
Congestion with adequate perfusion: Reduce preload, consider fluid restriction
- Rapidly reduce preload in acute pulmonary edema:
  - Sublingual or IV nitroglycerin
  - Nitro paste
  - IV diuretics (less rapid/effective in patients with poor renal perfusion)
- Avoid preload reduction in ADHF when suspected etiology is aortic stenosis, HOCM, or pulmonary hypertension.
- Cautious afterload reduction in ADHF: Avoid ACEi and ARBs in cases of hypotension, acute renal failure, and hyperkalemia.
  - Nesiritide
- Limited benefit, may cause hypotension
Poor perfusion with hypotension:
- Agents that increase contractility:
  - Dobutamine
  - Dopamine
  - Milrinone
- Avoid vasodilators (nitrates, morphine)
- Initiate diuretics after inotropes.
Initiate venous thromboembolism prophylaxis in those with ADHF without contraindications

Neonates (1st weeks of life):
- Suspect ductal-dependent cardiac lesions if clinical CHF and no improvement with O2:
  - PGE1 to maintain patent ductus
Children:
- IV furosemide, and dopamine or milrinone
- IV nitroglycerin for pulmonary edema

Medication

Aspirin: 325 mg PO/PR if AMI is suspected
Bumetanide (Bumex): 1-3 mg IV, max. 10 mg/day
Dobutamine: 2-10 Î¼g/kg/min IV, max. of 40 Î¼g/kg/min
Dopamine: 2-20 Î¼g/kg/min IV, max. of 50 Î¼g/kg/min
Enalapril: 0.625-1.25 mg IV; 2.5-20 mg/d PO
Furosemide (Lasix): No prior use: 40 mg IVP; prior use: Double 24-hr dose (80-180 mg IV); no effect in 30 min: Redouble dose
Milrinone: 50 Î¼g/kg IV load; 0.375-0.75 Î¼g/kg/min IV
Nesiritide: 2 Î¼g/kg bolus, then infusion of 0.01 Î¼g/kg/min
Nitroglycerin: 0.4 mg sublingual; 1-2 in of nitro paste; 5-20 Î¼g/min IV, max. of 100-200 Î¼g/min IV. USE NON-PVC tubing.
Nitroprusside: 0.3-10 Î¼g/kg/min IV (starting dose), max. of 10 Î¼g/kg/min

ACEi and ARBs are associated with multiple fetal abnormalities and should be held

Oxygen
Nitroglycerin
Furosemide

Follow-Up

Disposition

Admission Criteria

ICU:
- Pulmonary edema
- Cardiogenic shock
- Concomitant MI or ischemia
Medical wards:
- New-onset CHF
- Symptoms not relieved by ED therapy

Discharge Criteria

Mild exacerbation of chronic CHF:
- Responds to ED treatment
- No other cardiac and pulmonary findings
Close follow-up should be arranged with continuation of diuretic, vasodilator, or ACE inhibitor therapy and patient lifestyle education.

Issues for Referral
Consider ICD and/or BV pacer in advanced HF

Shown to decrease mortality and hospitalization rates in select patient groups

Follow-Up Recommendations

Close follow-up within 1 wk of discharge
Medication and dietary compliance
Frequent home monitoring of body weight
Monitor electrolytes and renal function during chronic diuretic therapy

Pearls and Pitfalls

BNP may be useful if CHF diagnosis uncertain.
In severe CHF, NIPPV can improve impending respiratory compromise.
Be vigilant in searching for and treating the underlying cause of the heart failure exacerbation (e.g., MI, PE, valvular pathology).

Additional Reading

Heart Failure Society of America. Executive summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):475-535.
Singer AJ, Birkhahn RH, Guss D, et al. Rapid Emergency Department Heart Failure Outpatients Trial (REDHOTII): A randomized controlled trial of the effect of serial B-type natriuretic peptide testing on patient management. Circ Heart Failure. 2009;2:287-293.
Silvers SM, Howell JM, Kosowsky JM, et al. ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes. Ann Emerg Med. 2007;49(5):627-669.

Codes

ICD9

428.0 Congestive heart failure, unspecified
428.20 Systolic heart failure, unspecified
428.30 Diastolic heart failure, unspecified
428.40 Combined systolic and diastolic heart failure, unspecified
428.1 Left heart failure
428.21 Acute systolic heart failure
428.22 Chronic systolic heart failure
428.23 Acute on chronic systolic heart failure
428.2 Systolic heart failure
428.31 Acute diastolic heart failure
428.32 Chronic diastolic heart failure
428.33 Acute on chronic diastolic heart failure
428.3 Diastolic heart failure
428.41 Acute combined systolic and diastolic heart failure
428.42 Chronic combined systolic and diastolic heart failure
428.43 Acute on chronic combined systolic and diastolic heart failure
428.4 Combined systolic and diastolic heart failure
428 Heart failure

ICD10

I50.9 Heart failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.40 Unsp combined systolic and diastolic (congestive) hrt fail
I50.1 Left ventricular failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.2 Systolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.3 Diastolic (congestive) heart failure
I50.41 Acute combined systolic and diastolic (congestive) hrt fail
I50.42 Chronic combined systolic and diastolic hrt fail
I50.43 Acute on chronic combined systolic and diastolic hrt fail
I50.4 Combined systolic and diastolic (congestive) hrt fail
I50 Heart failure

SNOMED

42343007 congestive heart failure (disorder)
10633002 acute congestive heart failure (disorder)
74960003 Acute left-sided congestive heart failure (disorder)
80479009 Acute right-sided congestive heart failure (disorder)
426263006 Congestive heart failure due to left ventricular systolic dysfunction
5375005 Chronic left-sided congestive heart failure (disorder)
66989003 Chronic right-sided congestive heart failure (disorder)
88805009 Chronic congestive heart failure
92506005 Biventricular congestive heart failure (disorder)

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