BETA / UNDER CONSTRUCTION
Must consider contributing causes including MI, valve rupture, rapid AFib, thiamine deficiency, hyperthyroidism, sepsis, PE — if you miss these, the patient will have CRASHED on the floor.
CRASH
CAD / MI
Ruptured valve
Alcohol (thiamine depleted) / Anemia
Sepsis
Hyperthyroid
Elevated BP
Dysrythmia
Other known causes include NSAID use (increases risk 2-fold), COPD exacerbation, dietary indiscretion, med non-compliance, PE
HPI
- Dyspnea of SUDDEN onset? (Favors MI, PE, valve rupture, etc.)
- Highest OR for dyspnea being from CHF:
weight gain 3.6
nocturia 2.4
paroxysmal nocturnal dyspnea 2.4
("Have you gained weight? Are you waking up to pee, or to gasp for breath?")
Exam
Low yield
- JVP & peripheral edema are seen in acute decompensated CHF from L ventricular dysfunction, but also in cor pulmonale from pulmonary HTN (i.e., from COPD damage).
- Sensitivity of JVP (which reflects RA pressure) for acute HF is around 20%.
- Sensitivity of leg edema 46%, specificity 76%
- Severe chronic HF often lack rales or alveolar edema (reduced pulm microvascular permeability, increased lymph flow), and hearing rales is very non-specific
- Sensitivity & specificity ~ 60%
Testing
[] CBC BMP
- Hypontremia, anemia and renal failure are all concerning. Hyponatremia is a sign of failing circulatory homeostasis. Anemia can in fact be a driver of acute CHF.
[] BNP
- Half-life of BNP is ~ 20 mins, of NT-proBNP 120 mins
- Renally cleared
- Degree of elevation proportional to disease severity
- In Breathing Not Properly (BNP) Trial (1,600 patients):
- High NPV at cutoff of 100 pg/mL, but to get to 95% NPV need less than 30 pg/mL
- High PPV at cutoff of 500 pg
- In Pro-BNP Investigation of Dyspnea in the ED (PRIDE) trial:
- High NPV at 300 pg/mL
- High PPV at 900 pg/mL
[] Trop
[] Thiamine TSH Ferritin Transferrin Saturation
[] US for B-lines, cardiac evaluation (valve? PE?)
[] CXR
[] Formal Echo
Acute Treatment
[] CPAP 5-10 cm H2O (BiPaP if COPD)
- Good for the LV
- Reduces intubations & mortality
- Usually only an oxygenation problem, only see hypercarbia with concomittant COPD
[] Nitroglycerine IV
[] Reversible causes, i.e. valve surgery, abx, heparin & cath for MI, etc.
Subacute Treatment
[] Furosemide 40 mg IV x 1 dose then PO (not to exceed 80 mg daily)
[] B-blocker (carvedilol)
[] Consider low-dose oral ACE inhibitor (NOT if worsening renal function)
In-House
[] IV iron if iron deficiency
[] Nutritional optimization (thiamine, etc.)
[] Consider ultrafiltration in select patients
Avoid!
- High-dose loop diuretics (>80 mg furosemide day)
- Diuretics in general with worsening renal function (cardiorenal syndrome)
- Morphine (OR for death of 5!)
- Inotropes (dobutamine, milrinone)
- Nesiritide, Nitroprusside
- Blood transfusion
- NSAIDs