IM CHF A-fib

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Author:
TerryZ
ID:
246723
Filename:
IM CHF A-fib
Updated:
2013-11-27 09:39:18
Tags:
internal medicine IM congestive heart failure CHF HF atrial fibrillation fib
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IM
Description:
Internal medicine - congestive heart failure and atrial fibrillation
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  1. Transudate vs Exudate
    • Exudate       Transudate
    • Protein             >3 g/dL       <3 g/dL
    • Pleur:ser prot    >0.5           <0.5
    • LDH conc          >200          <200
    • Pleur/ser LDH    >0.6           <0.6
    • Pathophys         damage      osm/hydrostat
    • Causes        PE,PNA,CA,RA   LV HF, cirrhosis
  2. Frank-Starling relationship
    In nl <3, /preload -> /contractility
  3. CHF - physiology
    • In failing <3, less contractility -> CO ->
    • Activation of RAAS & sympathetic NS ->
    • Systemic vasoconstriction & vol retention ->
    • /venous return & preload ->
    • /LVEDV -> /LVEDP ->
    • /pulmonary vein P -> pulmonary congestion
  4. CHF - systolic dysfn
    • Physio: Impaired contractility (EF < 45%)
    • Causes: ischemia/MI, HTN, valves, myocarditis
  5. CHF - diastolic dysfn
    • Physio: impaired ventr diast filling (relax,/stiff)
    • Causes: HTN->hypertrophy, valve, restrictive cardiomyopathy (amyloid, sarcoid, hemochrom)
    • Dx: Echo shows impaired relax L ventr; EF>45)
  6. Heart failure, L - S/Sx
    • Lungs: dysp, orthop, PND, pm cough, crackles,rales,dull percuss,tact frem LL
    • Brain: confusion & memory impair (profus)
    • Extrem: diaphor, cool @ rest
    • Heart: displaced PMI; path S3 fill (apex bell);     S4 eject (LSB bell); /P2 (L USB)
  7. Heart failure, R - S/Sx
    • Peripheral pitting edema
    • Nocturia
    • JVD
    • Hepatomegaly/hepatojugular reflex
    • Ascites
    • Right ventricular heave
  8. NYHA classification
    • New York Heart Association classification of CHF
    • Class I: sxs w/vigor activities (almost asympt)
    • Class II: sxs w/ prolonged/mod exert
    • Class III: sxs with usual activities, minimal exert
    • Class IV: sxs @ rest, incapacitating
  9. ACC/AHA classification
    • A: ^risk for HF, ~struct HD or HF sx (CAD/HTN)
    • B: struct HD w/out HF sxs
    • C: struct HD w/ prior/current HF sxs
    • D: refractory HF req'g specialized interventions
  10. CHF - Dx
    • CXR: cardiomeg, Kerley B lines, prominent interstitial markings, pleural effusions (trans)
    • TTE: est EF (<40-50%=syst dysfn)
    • ECG: chamber enlarge, ischemic HD, prior MI
    • Radionuclide ventriculography: /echo
    • Cardiac catheterization: .
    • Stress test: ID's ischemia/infarct; card vs pulm
    • Labs: CBC (r/o infect/anemia), BUN, Cr, lytes, LFT, TSH, BNP (vol o'load, >150->decomp HF, dyspn <- CHF vs COPD), N-terminal pro-BNP (>300 excludes HF)
  11. CHF, systolic dysfn - Tx, drug
    • Diuretics: sympt relief (mod-sev); syst fail & vol o'load; loop! (furosemide), thiazide (HCTZ)
    • Spironolactone: III-IV /survive, mon K/renal fn
    • ACEI: captopril, lisinopril. Syst LVEF <40, pre&afterload, mort, mon BP, K, BUN, Cr
    • ARBs: if can't take ACEI due to cough
    • BB: mort in post-MI HF, stable CHF I-III. metoprolol, bisoprolol, carvedilol
    • Digitalis: +ion, EF<40%, sev CHF/Afib; sympt
    • Hydralazine, isosorbide diNO3: can't do ACEI
    • CI: X metformin, thiazolidinediones, NSAIDs, some antiarrhythmic agents
  12. CHF, systolic dysfn - Tx, non-drug
    • Lifestyle mod: Na<4g/d, wt loss, xSmoke, EtOH, exer, annual flu/pneumococcal shot
    • Devices
    • ICD: implantable cardioverter defibrillator - prevent sudden cardiac death; 40 days post-MI, EF < 35%, class II
    • CRT: cardiac resynchronization tx - biventricular pacemaker, QRS>120 ms
    • VAD: ventricular assist device, support L and or R ventricle, anticoag for life.
    • Cardiac transplantation - last alternative
  13. CHF, diastolic dysfn - Tx
    • Pts treated symptomatically
    • ! BB, diuretics
    • ? ACEIs & ARBs
    • X digoxin, spironolactone
  14. CHF - general Tx principles
    • Mild (I-II): phys active & Na (4g/d), loop diuretic, ACEI
    • Mild-mod (II-III): + BB if needed
    • Mod-sev (III-IV): + digoxin, ?spironolactone
  15. Acute decompensated HF (ADHF) - description
    • Acute dyspnea + /L fill press, ?pulm edema
    • MC LV syst/diast dysfn
  16. Acute decompensated HF (ADHF) - Dx
    • ECG, CXR, ABG, BNP, echo, ?coron angiogram
    • ddx: PE, asthma, pneumonia
    • hospital admission; daily weights
  17. Acute decompensated HF (ADHF) - Tx
    • O2 & ventilator
    • diuretics
    • Na restriction
    • nitrates (IV NTG if no HoTN)
    • pulm edema - inotropic agents (dobutamine)
  18. A-fib - causes
    • HD: CAD, MI, HTN, mitral valve dz
    • Peri: pericarditis, pericardial trauma
    • Pulm: pulm dz, incl PE
    • Thy: H/HoThy
    • Syst: sepsis, malignancy, DM
    • Stress: postop
    • EtOH: excessive intake
    • Sinus: sick sinus syndrome
    • Pheo: pheochromocytoma
  19. A-fib - S/Sx
    • fatigue, DOE
    • ?palpitations, dizzy, angina, syncope
    • irregularly irregular rhythm, no IDable P waves
    • blood stasis->intramural thrombi->brain emb
  20. Acute A-fib - Tx
    • Anticoag: any w/ stroke risk. >48h, 3wk before and 4 weeks after (or do TTE - heparin)
    • ASA: <65 (>75 Coumadin) INR -> 2-3
    • Unstable, worse sx, 1st time: cardiovert
    • Stable: rate cntl (BB best, CCB alt)
  21. Chronic A-fib - Tx
    • Rate cntl: BB (CCB)
    • Anticoag: none if <60 no underlying HD (ASA); all others with warfarin.
  22. CHADS-2 score
    • CHF anticoagulation score
    • C: H/o CHF - 1 pt
    • H: H/o HTN - 1 pt
    • A: Age 75+ - 1 pt
    • D: H/o DM  - 1 pt
    • S-2: Previous stroke/TIA - 2 pts
    • 0: ASA 325 mg/day
    • 1: ASA or Warfarin (pt preference)
    • 2+: anticoagulation

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