CHF - Drug Management

BNP

Acute Decompensated HF

CHF - non-drug Mx

Additional notes (from the other “Heart Failure” page)

• Cheyne–Stokes breathing can be seen in advanced CHF and can be a poor prognostic sign.
• Chronic HF mortality benefit: ACEi, beta blockers (carvedilol, metoprolol, bisoprolol), aldosterone antagonists.
• Loop diuretics improve symptoms from congestion but do not improve long-term mortality.
• Acute pulmonary oedema approach: look for a trigger (arrhythmia, ischaemia, infection, non-adherence, meds) and treat preload/afterload appropriately.
• Diastolic HF: focus on rate control to improve filling; avoid excessive diuresis/vasodilation.

Heart Failure

Cheyne-Stokes breathing (CSB)

Cheyne-Stokes breathing (CSB), which is commonly seen in patients with advanced congestive heart failure (CHF). CSB is a cyclic breathing pattern in which apnea is followed by gradually increasing then decreasing tidal volumes until the next apneic period. Patients with CHF have chronic hyperventilation with hypocapnia, which induces apnea during sleep when the partial pressure of carbon dioxide (PaCO2 falls below a certain level ("apneic threshold"). Apnea causes excessive buildup of C02 (hypercapnia); this stimulates a ventilatory response that overshoots (hyperpnea), causing the PaCO2, to again fall below the apneic threshold. This cycle of apnea and hyperventilation is further perpetuated by prolonged circulation time between the lungs and brain, which results in a discrepancy between PaC02 levels sensed by central chemoreceptors and PaC02 concentration in alveoli. CSB is also seen in neurologic disease (eg, stroke, brain tumors, traumatic brain injury) and is frequently a poor prognostic sign.

Management

In Heart failure, aldosterone is also produced in the myocardium and acts locally, leading to fibrosis and myocardial hypertrophy. The resulting cardiac remodeling worsens LV dysfunction