CURRENT Essentials of Critical Care.pdf

Chapter 9 Cardiology 121■■■Congestive Heart FailureEssentials of Diagnosis• Shortness of breath, dyspnea on exertion, orthopnea, paroxysmalnocturnal dyspnea, weight gain, leg swelling, pink frothysputum• Tachypnea, inspiratory crepitations, gallops, cyanosis, peripheraledema• Chest radiograph with pulmonary edema, pleural effusions, cardiomegaly• Elevated B-type natriuretic peptide, hypoxemia, metabolic acidosis• Echocardiogram or right heart catheterization with reduced ejectionfraction (systolic dysfunction) or inadequate diastolic filling(diastolic dysfunction)Differential Diagnosis• Noncardiogenic pulmonary edema: ARDS• Valvular heart disease • Pericardial disease• Hypoalbumin states • Fluid overload• Hypothyroidism and myxedema• Pulmonary vascular diseaseTreatment• Acute left ventricular failure: oxygen; preload and afterload reduction:nitrates, nitroprusside, morphine; diuresis: loop diuretics(furosemide), spironolactone• ACE inhibitors, angiotensin-receptor antagonists recommended;hydralazine and nitrates for those intolerant of these agents• Beta-blockers may exacerbate short-term symptoms; beneficiallong-term• Digoxin improves symptoms in systolic failure• Dietary sodium and fluid restriction• Anticoagulation in normal sinus rhythm controversial• Dobutamine, milrinone, intra-aortic balloon pumps used in refractorycardiac failure as a bridge to surgery• Optimal management of diastolic heart failure: primarily betablockersand calcium-channel blockers■ PearlSymptomatic heart failure confers a worse prognosis than most cancersin the United States with a one-year mortality rate approaching45%.ReferenceLiu P et al: The 2002/3 Canadian Cardiovascular Society consensus guidelineupdate for the diagnosis and management of heart failure. Can J Cardiol2003;19:347. [PMID: 12704478]