Congestive Heart Failure ======================== þ Acute CHF with hypotension - high mortality - if 90-85 try low-dose trial of NTG IV, stay at bedside - can try IV fluids (250-500 mL) as some are intravascularly dry. - if those don't work, try dobutamine, but no effect on mortality as lots of arrhythmias (NB vasodilates, so may drop BP) - dopamine if BP <80 - NEJM study of early shock: CHF patients did better with norepi than dopamine so maybe try that? þ Ultrasound for CHF - look for "lung rockets": have to shoot all the way across the screen. + sensitivity and specificity ~90% for fluid-filled alveoli + if + bilaterally, is either ARDS or CHF. + But if > 5 lung rockets after 30 windows in study! + ED studies limited. + if IVC plethora (diameter is > 2 cm), then R atrial filling pressure high; in sepsis will be small þ Jerry Hoffman, ACEP 2006: - O2 - Nitrates - NO Lasix until nitrates given; without nitrates, Lasix is a vasoconstrictor; may give after this - NO Morphine, not proven to help and one study shows it may hurt - BIPAP or CPAP are good - no nesiritide, do BNP, no morphine þ Rating Scales: - NYHA Classification: useless in ED - AHRQ, ACC: useless, gone - ADHERE trial: BUN, Cr, BP: OK but limited to "inhospital" deaths Yealy: studied, couldn't come up with rule. þ BNP (Brain Natriuretic Peptide) - Meta-analysis shows it to be a useful study, though those with new CHF also need a followup echo. [Doust JA et al. A systematic review of the diagnostic accuracy of natriuretic peptides for heart failure. Arch Intern Med 2004 Oct 11; 164:1978-84.] - correlates with CHF severity - patients with CHF and COPD: does it help distinguish? Canadian study 2003, compared to "gold standard" of cardiologist review. Some overlap: if underlying CHF, levels indeterminate. - 80-125 is indeterminate - higher in females and elderly, lower in obese patients. - may be falsely very low if very obese - may be falsely elevated in sepsis. þ Treating Acute CHF - one opinion is that acute CHF is really a hypertensive crisis, and that anything that lowers BP will work -- but as with acute HTN, we should only use things that go away quickly (e.g., NTG, nipride) or are reversible. - Natrecor (nesiritide): Human brain natriuretic peptide: works similar to NTG, but unlike NTG, can't turn off if BP drops. Albuterol BiPAP helps Dubutamine Oxygen Lasix - For the patient in true pulmonary edema not due to a high output state, lasix is still a mainstay of therapy. The acute effects of IV lasix have been proven to be due initially to increased pulm.venous capacitance since the innovative work of Dikshit et al in anephric patients (lead article in NEJM early '70s). --Bob Oatfield, MD. ACE inhibitors (Angiotensin Converting Enzyme Inhibitors) - captopril in a dose of 25-50 mg SL has been effective in a study presented in an abstract by the Jacoby EM residency at SAEM in 1994. Later reported in a study in the Academic Emergency Medicine [Hamilton RJ. Rapid improvement of acute pulmonary edema with sublingual captopril. Acad Emerg Med 1996;3:205-212.] Some other evidence as well, in the abstracts Abstract: - IV enlapril for CHF? "I am under the impression that severe hypotension occurs more frequently in patients who are at risk for "high renin states" and that when using meds such as captopril for patients who are on high doses of diuretics (greater than 120-160mg/ day) that these are often the individual who tend to become profoundly hypotensive. The recommendation from many of the proponents of ACEI in APE state that in this subsection of patients that the usual dose of captopril be reduced by half. --Paul R. Sierzenski, MD Chief Resident Emergency Medicine Residency Program Medical Center of Delaware Work (302) 733-4176 Fax (302) 733-1595 [Annane D, Bellissant E, Pussard E: Placebo-controlled, randomized, double-blind study of intravenous enalaprilat efficacy and safety in acute cardiogenic pulmonary edema. Circulation 1996; 94: 1316-1324.] - pithy comment by Dr. Handler NTG IV - boluses of IV NTG found to be effective as reported by AJEM May 1994. Nipride (nitroprusside): - for "clamped-down" hypertensive patients with CHF: one person recommends 20-40 mcg/min (_not_ per kg) drip. Milrinone (Primacor): - Inotropic and vasodilator. - Inotropic by different mechanism than digitalis. - Not for acute MIs. - No effect on heart rate. - Can treat up to 5 days. - May increase conduction through AV node and thus increase rate of atrial flutter or atrial fibrillation. - Incompatible with Lasix in IV line. - Main adverse reaction is dysrhythmia: sustained V Tach 1%, V Fib 0.2%. May also cause hypotension in 3%, angina in 1%, and headache in 3%. - dose: 50 ug/kg over 10 minutes, followed by 0.5 ug/kg/min infusion. May need to adjust dosage for renal failure, but not for age. þ Morphine - "I'll merely point out that in a recent consensus statement on the treatment of CHF by an expert panel, the continued use of morphine for acute pulmonary edema uncomplicated by COPD was still being advocated." --H. Louzon MD [Guidelines for the Evaluation and Management of Heart Failure. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure). Circulation 1995;92:2764-2784.] þ Diagnosing CHF þ Treating Chronic CHF - Beta Blockers for Chronic CHF þ Prehospital treatment of CHF: þ CHF etiology and natural history - is primarily a neurohormonal problem, not pump failure. - recent trials show increased mortality from inotropes - vasodilators and inotropes make patients feel worse and do worse. - beta blockers show some benefit in treating CHF [anon. Randomized trials shed new light on CVD treatments. American Heart News 1994:2.] þ Diastolic Dysfunction and CHF - Wei. NEJM 1992;327:1735 - Topol. NEJM 1985;312:277 - Kessler Arch IM 1988:148:2109. þ AHA-ACC CHF recommendations