CONGESTIVE HEART

FAILURE
SYMPTOMS
SIGNS
COMPLICATIONS
MANAGEMENT
Chizner, M.A. Clinical Cardiology Made Ridiculously Simple.Medmaster, Inc.2004. P. 235.
THE CENTRAL CIRCULATION
.
= PCWP
THE CENTRAL CIRCULATION
25/10
(15)
mmH
g 10 mmHg

10
mmH
g

Lilly, Pathophys. of Hrt.Dis., 2nd Ed.

CONSEQUENCES OF LV DYSFUNCTION
 TACHYCARDIA
RALES
S3 GALLOP

Chizner, M.A. Clinical Cardiology made ridiculously simple. P. 239.

Goldman and Braunwld. Primary Cardiology. P.315
 NORMAL

Merck-Medicus- Topol- Cardiovascular Medicine – Non-invasive imaging

 CARDIOMYOPATHIES

.
.

Goldman and Braunwald: Primary Cardiology

Lilly, L.S. Pathophysiology of Heart Disease. P. 201.
 Mngmnt of ADHF
• Diuretic regimens – for overload states
• IV furosemide – 40-80-160 mg q12h.
• Metolazone priming- 2.5-5 mg po.
• Furosemide drip- 2-10 mg/hr.
• Other diuretics: Demadex, Torsemide, Ethacrynic A. (no S).
• Inotropes, vasodilators- for decreased perfusion
-esp. overload with rising BUN/creatinine
• Milrinone - Neseritide – Dobutamine – Dopamine
• LVAD – Bridge to transplant
- Destination (sometimes temporary LV
furlough)
• Transplantation. 70% 5-yr. survival
 Addition of -Blockade to ACE Inhibition
Reduces Mortality in Heart Failure
US Carvedilol Trials MERIT-HF
1.0 20
34% 
Probability of

Carvedilol (n=696) Placebo

Mortality (%)
Cumulative
15 P=.0062
Survival

0.9 (n=2,001)
(adjusted)
Placebo
(n=398) 10
0.8 65% 
Metoprolol CR/XL
P<.001 5 (n=1,990)
0.7
0.0 0
0 100 200 300 400 0 100 200 300 400 500 600
Days Days

1.0 CIBIS-II 100 COPERNICUS

Bisoprolol (n=1,327)

Survival (%)
90 Carvedilol (n=1,156)
Survival

0.8 34% 
Placebo
80 35% 
P<.0001 Placebo
(n=1,320) 70 P=.0014 (n=1,133)
(adjusted)
0.6 60

0.0 0
0 200 400 600 800 0 3 6 9 12 15 18 21
Days Months
Packer M, et al. N Engl J Med. 1996;334:1349-1355. MERIT-HF Study Group. Lancet. 1999;253:2001-2007.
CIBIS-II Investigators. Lancet. 1999;353:9-13. Packer M, et al. N Engl J Med. 2001;344:1651-1658.
 CHARM-Alternative
Primary outcome of CV death or CHF hospitalization
50
406 (40.0%)
or CHF Hospitalization (%)
Proportion With CV Death

Placebo
40
334 (33.0%)

30
Candesartan
20

10 HR 0.77 (95% CI 0.67-0.89), P=.0004

Adjusted HR 0.70, P<.0001
0
0 1 2 3 3.5
Number at risk Years
Candesartan 1,013 929 831 434 122
Placebo 1,015 887 798 427 126
Granger CB, et al. Lancet. 2003;362:772-776.
 A-HeFT: Overall Survival
43% Decrease in Mortality
100

Fixed-dose HYD/ISDN
Survival (%)

95

90
Placebo

Hazard ratio=0.57
P=.01
85
0 100 200 300 400 500 600
Days Since Baseline Visit Date
HYD/ISDN 518 463 407 359 313 251 13
Placebo 532 466 401 340 285 232 24

Adapted from Taylor AL, et al. N Engl J Med. 2004;351:2049-2057.

 V-HeFT I: Survival Benefit
in Subgroups
Non-African Americans African Americans

80%
n=128
80%
Relative Risk Reduction 47%; P=.04

Cumulative Mortality
Cumulative Mortality

70% 70%
HYD/ISDN Superior
60% 60%
n=324
50% 50%

40% 40%

30% 30%

20% 20%

10% 10%

0% 0%
0 6 18 30 42 54 66 0 6 18 30 42 54 66

Months Months
HYD/ISDN
HYD/ISDN=hydralazine/isosorbide dinitrate. Placebo
Carson P, et al. J Card Fail. 1999;5:178-187.
SCD-HeFT
 Surgical therapies
for CHF
CABS for ICM and viable myocardium, for
hibernating heart.

Remodelling therapy- Stitch for ICM, Doer for non-

ICM, with attention to MR.

“Destination therapy”- LVADs

Heart transplantation- 70% 5 yr. survival.

 COST OF RX FOR CHF

Digoxin --- -------------------- $ 5/ month

Furosemide---------------------10
Spironolactone-----------------10
Fosinopril------------------------25
Carvedilol-----------------------65
Aspirin----------------------------5
Statins---------------------------90

ICD/ biventricular pacing system---$25,000

The Hospitalized Patient
Precipitating Factors for Acute HF
I IIa IIb III
It is recommended that the following
common potential precipitating factors for
acute HF be identified as recognition of
these comorbidities, is critical to guide
therapy: New

• acute coronary syndromes/coronary

ischemia
• severe hypertension
• atrial and ventricular arrhythmias
• infections
• pulmonary emboli
• renal failure
• medical or dietary
33 noncompliance
 COMET: All-Cause Mortality
Metoprolol
40 Risk Reduction Tartrate
 17%
(7%, 26%) Carvedilol
30
P=.0017
Mortality (%)

20 “Extrapolation from the survival curves

suggested that [carvedilol] extended
median survival by 1.4 years*... as
10 compared with metoprolol [tartrate]....Ӡ

Mortality rates: metoprolol 40%; carvedilol 34%.

0
0 1 2 3 4 5
Time (years)
Number at Risk
Metoprolol Tartrate 1,518 1,359 1,234 1,105 933 352
Carvedilol 1,511 1,366 1,259 1,155 1,002 383
*95% CI, 0.5 to 2.3.
†Estimated median: carvedilol=8.0 years (95% CI, 7.3 to 8.7); metoprolol tartrate=6.6 years (95% CI, 6.1 to 7.1).

Rates for the composite endpoint of mortality or all-cause hospital admission were 74% (carvedilol) and 76%
(metoprolol), RR 6% (95% CI, -2% to 14%, P=.122).
Metoprolol mean dose: 85 mg QD; carvedilol mean dose: 42 mg QD.
Poole-Wilson PA, et al. Lancet. 2003;362:7-13.
The Hospitalized Patient
Treatment With Intravenous Loop Diuretics

Patients admitted with HF and with evidence of

I IIa IIb III significant fluid overload should be treated with
intravenous loop diuretics. Therapy should begin in
the emergency department or outpatient clinic
without delay, as early intervention may be
associated with better outcomes for patients
hospitalized with decompensated HF (Level of
I IIa IIb III Evidence: B). If patients are already receiving
loop diuretic therapy, the initial intravenous dose
should equal or exceed their chronic oral daily dose.
Urine output and signs and symptoms of congestion
should be serially assessed, and diuretic dose
New
should be titrated accordingly to relieve symptoms
and to reduce extracellular fluid volume excess.
(Level of Evidence: C).
35
The Hospitalized Patient
Intensifying the Diuretic Regimen
I IIa IIb III

When diuresis is inadequate to relieve

congestion, as evidence by clinical
evaluation, the diuretic regimen should New
be
intensified using either:
a. higher doses of loop diuretics;
b. addition of a second diuretic (such
as metolazone, spironolactone or
intravenous chlorthiazide) or
c. Continuous infusion of a loop
diuretic.

36
 The Hospitalized Patient
Preserving End-Organ Performance

I IIa IIb III In patients with clinical evidence of hypotension

associated with hypoperfusion and obvious evidence of
elevated cardiac filling pressures (e.g., elevated jugular
venous pressure; elevated pulmonary artery wedge
pressure), intravenous inotropic or vasopressor drugs
should be administered to maintain systemic perfusion
and preserve end-organ performance while more
definitive therapy is considered.
New

I IIa IIb III Invasive hemodynamic monitoring should be performed

to guide therapy in patients who are in respiratory
distress or with clinical evidence of impaired perfusion in
whom the adequacy or excess of intracardiac filling
pressures cannot be determined from clinical
assessment. New 37
The Hospitalized Patient
Invasive Hemodynamic Monitoring

I IIa IIb III

Invasive hemodynamic monitoring can be useful for
carefully selected patients with acute HF who have
persistent symptoms despite empiric adjustment of
standard therapies, and New

a. whose fluid status, perfusion, or systemic or

pulmonary vascular resistances are uncertain;
b. whose systolic pressure remains low, pr is
associated with symptoms, despite initial
therapy;
c. whose renal function is worsening with therapy;
d. who require parenteral vasoactive agents; or
e. who may need consideration for advanced device
therapy or transplantation.

38
 Initial Clinical Assessment of Patients
Presenting With Heart Failure
Measurement of BNP and Noninvasive Imaging

I IIa IIb III

Measurement of natriuretic peptides (B-
type natriuretic peptide (BNP) or N-
terminal pro-B-type natriuretic peptide
(NT-proNBP)) can be useful in the
evaluation of patients presenting in the
urgent care setting in whom the clinical
diagnosis of HF is uncertain. Measurement
of natriuretic peptides (BMP and NT-
I IIa IIb III proBNP) can be helpful in risk stratification.
Modified
Noninvasive imaging may be considered to
define the likelihood of coronary artery
disease in patients with HF and LV
dysfunction. 39
NO CHANGE
 Patients With Reduced Left Ventricular
Ejection Fraction
Measuring LVEF
I IIa IIb III
Angiotensin-converting enzyme (ACE)
inhibitors are recommended for all patients
with current or prior symptoms of HF and
reduced LVEF, unless contraindicated .
NO CHANGE
I IIa IIb III
Use of 1 of the 3 beta blockers proven to
reduce mortality (i.e., bisoprolol, carvedilol,
and sustained release metoprolol succinate) is
recommended for all stable patients with
current or prior symptoms of HF and reduced
LVEF, unless contraindicated. Modified

40