Congestive Heart Failure

Today, in addition to piloting another format to morning report, we discussed congestive heart failure. Management issues surrounding associated acute renal failure and atrial fibrillation were also reviewed. Here is a brief summary:

ARF

This can make management difficult. When the renal failure is secondary to poor perfusion pressure, this sometimes improves with diuresis. ACE/ARBs are vital to the management of CHF and should be continued whenever possible.

Atrial Fibrillation

This is a classic "chicken or the egg" scenario in that did the AFib push the patient into failure, or did the "atrial stretch" from fluid overload cause the patient to go into Afib? In any case, diuresis is paramount. If needed, rate controlling agents (Digoxin, Amiodarone, intravenous magnesium) can all be used to slow the patient down, but all will be ineffective without diuresis.

In both scenarios above, a trial of BiPaP can go a long way in stabilizing the patient (decreases afterload, increases preload and increases CO) while you are awaiting the effects of diuresis.

Here is a recent review on CHF from NEJM. Also, here is an interesting article on using intravenous iron therapy for iron deficient patients in heart failure.