Congestive Heart Failure and Pulmonary Edema
Follow-Up
Follow-up
Further Inpatient Care:- Depending on the response to initial ED therapy, disposition decisions vary.
- With few exceptions, patients presenting with acute symptoms of CHF or pulmonary edema require hospital admission. Many patients, however, who respond rapidly to early therapy may require only standard hospital ward admission with telemetry monitoring if ischemic etiologies are being considered.
- Some criteria for discharge from the ED would include gradual onset of shortness of breath, rapid response to therapy, oxygen saturation greater than 90%, and acute coronary syndromes and MI unlikely as the precipitating event.
- Those patients who require intubation or remain with significant respiratory, hemodynamic, and/or cardiovascular compromise often require ICU or CCU admission.
- If left ventricular function has not been well established previously, obtain either a multigated nuclear imaging (MUGA) scan or an echocardiogram, which enable assessment of valvular function and wall motion abnormalities as well as ejection fraction.
- In patients refractory to medical therapy or with evidence of cardiogenic shock, cardiac catheterization, angioplasty, coronary bypass, or intraaortic balloon pump (IABP) may be helpful.
Further Outpatient Care:
- Center outpatient care around patient education with specific instructions regarding dietary restrictions and compliance with medical therapy.
In/Out Patient Meds:
- ACE inhibitors are indicated in patients with ejection fractions of 35% or less.
- Digoxin also may be helpful in patients with ejection fractions of 35% or less.
- Diuretics, such as furosemide, may be helpful regardless of ejection fraction.
- Beta-blockers appear to be cardioprotective in patients with depressed left ventricular function. The US carvedilol heart failure study group demonstrated a two-thirds decrease in mortality in patients taking carvedilol with left ventricular ejection fractions of 35%. Beta-blockers are indicated as therapy for patients with diastolic dysfunction or for patients with coronary insufficiency.
- Calcium channel blockers, such as nifedipine and nondihydropyridines, increase mortality rates and incidence of recurrent CHF with chronic use in patients with depressed LV function. Amlodipine is the exception to this rule. Calcium channel blockers are useful in patients with diastolic dysfunction and heart failure.
Transfer:
- Consider transfer for unstable patients being evaluated in a center without access to cardiac catheterization or IABP. These patients may include the following:
- Those who are refractory to medical therapy
- Those in cardiogenic shock
- Those with significant aortic stenosis or other valvular abnormalities possibly requiring surgical intervention or valvuloplasty
Deterrence/Prevention:
- Emphasize patient education with intense instruction regarding compliance with dietary restrictions and medical therapy.
- Emphasize close monitoring of blood pressure, particularly in patients with diastolic dysfunction.
- Patient should modify diet as follows:
- Sodium restriction (initially 4 g/d)
- Weight reduction (if appropriate)
- Appropriate fluid restriction
- Patient should modify activity as follows:
- During severe stage, bed rest with elevation of head of bed and anti-embolism stockings to help control leg edema
- Gradual increase in activity with walking to help increase strength
Complications:
- Acute MI
- Cardiogenic shock
- Arrhythmias (most commonly atrial fibrillation)
- Ventricular arrhythmias, such as ventricular tachycardia, often are seen in patients with significantly depressed left ventricular function.
- Electrolyte disturbances
- Mesenteric insufficiency
- Protein enteropathy
- Digitalis intoxication
Prognosis:
- Based on data from 4606 patients hospitalized with CHF between 1992-1993, the total in-hospital mortality rate was 19%, with 30% of deaths occurring from noncardiac causes. These patients, however, were noted to have had suboptimal use of proven efficacious therapy, compared with those who survived hospitalizations, particularly among women and the elderly. Thirty-year data from the Framingham heart study demonstrated a median survival of 3.2 years for males and 5.4 years for females.
- Results of initial treatment are usually good, regardless of cause.
- Long-term prognosis is variable. Mortality rates range from 10% in patients with mild symptoms to 50% with advanced, progressive symptoms.
Patient Education:
- Provide instructions to patients discharged home to return to the ED for recurrence or changes in severity of symptoms.
- Provide specific instructions to patients discharged regarding dietary restrictions and compliance with medical therapy.
- Require patients to promptly follow up with their primary care physician or cardiologist.
- Advise patients that printed information is available from the following organizations:
- American Heart Association, 1615 Stemmons Freeway, Dallas, TX 75207, (214) 748-7212
- American College of Cardiology, 9111 Old Georgetown Rd, Bethesda, MD 20814, (301) 897-5400
- For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education article Congestive Heart Failure.
Miscellaneous
Medical/Legal Pitfalls:- Failure to recognize and initiate early management of a patient presenting with signs and symptoms of CHF and pulmonary edema is a pitfall because therapy must begin with the ABCs, and early treatment should include nitrates and diuretics, if hemodynamics are stable.
- Failure to obtain an ECG early is a pitfall because this may be useful in diagnosing dysrhythmias, concomitant cardiac ischemia, or prior MI; early ECG also is helpful in differentiating CHF from other etiologies. Remember, the most common cause of CHF is coronary artery disease.
- Failure to consider use of both CPAP and BiPAP early in therapy as a means to decrease need for intubation and improve acute respiratory status
- Failure to consider and evaluate for diseases with similar presentations
- Failure to educate patients concerning changes or noncompliance with medical therapy and dietary restrictions to help prevent further recurrence
- Discharging patients who may have had acute MI as a cause of CHF
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Synonyms And Related Keywords
CHF, pulmonary edema, ventricular failure, forward ventricular failure, backward ventricular failure, systolic dysfunction, diastolic dysfunction, dyspnea, beta natriuretic peptide, BNP, orthopnea, paroxysmal nocturnal dyspnea, PND, cardiomyopathy, valvular heart disease, hypertension, peripheral edema, jugular venous distention, tachycardia, coronary artery disease, congenital heart disease, myocarditis, infectious endocarditis, pulmonary embolus, hyperthyroidism
