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CONGESTIVE HEART FAILURE

ACUTE PULMONARY EDEMA : Dyspnea, orthopnea, rales,
and wheezing. X-ray ; perihilar congestion, hypoxemia.

CARDIOGENIC SHOCK ; Hypotension; abnormal renal,

hepatic and CNS function due to decreased perfusion and
lactic acidosis.

Cardiomegaly, decreased VEF/abnormal ventricular wall

motion, elevated PAWP, low cardiac output.

May have a previously known cause such as valvular heart

disease/cardiomyopathy but may present also as a result
of ischemia or secondary to severe systemic hypertension.
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 Pneumonia, ARDS, fluid overload, COPD, asthma.

Pericardial effusion,

Cor pulmonale, pulmonary arteriopathy/PPH. Pulmonary

emboli

Volume depletion, sepsis, pulmonary embolism

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1. Systolic dysfunction without hypotension.

Digoxin, diuretics, ACEI

Metolazone/HCT
Nesiritide ( a recombinant human BNP)
Spironolactone
Nitrate/hydralazine
Ultrafiltration
Mechanical ventilation

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2. Severe CHF with hypotension (Cardiogenic shock)

BP < 90 mmHg :
Intravenous dopamine (titrated)
Intravenous dobutamine/milrinone

BP = 90-100/>100 mmHg:
Nitroprusside-drips (titrated)
Intravenous Diuretics (Furosemide)
Intravenous NTG
Nesiritide (with caution)
IABP (Intra aortic balloon pumping)
PTCA/CABG/transplantation

After optimizing hemodynamic variables:

ACEI, ARB, BB, hydralazine
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 3. CHF with severe systemic hypertension

Initial therapy : Control of BP

Intravenous nitroprusside/ NTG
Intravenous enalaprilat

Continued treatment
BB/ CCB (with caution)

4. High output or volume overload CHF

Treatment should be directed at the cause of high

cardiac output (eg, anemia, B1 defficiency, sepsis,
hyperthyroidism
Volume overload state (renal failure, excessive Na intake)
---- ultrafiltration 6
 5. CHF with diastolic dysfunction
Beta adrenergic blockade
Attention : aggressive diuretic therapy is
counterproductive

6. Isolated right heart failure with pulmonary

hypertension
Diuretics
Oxygen therapy
Digoxin
NO/intravenous prostacyclin

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 CARDIAC TAMPONADE
Evidence of elevated pericardial pressure manifested
as elevated systemic venous pressure .
Decreased cardiac output and hypotension;
evidence of decreased peripheral perfusion.

Echocardiography : large pericardial effusion;

RV early diastolic collapse, RA diastolic collapse,
LA diastolic collapse; etc.

Right heart catheterization: Equalization of RA pressure,

LA pressure, PCWP, and Ventricular EDP.

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 Initial treatment / Medical therapy :
Rapid intravenous fluid loading and dopamine
Avoidance diuretics or vasodilators.

Priority of therapy (percuteneous or surgical therapy) :

Drainage (Tapping)--- needle pericardiocentesis
Surgical drainage : subxiphoid pericardioectomy,
pericardial window, and subtotal pericardiectomy
Percutaneous balloon pericardiotomy

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 HYPERTENSIVE CRISIS AND
MALIGNANT HYPERTENSION
Hypertensive crisis : Systemic BP > 240/130 mmHg
without symptoms, or elevated BP with chest pain,
headache, or heart failure. May have intracranial
hemorrhage, aortic dissection, pulmonary edema,
myocardial infarction, or unstable angina.
Hypertensive crisis traditionally has been classified as:
Emergency and
Urgency

Malignant hypertension : Severe hypertension

associated with encephalopathy, renal failure, or
papiledema. 10
 (Rapid decompensation of vital organ function)

In general, diastolic BP >120 mmHg

Malignant htn with papiledema
Hypertensive encephalopathy
Severe htn in the setting of stroke, subarachnoid
hemorrhage, head trauma
Acute aortic dissection
Htn and LV failure
Htn and myocardial ischemia/infarction
Htn after CABG operation
Pheocromocytoma crisis
Food and drug interactions with MAO inhibitors
Cocain abuse
Rebound htn after sudden drug withdrawal (clonidine)
Idiosyncratic drug reactiopns ( atropin)
Eclampsia 11
 (Marked elevations of BP without acute or progressive target organ )

Diastolic BP > 120 mmHg, but no symptoms and sign of

tissue damage
Severe htn, accelerated htn
Pheochrtomocytoma crisis
Food and drug interactions with MAO inhibitors
Rebound htn after sudden drug withdrawal
Idiosyncratic drug reactions
Preoperative htn
Postoperative htn

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 The goal therapy : immediate, controlled reduction in BP.
BP initially be reduced by no more than 25% of MAP
over minutes to hours. (exception : aortic dissection, LV
failure, and Pulmonary edema

Medical therapy :
Nitroprusside (drug of choice), Glyceryl trinitrate,
Labetalol ( contraindicated for patients with CHF,
bradycardia, heart block, reactive airway disease),
Nicardipine, Enalapril, Phentolamine, Hydralazine,
Fenoldopam.

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 Captopril (Fastest-acting oral ACEI)
caution : marked renal insufficiency/ volume depletion

Clonidine

Labetalol

Nifedipine (Sublingual nifedipine should not be used

in the treatment of patients with htn).

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 EVALUATION OF CHEST PAIN
IN THE EMERGENCY DEPARTMENT
Chest pain : substernal pressure, squeezing, or sensation
of suffocation. Some patients describe aching, burning,
tightness. The pain radiate to the shoulder, neck, jaw,
left or right arm and the fingertips. Occasionally the pain
predominantly epigastric or intrascapular.

Dyspnea may also be the only major presenting symptom

in about 10% patients wit AMI (atypical presentation)

Other atypical : fatigue, syncope, altered sensorium, stroke,

nausea, vomiting and lethargy

Atypical presentations: 15
More common in elderly, diabetics, women
 Cardiac causes:
ACS Costochondritis :
Syndrome X Tietzes syndrome
Pericarditis
MVP
Aortic stenosis
Hypertrophic cardiomypathy Neurologic causes :
Cervical spondylosis
Other compression neuropathy
Aortic causes:
Herpes
Aortic dissection
Penetrating ulcer of aorta

Pulmonary causes :
Embolism Psychological causes :
Panic disorder
Anxiety
Gastrointestinal causes: Depression
Esophageal spasm, reflux Hysteria
Gastritis, gastric ulcer
Cholecystitis 16
 ECG

Biochemical markers : CK/CKMB, Myoglobin, Troponins

BNP, hsCRP

Imaging studies : Echocardiography, Radionuclide

perfusion imaging (Thalium/Technetium)

Early exercise stress testing (Treadmill)

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 Depend on the causes of the chest pain

ACS
Pericarditis
Aortic dissection
Pulmonary embolism

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