Hypotension

Low blood pressure
Orthostatic hypotension – a decrease in systolic BP of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg when going from lying to sitting or sitting to standing.
Significant cause of syncope and falls in elderly patients

Causes

A decrease in systolic BP of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg when going from lying to sitting or sitting to standing.
If associated with a heart rate increase of more than 15 beats per minute the problem is probably low blood volume.

Treat underlying cause ie. give fluids for fluid depletion, check BP medications

CHF is the inability of the heart to pump enough blood to meet the needs of the body.
Typically this involves fluid overload/retention, decreased cardiac contractility and decreased cardiac output.

Congenital heart disease
Heart valve problems
Severe anemia
Acute Exacerbations
Holidays often lead to
- excessive salt intake
- excessive fluid intake
- excessive alcohol
- excessive physical activity
Arrhythmias
Pulmonary emboli
Systolic dysfunction – cardiac contractility is decreased
Post myocardial infarction
Coronary artery disease
Chronic alcohol abuse
Myocarditis
Diastolic dysfunction – abnormal filling of the ventricles
Chronic HTN
LV hypertrophy
Diabetes

Exertional dyspnea (How many blocks / flights of stairs can you go before resting?)
Worse disease has resting dyspnea
Paroxysmal nocturnal dyspnea (How many pillows do you sleep on?)
Cough (non productive)

Cyanosis (is he blue?)
Dyspnea
Blood pressure may be low, normal or high
-Pulse
- Tachycardia is one way to bring up cardiac output
- Weak
- Thready
Pulsus alternans – alternating strong and weak beats
Cheyne-Stokes breathing
Jugular Venous Distention (JVD)
- Patient sitting at 45 degrees
- Jugular vein pulsation higher than 4 cms above the sternal angle is considered to be elevated venous pressure
Displaced apical impulse (It should be on the midclavicular line in the 5th intercostal space)
Dullness to percussion in the bases of the lungs
Heart sounds
- Diminished first heart sound
- S3 gallop may be present
- Fourth heart sound (S4) may be present
- Murmurs may indicate possible causes
Breath sounds
- Rales – fluid build up
- Wheezing
Hepatomegaly
Hepatojugular reflex – patient sitting at 45 degree angle. Pressure is applied to the abdomen for about a minute and if the neck vein height increases by 3 cm the test is positive.
Lower extremity edema

Chest X-ray
- Cardiomegaly
- Pleural effusion – ground glass appearance. Fluid buildup in the pleural space
- Kerley B lines – These are short parallel lines at the lung periphery near the bases.
- Peribronchial cuffing
  - Interstitial fluid builds around the bronchi
  - When seen on end you can see the circle.
- Batwing or Butterfly shadow – enlarged hila and alveolar edema
- Water bottle or boot shaped heart
ECG
- Arrhythmia
- MI
- LV hypertrophy
- Pericardial effusion
Echo
- Asses ejection fraction
- Assess ventricular function
- Asses valves
  -Catheterization
- Asses valves
- Asses coronary artery disease
Beta natriuretic peptide (BNP)
- Elevated BNP is a good indicator of CHF however it may not be as specific in patients who are old or have COPD
Troponins
BUN
CBC – severe anemia is a possible cause of CHF
BMP – electrolytes are usually normal
Thyroid panel

Control underlying cause if possible
- Arrhythmia
- HTN
- Hyperthyroid
- etc.
Behavior modifications
Exercise
Low sodium diet
Medications
Diuretics
- Thiazide or loop diuretic with an ACEI
- Beta blockers
- Inotropic agents
  - Digitalis
Surgical
- Coronary revascularization
- Heart transplant

You may have to say no to some really good things.