Tuesday, March 9, 2010

Congestive heart disease or CHF

Congestive heart disease


 

Definition  

A complex clinical syndrome resulting from any structural or functional cardiac abnormality that impairs the ability of the ventricle to fill with or eject blood

Because not all patients with heart failure have volume overload at the time of the initial or subsequent evaluation, the term heart failure is preferred over the older congestive heart failure term.


 

Suspected or known coronary artery disease and evaluation of functional impairment  

* Cardiovascular stress test using treadmill


 

Coronary arteriosclerosis  

* Coronary angiography


 

Suspected or known coronary artery disease  

* Radionuclide study of heart

* Stress echocardiography


 

Evaluation of nutritional status  

* Prealbumin measurement

* Nitrogen balance test


 

Reassessment  


 

Laboratory Reassessment  


 

Suspected or known heart failure  

* Serum potassium measurement: The target level of serum potassium in heart failure patients ranges from 4.0 to 5.5 mmol/L; hypokalemia is independently associated with increased mortality .


 

Suspected or known heart failure  

* Creatinine measurement, serum: Serum creatinine should be measured and followed closely in all patients with heart failure. Creatinine levels provide management guidance as well as prognostic information .


 

Suspected or known heart failure .  

* Two dimensional echocardiography: All patients presenting with heart failure should receive echocardiographic evaluation of left ventricular ejection fraction, left and right ventricular size and function, ventricular wall thickness, valve function, and pericardial pathology .


 

Medical History  

* Coronary arteriosclerosis

* Hypertension [Hypertension - Chronic]

* Diabetes mellitus [Diabetes mellitus - Chronic]

* Obesity [Obesity - Chronic]

* Smoking

* Alcohol Abuse

* Anemia [Anemia - Chronic]

* Family history of Cardiomyopathy


 

Findings  

* Dyspnea - Chronic

* Fatigue

* Peripheral edema

* Respiratory crackles

* Decreased breath sounds

* Orthopnea

* Paroxysmal nocturnal dyspnea

* S3 gallop

* Jugular venous distention

* Hepatojugular reflux

* Hepatomegaly

* Ascites

* Nocturnal cough

* Nocturnal asthma

* Second heart sound split

* Tricuspid valve regurgitation

* Tachycardia

* Palpitations

* Chest pain

* Early satiety

* Nausea and vomiting

* Abdominal pain

* Cold extremities

* Confusion

* Syncope


 

Tests  


 

Suspected or known heart failure  

* Plain chest X-ray: Radiographic findings in heart failure may include evidence of cardiac chamber enlargement, increased pulmonary venous pressure, interstitial or alveolar edema, pleural effusions, valvular or pericardial calcification, or lung disease , but a chest x-ray should not be used as a primary test for identifying the specific cardiac dysfunction associated with HF .


 

Suspected or known heart failure  

* 12 lead ECG: In patients with heart failure, a 12-lead ECG is frequently abnormal and may show evidence of ischemia, myocardial infarction, left ventricular hypertrophy, cardiac conduction abnormality, or cardiac arrhythmia .


 

Suspected or known heart failure  

* Brain natriuretic peptide measurement: Acute heart failure is likely in the presence of acute dyspnea if the B-type natriuretic peptide (BNP) level is greater than 500 picog/mL or NT-proBNP is greater than 1000 picog/mL and is unlikely if BNP is less than 100 picog/mL or NT-proBNP is less than 300 picog/mL . Although levels vary, these cut-off values may still be useful to assess decompensation of chronic heart failure .


 

Suspected or known heart failure .  

* Two dimensional echocardiography: All patients presenting with heart failure should receive echocardiographic evaluation of left ventricular ejection fraction, left and right ventricular size and function, ventricular wall thickness, valve function, and pericardial pathology .


 

Suspected or known heart failure  

* Complete blood count

* Magnesium measurement, serum

* Serum calcium measurement

* Blood urea nitrogen measurement

* Fasting blood glucose measurement

* Liver function tests - general

* Thyroid stimulating hormone measurement

* Fasting lipid profile


 

Suspected or known heart failure  

* Urinalysis: Urinalysis should be obtained in all patients presenting with acute heart failure to detect infection and assess renal function, especially if hypotension may have occurred .


 

Suspected or known heart failure  

* Serum potassium measurement: The target level of serum potassium in heart failure patients ranges from 4.0 to 5.5 mmol/L; hypokalemia is independently associated with increased mortality .


 

Suspected or known heart failure  

* Sodium measurement, serum: In heart failure, serum sodium levels below 136 mEq/L are associated with increased risk of mortality and prolonged hospitalization .


 

Suspected or known heart failure  

* Creatinine measurement, serum: Serum creatinine should be measured and followed closely in all patients with heart failure. Creatinine levels provide management guidance as well as prognostic information .


 

Suspected or known heart failure  

* Albumin measurement, serum


 

Suspected or known acute coronary syndrome  

* Coronary angiography: Coronary angiography assesses risk and guides therapy in high-risk acute coronary syndrome patients, especially when invasive treatment is planned .


 

Differential Diagnosis  

* Acute myocardial infarction - Acute

* Pulmonary embolism - Acute

* Community acquired pneumonia - Acute

* Asthma - Acute

* Chronic obstructive pulmonary disease - Chronic

* Pulmonary hypertension - Chronic

* Obstructive sleep apnea - Chronic

* Renal failure

* Liver failure - Chronic

* Obesity - Chronic

* Physical deconditioning

* Anemia

* Hypoalbuminemia

* Deficiency of macronutrients

* Anxiety

* Depression - Chronic


 

Treatment  


 

Drug Therapy  


 

First-line therapy for fluid overload and maintenance of euvolemia  


 

FUROSEMIDE  

Adults: Initial dose 20 to 40 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum total daily dose 600 mg


 

BUMETANIDE  

Adults: Initial dose 0.5 to 1 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum daily dose 10 mg


 

TORSEMIDE  

Adults: Initial dose 10 to 20 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum daily dose 200 mg


 

Heart failure with hypertension or alternative diuretic therapy for mild volume overload, or combination therapy with loop diuretics for decreased diuretic response  


 

CHLOROTHIAZIDE  

Adults: Initial dose 250 mg to 500 mg orally once or twice daily; maximum total daily dose 1000 mg


 

CHLORTHALIDONE  

Adults: Initial dose 12.5 to 25 mg orally daily; maximum daily dose 100 mg


 

HYDROCHLOROTHIAZIDE  

Adults: Initial dose 25 mg orally daily or twice daily; maximum total daily dose 200 mg


 

METOLAZONE  

Adults: Initial dose 2.5 mg orally once daily; maximum daily dose 20 mg


 

INDAPAMIDE  

Adults: Initial dose 2.5 mg orally once daily; maximum daily dose 5 mg


 

Heart failure with reduced left ventricular ejection fraction (LVEF) or with preserved LVEF and increased cardiovascular risk  


 

CAPTOPRIL  

Adults: 6.25 mg orally 3 times daily; maximum 50 mg orally 3 times daily


 

ENALAPRIL MALEATE  

Adults: 2.5 mg orally twice daily; maximum 10 to 20 mg twice daily


 

LISINOPRIL  

Adults: 2.5 to 5 mg orally once daily; maximum 20 to 40 mg once daily


 

PERINDOPRIL ERBUMINE  

Adults: Initial dose 2 mg orally once daily; maximum 8 to 16 mg once daily


 

RAMIPRIL  

Adults: Initial dose 1.25 to 2.5 mg orally once daily; maximum 10 mg once daily


 

TRANDOLAPRIL  

Adults: Initial dose 1 mg orally once daily; maximum 4 mg once daily


 

FOSINOPRIL SODIUM  

Adults: Initial dose 5 to 10 mg orally once daily; maximum 40 mg once daily


 

QUINAPRIL HYDROCHLORIDE  

Adults: Initial dose 5 mg orally twice daily; maximum 20 mg twice daily


 

Intolerance to ACE inhibitors or in combination with ACE inhibitors for persistent symptoms  


 

CANDESARTAN CILEXETIL  

Adults: 4 to 8 mg orally once daily; maximum 32 mg once daily


 

VALSARTAN  

Adults: 20 to 40 mg orally twice daily; maximum 160 mg twice daily


 

LOSARTAN POTASSIUM  

Adults: 25 to 50 mg orally once daily; maximum 50 to 100 mg once daily


 

Clinically stable heart failure due to reduced left ventricular systolic ejection fraction  


 

BISOPROLOL FUMARATE  

Adults: 1.25 mg orally once daily; maximum 10 mg once daily


 

CARVEDILOL

Adults: Initial dose 3.125 mg orally twice daily; maximum 25 mg twice daily (50 mg twice daily for patients over 85 kg)


 

METOPROLOL SUCCINATE  

Adults (extended release tablets): Initial dose 12.5 to 25 mg orally once daily; maximum 200 mg once daily


 

Selective use for moderate to severe symptoms of HF and decreased left ventricular ejection fraction with recent decompensation, or LV dysfunction after myocardial infarction  


 

SPIRONOLACTONE  

Adults: Initial dose 12.5 to 25 mg orally once daily; maximum 25 mg once or twice daily


 

EPLERENONE  

Adults: Initial dose 25 mg orally once daily; maximum 50 mg once daily


 

Mild to moderate heart failure with decreased left ventricular ejection fraction and persistent symptoms despite standard therapies or atrial fibrillation, or severe heart failure while awaiting response to standard therapies  


 

DIGOXIN

Adults: 0.125 mg to 0.25 mg orally daily; target plasma concentration 0.5 to 1 nanogram/mL

Adults (over 70 years, lean body mass, or renal dysfunction): Initial dose 0.125 mg orally daily or every other day


 

Blacks with symptomatic heart failure with decreased left ventricular ejection fraction, and consideration for non-blacks with persistent symptoms despite standard therapies  


 

ISOSORBIDE DINITRATE / HYDRALAZINE  

Adults: Initial dose 1 tablet orally three times daily; titrate upward as tolerated to maximum 2 tablets three times daily


 

Prevention of ischemic stroke in heart failure complicated by atrial fibrillation  


 

WARFARIN SODIUM  

Adults: Initial dose not to exceed 5 mg orally daily ; adjust subsequent doses to achieve a target INR of 2.5 (range, 2 to 3)


 

Procedural Therapy  


 

Acute coronary syndrome  

* Percutaneous coronary intervention: Coronary revascularization with percutaneous coronary intervention is suitable for most high-risk patients with ST-segment elevation MI, non-ST-segment elevation MI, and unstable angina .


 

Dyssynchronous ventricular contraction  

* Implantation of biventricular cardiac pacemaker system


 

Coronary artery disease  

* Coronary artery bypass graft: CABG is the preferred revascularization strategy for most patients with significant left main coronary artery stenosis, 3-vessel coronary artery disease, and multivessel disease with treated diabetes or left ventricular dysfunction . It is appropriate in high-risk acute coronary syndrome when fibrinolysis or catheter-based treatment fails or is not indicated .


 

Severe refractory heart failure  

* Transplantation of heart: Although heart transplantation is the only established surgical treatment for refractory heart failure, the procedure is available to only a limited number of patients .


 

Non-Procedural Therapy  


 

Chronic heart failure  

* Lifestyle Modification

* Education and Counseling

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SYSTEM BASED CLASSIFICATION OF DISEASES

SYSTEM BASED CLASSIFICATION OF DISEASES

Bone and Joint Diseases

  1. Gout and Hyperurecemia
  2. Osteoarthritis
  3. Rheumatoid Arthritis
  4. Acute coronary Syndroms

Cardiovascular Diseases

  1. Arrhymias
  2. Cardiopulmanary Resuscitation
  3. Heart Failure
  4. Hypertension
  5. Hyperlipidemia
  6. Ischemic Heart Diseases
  7. Shock
  8. Stroke
  9. Venous Thromboembolism

Dermatrologic Diseases

  1. Acne
  2. Psoriasis
  3. Skin Disorders and Cutaneous Drug Eruptions

Endocrine Diseases

  1. Cirrhosis
  2. Portal Hypertension

Gastrointestinal Diseases

  1. Irritable Bowel Syndrome
  2. Constipation
  3. Diarrhea
  4. Gastroesophagal Reflux Disease
  5. Hepatitis, Viral
    1. Hepatitis A
    2. Hepatitis B
    3. Hepatitis C
  6. Nausea and Vomiting
  7. Pancreatitis
  8. Peptic Ulcer disease

Gynecologic and Obstetric Diseases

  1. Contraception
  2. Hormone therapy

Hematologic Diseases

  1. Anemia
    1. Megaloblastic Anemia

i. Megaloblastic Anemia due to Folate Deficiency

ii. Megaloblastic Anemia due to Vitamine B12 Deficiency

    1. Sickle Cell anemia
    2. Hemolytic Anemia
    3. Iron Deficiency Anemia
    4. Aplastic Anemia
    5. Iron Deficiency Anemia

Infectious Diseases

  1. Central Nervous System infections
  2. Endocarditis
  3. Fungal infections, Invasive
  4. Gastrointestinal Infection
  5. HIV / AIDS
  6. Intra-Abdominal Infection
  7. Respiratory Tract infections, Lower
  8. Respiratory Tract infections, Upper
  9. Sepsis and Septic Shock
  10. Sexually transmited Diseases (STD)
  11. Skin and soft tissue infection
  12. Tuberculosis
  13. Urinary tract infection and prostatitis

Neurologic Diseases

  1. Epilepsy
  2. Headache
    1. Migraine
    2. Cluster Headache
  3. Pain management
  4. Parkinson’s Diseases
  5. Status epilepticus

Nutritional Diseases

  1. Enteral Nutrition
  2. Obesity
  3. Parentaral Nutrition

Onchologic Diseases

  1. Breast cancer
  2. Colorectal Cancer
  3. Lung cancer
  4. Lymphomas
  5. Prostate cancer
  6. Cervical Cancer
  7. Esophageal Cancer
  8. Gastric Cancer
  9. Head and Neck Cancer
  10. Lung Cancer
  11. Ovarian Cancer
  12. Pancreatic Cancer
  13. Primary bone Cancer
  14. Primary Brain cancer
  15. Testicular Cancer
  16. Thyroid Gland Cancer
  17. Urinar Bladder cancer
  18. Uterine Cancer

Ophtalmic Diseases

  1. Glaucoma

Psychiatric Diseases

  1. Alzhimer’s Diseases
  2. Anxiety Disease
  3. Bipolar Diseases
  4. Depressive diseases
  5. Schizophrenia
  6. Sleep Diseases
  7. Substance-Related Diseases

Renal Diseases

  1. Acid base Diseases
  2. Acute renal Failure
  3. Chronic Renal Failure
  4. Drug Dosing in renal insufficiency
  5. Electrolyte Homeostasis

Respiratory Diseases

  1. Allergic Rhinitis
  2. Asthma
  3. Chronic Obstructive Pulmonary Diseases

Urologic Diseases

  1. Benign Prostatic, Hyperplasia
  2. Erectile Dysfunction
  3. Urinary Incontinence