Heart attack and heart failure share many of the same risk factors and underlying health conditions. Learn about the many differences between heart…. There are different types of heart failure, each with distinct causes and symptoms. Learn about how left- and right-sided heart failure are similar….
Underlying health conditions, family history, and certain lifestyle choices may increase your risk of heart disease. Read on to learn the risk factors…. A doctor diagnoses heart failure based on symptoms, a physical exam, and diagnostic tests. Then, they can suggest treatment that's right for your…. Diastolic heart failure is a serious heart condition. Learn about the symptoms, causes, treatment options, and outlook.
Edema is swelling that occurs from fluid retention. Read more on what causes it, when to seek emergency medical help, and how to treat it. Health Conditions Discover Plan Connect. Medically reviewed by Dr. Payal Kohli, M. Heart failure and edema Types of edema Types of heart failure Treatments Takeaway Edema is the clinical term for swelling caused by fluid retention.
Why does heart failure cause edema? What are the different types of edema? What are the different types of heart failure? What are the current treatment options for edema?
The standard of care has been shotgun therapy, namely treating patients for both CHF and an acute pulmonary process such as asthma, with both diuretics and beta agonists. Mueller found a reduction in hospital length of stay of three days when BNP levels were utilized.
However, this study assumed an average length of stay of 11 days. In addition, although the time to initiation of therapy was reduced in this study from 90 to 60 minutes, the general practice in the US is immediate initiation of shotgun therapy. In the primary care setting, Wright identified patients with heart failure and revaluated them with or without the Pro-BNP result.
BNP is available as a point-of-care test, with results available within 15 minutes. However, other conditions that also elevate right filling pressures such as pulmonary embolus, primary pulmonary hypertension, end stage renal failure, cirrhosis and hormone replacement therapy may also cause elevated BNP levels in this range.
Other serum laboratory values may identify prerenal azotemia or elevated alanine aminotransferase ALT , aspartate aminotransferase AST , or bilirubin, suggestive of a congestive hepatopathy. Mild azotemia, decreased erythrocyte sedimentation rate ESR , and proteinuria are observed in early and mild-to-moderate disease.
Increased creatinine, hyperbilirubinemia, and dilutional hyponatremia are observed in severe cases. Cardiac enzymes and other serum markers for ischemia or infarction may be useful as well. Pleural effusions may be present bilaterally or, if they are unilateral, are more commonly observed on the right. Pulmonary edema is observed as perihilar infiltrates often in the classic butterfly pattern reflecting a PCWP greater than 25mmHg.
Several limitations exist in the use of chest X-rays when attempting to diagnose CHF. Classic radiographic progression often is not found, and as much as a hour radiographic lag from onset of symptoms may occur. In addition, radiographic findings frequently persist for several days despite clinical recovery.
Emergency transthoracic echocardiography ECHO may help identify regional wall motion abnormalities as well as globally depressed or myopathic left ventricular function. ECHO may help identify cardiac tamponade, pericardial constriction, and pulmonary embolus. ECHO also is useful in identifying valvular heart disease, such as mitral or aortic stenosis or regurgitation. Electrocardiogram ECG is a non-specific tool but may be useful in diagnosing concomitant cardiac ischemia, prior myocardial infarction MI , cardiac dysrhythmias, chronic hypertension, and other causes of left ventricular hypertrophy.
No defined role exists for invasive monitoring devices such as central venous placement CVP lines. Time-consuming placement of pulmonary artery catheters has not been shown to prolong survival, even in the coronary care unit and, thus far, has not been well studied in the ED setting.
Cardiac catheterization may be necessary for a complete evaluation, treatment and assessment of prognosis. In patients refractory to medical therapy or with evidence of cardiogenic shock, cardiac catheterization, angioplasty, coronary bypass, or intra-aortic balloon pump IABP may be helpful.
Cardiac monitoring and continuous pulse oximetry must also be utilized, and intravenous IV access obtained. To reduce venous return, the head of the bed should be elevated. Patients may be most comfortable in a sitting position with their legs dangling over the side of the bed, which allows for reduced venous return and decreased preload. Therapy generally starts with nitrates and diuretics if patients are hemodynamically stable.
Many other treatment modalities may play some role in acute management. If possible, the underlying cause should be treated as well. This is particularly true for patients with known diastolic dysfunction who respond best to reductions in blood pressure rather than to diuretics, nitrates, and inotropic agents. Contributing factors must be eliminated where possible, and fluid and sodium restricted.
Recent data comparing nasal CPAP therapy with facemask ventilation therapy has demonstrated a decreased need for intubation rates when these modalities are used.
BiPAP and CPAP are contraindicated in the presence of acute facial trauma, the absence of an intact airway, and in patients with an altered mental status or who are uncooperative. These goals may need to be modified for some patients. Use of diuretics, nitrates, analgesics, and inotropic agents are indicated for the treatment of CHF and pulmonary edema. Calcium channel blockers, such as nifedipine and nondihydropyridines, increase mortality and increase incidence of recurrent CHF with chronic use.
Conflicting evidence currently exists in favor as well as against the use of calcium channel blockers in the acute setting - at this time is limited to acute use in patients with diastolic dysfunction and heart failure, a condition not easily determined in the emergency department ED. First-line therapy generally includes a loop diuretic such as furosemide, which will inhibit sodium chloride reabsorption in the ascending loop of Henle.
Loop diuretics should be administere IV, since this allows for both superior potency and higher peak concentration despite increased incidence of side-effects, particularly ototoxicity. Higher doses and more rapid redosing may be appropriate for the patient in severe distress. Metolazone and chlorothiazide have been used as adjunctive therapy in patients initially refractory to furosemide. Nitrates reduce myocardial oxygen demand by lowering preload and afterload. Nitoglycerin is particularly useful in the patient who presents with acute pulmonary edema with a systolic blood pressure of at least mmHg.
However, oral nitrates, due to delayed absorption, have little role in the acute presentations of CHF. Morphine IV is an excellent adjunct in acute therapy. In addition to being both an anxiolytic and an analgesic, its most important effect is venodilation, which reduces preload. Morphine also causes arterial dilatation, which reduces systemic vascular resistance SVR and increases cardiac output. Narcan can also reverse the effects of morphine.
However, some evidence indicates that morphine use in acute pulmonary edema may increase the intubation rate. Angiotensin converting enzyme ACE inhibitors, such as SL captopril or IV enalapril, may rapidly reverse hemodynamic instability and symptoms, possibly avoiding an otherwise imminent intubation. Haude compared 25mg of SL captopril with 0.
Annane gave 1mg of IV enalapril to 20 patients presenting with acute class III and class IV CHF over two hours and demonstrated rapid hemodynamic improvement with no significant adverse effects on cardiac output or hepatosplanchnic measurements. In: Harrison's Principles of Internal Medicine. New York, N. Accessed Aug. McKean SC, et al, eds. In: Principles and Practice of Hospital Medicine.
Trayes KP, et al. Edema: Diagnosis and management. American Family Physician. Papadakis MA, et al, eds. Common symptoms. Sterns R, et al. Clinical manifestations and diagnosis of edema in adults. General principles of the treatment of edema in adults. Mayo Clinic Press Check out these best-sellers and special offers on books and newsletters from Mayo Clinic.
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