1. Congestive heart failure guideline

2. Functional classification( NYHA) Class IV: symptoms at rest Class III: symptoms on less-than-ordinary exertion Class II: On ordinary exertion Class I: only at levels that would limit normal individuals

3. FRAMINGHAM CRITERIA FOR CONGESTIVE HEART FAILURE

4. Etiology of Heart failure Myocardial disease –Coronary artery disease –Infectious/ viral –Inflammatory –Alcohol/ substance abuse –Idiopathic/ genetic Infiltrative Valvular heart disease Hypertension Diabetes

5. History taking Etiology seeking Etiology seeking Complications Complications Risk factors Risk factors Left heart failure Left heart failure Right heart failure Right heart failure NYHA Classification NYHA Classification Precipitating factors Precipitating factors

6. Physical Examination Vital signs Vital signs Pulse characters Pulse characters Jugular vein pressure Jugular vein pressure Thyroid :Goiter Thyroid :Goiter Breathing sound and respiratory pattern Breathing sound and respiratory pattern Heart Beat ; S1,S2, S3,S4;PMI location,heave, thrill Heart Beat ; S1,S2, S3,S4;PMI location,heave, thrill Murmur ( characters and radiation ) Murmur ( characters and radiation ) Liver (hepatomegaly ) Liver (hepatomegaly ) Extremity (edema) Extremity (edema) Skin ( cool, cyanosis ) Skin ( cool, cyanosis )

7. Laboratory examination Twelve –lead EKG Chest X-Ray Blood serum (CBC,electrolyte, BUN, Cr, Liver function, thyroid function ) Arterial blood gas Echocardiography Treadmill Exercise test Swan –Ganz monitor as indicated Swan –Ganz monitor as indicated Cardiac catheterization /coronary angiogram Cardiac catheterization /coronary angiogram

8. Symptoms and signs of left side heart failure Pulmonary rales Tachycardia Dullness at base (secondary pleural effusions) Cheyne-Stoke respiration Abnormal PMI S3, S4 S3, S4

9. Symptoms and signs of right side heart failure Jugular vein increased Pleural effusions Congestive hepaomegaly Ascites Peripheral edema

10. Approach to left side heart faliure

11. Goals of HF Therapy Improve hemodynamics/ symptoms Reduce remodeling/ prevent cell death Increase survival –Risk factor modification( BP, statins, exercise) –ACE inhibitors,  -blockers –Arrhythmias( Amiodarone, AICD) –Transplantation, heart replacement

12. Treatment of CHF General rule Bed rest Bed rest Restrict water and salt and record I/O Restrict water and salt and record I/O O2 therapy O2 therapy Preload reduction Afterload reduction Increased contractility Correct etiology and precipitation factor

13. Treatment Strategies(1) Asymptomatic Mild/ Mod SevereRefractory Angiotensin Converting Enzyme Inhibitors Angiotensin Converting Enzyme Inhibitors  - Blockers ( Carvedilol )  - Blockers ( Carvedilol ) Correct cause: Arrhythmias Arrhythmias Ischemia Ischemia Toxins/infection Toxins/infection Non-compliance Non-compliance Diuretics (Spironlactone) Diuretics (Spironlactone) Digoxin Digoxin Tailored Rx Tailored Rx Inotropes, resynch, surgery, transplant Inotropes, resynch, surgery, transplant No added salt 2gm Na 2gm Na Activity as tolerated Customized ex training Modified from Warmer-Stevenson, ACC HF summit Modified from Warmer-Stevenson, ACC HF summit

14. Treatment Strategies (2)

15. Treatment of acute heart failure with pulmonary congestion Airway managenent and O2 supply Airway managenent and O2 supply NTG :begin 10~20ug /min and titrate 5~10 ug per 5 minutes NTG :begin 10~20ug /min and titrate 5~10 ug per 5 minutes Nitroprusside :Initial 15ug /min and titrate to effect up to 200 ug /min Nitroprusside :Initial 15ug /min and titrate to effect up to 200 ug /min Morphine sulfate :2~5 mg and titrate to effect Morphine sulfate :2~5 mg and titrate to effect Diuretics : 40~80mg IV initially, double dose if output is unsatisfactory Diuretics : 40~80mg IV initially, double dose if output is unsatisfactory 2 hours later 2 hours later