Slides chf jsw

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65 y/o SOB Hypotensive

Transcript of Slides chf jsw

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65 y/o SOB Hypotensive

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CHF

J. Scott Wieters MD FAAEM  Assistant Professor Emergency Medicine  

Texas A&M University Health Science CenterScott and White Hospital, Temple, TX

Anything but a dry topic…

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Objectives

“Learn you fools bout CHF”

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Epidemiology

•5 million Americans •2.3% of general public •35% die in 2 yrs 80% at 6 yrs •1 million admits each year •Costs $27.9 billion •Chance to hear a CHF lecture.....

•Priceless....

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How’d you get it?

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Classifications?

•Left v. Right sided? •High v. Low output? •Ischemic v. Nonischemic? •Systolic v. Diastolic? •NY class I-IV?

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CHF The Big Picture

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Big Picture

•Preload •Afterload •Renin Angiotensin •Pulmonary edema •Cardiogenic Shock

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Systolic?

or

Diastolic?

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Low vs High?

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ACE-Inhibitors

•Afterload Reduction •First Dose Hypotesion?

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•Hypertensive  HF  48%  •Rapidly  SOB  •Minimal  weight  gain/edema  

•Normotensive  HF  48%  •Progressive  Weight  gain,  edema,    

•Hypotensive    HF  3%  •Cardiogenic  shock    

Initial Presentation

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specifisc

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I Wanagetta BNP

• <100- prob not CHF •100-500 not sure what to do? •>500- probably CHF

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False High BNP?

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False LOW BNP?

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False Positive (falsely high) BNP False Negative (falsely low) BNP

Left ventricular hypertrophy Obesity

Ischaemia Treatment with heart failure drugs

Tachycardia

Hypoxaemia including pulmonary

embolismRenal impairment (GFR<60 ml/

min)Sepsis

COPD

Diabetes

Age>70 years

Liver cirrhosis

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Treatment Options

•BIPAP/CPAP •Nitrates •Lasix •ACE-I

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L MN OP

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Lasix MorphineNitratesOxygen Pressure

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P O N D

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Pressure Oxygen Nitrates Diuresis

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NIPPV

•Reduces: •Preload/Afterload •BP •Work Of Breathing •Intubation rate •Mortality*

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Nitrates

•Stop dicking around! •Reduce preload •Afterload red. at higher doses •Nitrates better than Lasix

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What Dose?

• One tablet = 80mcg/min

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ACE-Inhibitors

•Afterload Reduction •First Dose Hypotesion?

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Nesiritide

•VMAC trial •No reduction in mortality •Just Say No...

AusNn  MarNn  Vanquish.    $279,999

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Lasix

•Mod/Severe helpful •Nitrates better than Lasix •Monotherapy? Really?

•Renal Failure •NO Mortality benefit

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Beta Blockers

•Really  no  role  in  ADCHF

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CRASHING CHF

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Crashing ADCHF

•Airway? •Rhythm? •Circulation

•Perfusion of vital organs

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Crashing ADCHF

•Hypotensive <100? •Dopamine 2-20mcg/kg/min •Dobutamine 2.5-20mcg/kg/min

•Still <70? •Norepi 4 -12 mcg/min •CATH lab for IABP?

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Post test CHF

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Twitter Email@jscottwieters [email protected]