Day #256 -Pleural Effusion/Congestive Heart Failure

I have previously blogged about the approach to pleural effusion here.

We reviewed some general causes of:

Exudate:

• Malignancy
• Infection
  
  • Parapneumonic
  • Empyema
  • TB
  • Subdiaphragmatic abscess
    
• Inflammatory
  
  • SLE/RA/FMF
• Pulmonary Embolism
  
• Hemothorax/Chylothorax

Transudates:

• CHF
• Cirrhosis (including sympathetic)
  
• Nephrotic Syndrome
• Malnutrition
• Hypothyroidism

I have previously discussed congestive heart failure here (link to guidelines there as well).

A summary of the class I recommendations:

• Moderate salt restriction in the diet with daily weights
• Exercise testing and exercise programme
• Stop offending medications (i.e. NSAIDS, most calcium channel blockers)

• Diuretics (e.g. furosemide) as required to keep euvolemic
• ACE inhibitor such as lisinopril, enalapril, ramipril, etc. as tolerated. ARB in patients who are intolerant of ACEi due to cough
  
• Beta-blockade with beta-blocker proven to influence outcome in CHF. Start slowly, when euvolemic, with very slow titration in advanced HF (e.g. carvedilol, bisoprolol)
• Consider adding digoxin (see dosing here) to improve symptoms and decrease hospitalization.
• Consider adding spironolactone in patients with NYHA III/IV symptoms and LVEF less than 35% to ACEi or ARB if Cr less than 150 and K+ less than 5 and you can monitor potassium and renal function. Caveat publication here.
  

Assessment of revascularization and modification of the cardiac risk factors is also important.

When he is no longer NYHA IV, and he is on MAXIMAL medical therapy, and he is expected to live more than one year, he can be considered for an ICD (Ischemic Cardiomyopathy with EF less than 35%) for primary prophylaxis of arrythmogenic death.

An article discussing LV thrombi in the context of ischemic cardiomyopathy is available here.