OiOESTlVe Heart Failure Amd Arrhythmias

Symptoms and signs of CHF » Fatigue

» Orthopnea (seen in left, ventricular failure; patient sleeps on more than one pillow) «Paroxysmal nocturnal dyspnea, (left ventricular failure) a Peripheral edema (right ventricular failure)

■ Jugular venous distention (right ventricular failure)

■ Peripheral edema (right ventricular failure)

e Pulmonary congestion (rales; seen in left ventricular failure)

a Hepatomegaly/ascites (right ventricular failure)

ts Chest x- ray abnormalities (cardiomegaly [seen in left or right: ventricular failure], Kerley B lines, pulmonary vascular congestion, and bilateral pleural effusions are seen in left ventricular failure)

Treatment: sodium restriction, angiotensin-converting enzyme inhibitor (first-line agents; proved to reduce mortality in CHF), beta blockers (also reduce mortality), diuretics, digoxin (not in hypertrophic obstructive cardiomyopathy or atrioventricular conduction blocks; usually reserved for moderate io severe CHF with low ejection fraction), vasodilators (arterial and venous), and I V sympathomimetics (dobutamine, dopamine, amrinone) for inpatients with severe CHE

Important points:

1. Many factors can precipitate exacerbation of CHF in a previously stable cardiac patient. Noncompliance, myocardial iniarction, hypertension, arrhythmias, iniections/iever, pul monary embolism, anemia, thyrotoxicosis, and myocarditis are common causes.

2. Cor pulmonale is right ventricular enlargement, hypertrophy, or failure due to primary lung disease. Common causes are c hronic obstructive pulmonary disease and pulmonary embolism. In a young woman (20-40) with no other medical history or risk factors, think of primary pulmonary hypertension, and treat with calcium channel blockers while awaiting heart-lung transplant. Sleep apnea also may cause cor pulmonale (an obese snorer who is sleepy during the day).

3. Patients with cor pulmonale have tachypnea, cyanosis, clubbing, parasternal heave, loud P2, and right- sided S4 in addition to signs and symptoms of pulmonary disease.

4. Restrictive cardiomyopathy usually results from amyloidosis, sarcoidosis, hemochromatosis or myocardial fibroelastosis (ventricular biopsy abnormal in all of these conditions). On the other hand, constrictive pericarditis can be simply treated by removing the pericardium (pericardial knock, calcification of pericardium, normal ventricular biopsy).

5. Dilated cardiomyopathy commonly is due. to alcohol, myocarditis, or doxorubicin.

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