CONGESTIVE HEART FAILURE

LEARNING OBJECTIVES :

KNOWLEDGE - Students should be able to describe:

  1. Be able to describe and define the terms preload, contractility and afterload and how these are affected in the heart with systolic dysfunction.
  2. Be able to describe and define compensatory mechanisms of heart failure: cardiac remodeling, activation of endogenous neurohormonal systems, cytokine systems, adrenergic nervous system, renin angiotensin-aldosterone system, endothelin, tumor necrosis factor, and vasopeptides.
  3. Interpret neck vein findings for jugular venous distention and abdominal jugular reflux.
  4. Identify and translate auscultatory findings of the heart including rate, rhythm, S3/S4 and murmurs in a patient with heart failure (overlap with Cardiac Clinical Correlation).
  5. Compare the differing etiologies and signs of left-sided vs right-sided heart failure.
  6. Be able to define and describe the types of processes that cause systolic vs. diastolic dysfunction and how treatment is different.
  7. Be able to define and describe the importance of age, gender and ethnicity on the prevalence and prognosis of HF.
  8. Identify and explain the factors leading to symptomatic exacerbation of HF, including ischemia, arrhythmias, valvular disease, anemia, hypertension, thyroid disorders, non-compliance with medications and dietary restrictions, and use of nonsteroidal anti-inflammatory drugs.
  9. Interpret B-type natriuretic peptide results.
  10. Be able to define and describe the staging system for heart failure:
    1. Stage A: high risk for HF but no structural heart disease is present
    2. Stage B: structural heart disease is present but never any symptoms
    3. Stage C: past or current symptoms associated with structural heart disease
    4. Stage D: end-stage disease with requirements for specialized treatment
  11. Assign a risk and prognosis to patients in NYHA Class I< II< III< IV without vasodilator or beta blocker therapy.
  12. Be able to define and describe physiological basis and scientific evidence supporting each type of treatment, intervention or procedure commonly used in the management of patients who present with HF.
  13. Compare and contrast ACE inhibitors, angiotensin receptor blockers, aldosterone inhibitors.
  14. Outline a treatment plan for patients with compensated or decompensated CHF including pharmacologic management: diuretics, digoxin, vasodilators and beta blockers assign a risk reduction.

 

PATIENT CARE SKILLS:

  1. Take a history and accurately assign a NYHA class in order to discuss prognosis and develop a treatment plan with your patient.
  2. Perform the key steps of the PE to detect the findings due to either right or left- sided failure.
  3. Critical in the evaluation of patients are:
  4. Develop a treatment plan for the stabilization and maintenance of patients with systolic heart failure.

 

ATTITUDES AND PROFESSIONALISM:

  1. Patients with congestive heart failure as a diagnosis have a heightened awareness of the potential for dying.   The word “failure” must be appreciated explained to the patient and their tests addressed as an individual.
  2. The physician needs to be aware of the risk of therapy and develop a partnership with the patient the care plan.   Patients that are informed have insight into the treatment plan will be more compliant.   Their rights must be respected.  

 

REFERENCES:

  1. Jessup M. Brozena S.   Heart Failure    NEJM 348(20):2007-2018, May 15, 2003.

  2. Badgett R., Lucey C., Mulrow C.   The Rational Clinical Examination.   Can the Clinical Examination Diagnose Left-Sided Heart Failure in Adults?   JAMA 277(21):1712-1719, June 4, 1997

  3. Heart Failure, Harrison's On-Line:   http://harrisons.accessmedicine.com/server-java/Arknoid/amed/harrisons/co_chapters/ch232/ch232_p01.html