Congestive Heart Failure Examination

General: Patient’s level of comfort, orthopnea, ability to speak

Signs of poor perfusion (forward failure)

  • Decreased mentation (decreased LOC)
  • Cold/clammy skin
  • Pallor or acrocyanosis
  • Urine output
  • Vitals – RR (rhythm), HR (rhythm) – likely tachy, BP (assess CO) – likely decreased

JVP assessment

  • Look between the heads of the SCM
  • Complex waveform – A wave coincident with S1, v wave with S2
  • Decreases with respiration (if no change or increases = Kussmaul)
  • Not palpable
  • Can be obliterated, fills from above
  • Hepatojugular reflex – gentle pressure of RUQ, JVP rises – will remain elevated (increase central blood volume, decrease RV compliance)
  • Changes with posture



 

Cardiac apex

  • Note position and character of beat (sustained, devaiated)
  • Normally size of a quarter, medial to mid-clavicular line and at or superior to the 5th intercostals space

Hepatomegaly

  • Palpate RUQ for liver – indicative of RHF
  • May be pulsatile

Peripheral edema exam

  • Over tibial tuberosities and sacrum
  • Note degree of pitting

Auscultation

  • Listen for S3 (vol overload), S4 (atrial kick into stiff ventricle) or murmurs
    • MR – mitral annular dilatation from dilated heart
  • Listen for crackles, wheezes, or decreased air entry in chest

Triggers
MI, arrhythmias, anemia (GI bleed), high output states (hypothyroid), mitral insufficiency, CM, pulmonary edema (show right sided heart strain), medication change, diet change

Diastolic dysfunction: EF normal, longstanding HTN leading to LVH, S4
Systolic dysfunction: EF decreased, Hx of MI, cardiomegaly, S3
*** Note greatest sensitivity and specificity with physical, EKG and CXR in combination

Etiology

  • ACS
  • Valvular
  • HTN
  • CM

Acute Treatment

  • Monitor
  • O2 PRN
  • Daily AM weights
  • Ins/outs
  • Saline lock IV
  • Low sodium diet
  • Medications which cause fluid retention (rosiglitazone for DM)
  • LASIX
  • LASIX (IV if SOB, PO if peripheral edema)
  • Morphine – wenodilation offloads heart, symptomatic relief, small dose only
  • Nitro – reduce preload
  • Oxygen – nasal prongs, mask, consider CPAP, intubation/ventilation reduces heart work by 20%
  • Positioning – pressor support for short term stabilization, PA catheter monitoring
  • Question: why?

Investigations

  • EKG: rapid AFib, heart lock, ischemia/infarct
  • CXR: Vascular redistribution, KB lines, Interstitial alveolar edema
  • Echo: EF, regional wall motion abnormalities (ischemia), valve function, diastology

Medications

  • ACE inhibition
  • Beta blocker
  • Counter aldosterone: Spironolactone
  • Digoxin
  • Euvolemia
  • Follow-up closely (weights, BP, lytes, Na+ restriction)

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