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Results from any structural or functional abnormality that impairs the ability of the ventricle to eject blood (Systolic Heart Failure) or to fill with blood (Diastolic Heart Failure).
•Approximately 4.9 million people have CHF •More than 550,000 cases detected annually •Account for 5 to 10% of all hospitalizations •250,000 deaths per year related to CHF •Five year mortality as high as 60% in men & 45% in women •Median survival is 3.5 years for men and 5.4 years women for
High-Output Heart Failure Right-Ventricular Failure . Low-Output Heart Failure Systolic Heart Failure: Decreased cardiac output Decreased Left ventricular ejection fraction Diastolic Heart Failure: Elevated Left and Right ventricular end-diastolic pressures May have normal LVEF Seen with peripheral shunting. anemia Often have normal cardiac output Seen with pulmonary hypertension. carcinoid. hyperthryoidism. large RV infarctions. beri-beri. low-systemic vascular resistance.
HIV. hypertension. perpartum. Systolic Dysfunction Coronary Artery Disease Idiopathic dilated cardiomyopathy (DCM) 50% idiopathic (at least 25% familial) 9 % mycoarditis (viral) Ischemic heart disease. substance abuse. doxorubicin Hypertension Valvular Heart Disease Diastolic Dysfunction Hypertension Coronary artery disease Hypertrophic obstructive cardiomyopathy (HCM) Restrictive cardiomyopathy . connective tissue disease.
Due to excess fluid accumulation: Dyspnea (most sensitive symptom) Edema Hepatic congestion Ascites Orthopnea. Paroxysmal Nocturnal Dyspnea (PND) Due to reduction in cardiac ouput: Fatigue (especially with exertion( Weakness .
diaphoresis and peripheral vasoconstriction Cool. but highly specific Have sinus tachycardia. S3 gallop Low sensitivity. pale. cyanotic extremities Crackles or decreased breath sounds at bases (effusions) on lung exam Elevated jugular venous pressure Lower extremity edema Ascites Hepatomegaly Splenomegaly Displaced PMI Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement> .
To evaluate for possible lupus If viral mycocarditis suspected Viral studies . and hypothyroidism can results in HF. CBC Since anemia can exacerbate heart failure before starting high dose diuretics Serum electrolytes and creatinine Fasting Blood glucose Thyroid function tests Iron studies ANA To evaluate for possible diabetes mellitus Since thyrotoxicosis can result in A. Fib. To screen for hereditary hemochromatosis as cause of heart failure.
atrial mycotes secrete increase amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures Usually is > 400 pg/mL in patients with dyspnea due to heart failure. . BNP With chronic heart failure.
Cardiomegaly Cephalization of the pulmonary vessels Kerley B-lines Pleural effusions .
Electrocardiogram: May show specific cause of heart failure: Ischemic heart disease Dilated cardiomyopathy: first degree AV block. LBBB. Left anterior fascicular block Amyloidosis: pseudo-infarction pattern Idiopathic dilated cardiomyopathy: LVH Echocardiogram: Left ventricular ejection fraction Structural/valvular abnormalities .
Should be performed in patients presenting with heart failure who have angina or significant ischemia Reasonable in patients who have chest pain that may or may not be cardiac in origin. and left ventricular end-diastolic pressure. and in patients with known or suspected coronary artery disease who do not have angina. Measure cardiac output. in whom cardiac anatomy is not known. Coronary arteriography . Exercise Testing Should be part of initial evaluation of all patients with CHF. degree of left ventricular dysfunction.
Endomyocardial biopsy Not frequently used Really only useful in cases such as viral-induced cardiomyopathy .
5 kg in five days Cardiomegaly on chest xray Pulmonary edema on chest x-ray Weight loss ≥4. Major Minor Bilateral leg edema Paroxysmal nocturnal dyspnea Nocturnal cough Orthopnea Dyspnea on ordinary exertion Hepatomegaly Elevated jugular venous Pleural effusion pressure Tachycardia (heart rate ≥120 Pulmonary rales beats/min) Third heart sound Weight loss ≥4. heart failure .5 kg in five days in response to Diagnosis: treatment of presumed 2 major or 1 major and 2 minor criteria cannot be attributed to another medical condition.
Class II – symptoms of HF with ordinary exertion Class III – symptoms of HF on less than ordinary exertion Class IV – symptoms of HF at rest . New York Heart Association (NYHA) Class I – symptoms of HF only at levels that would limit normal individuals.
without structural heart disease or symptoms Stage B – Heart disease with asymptomatic left ventricular dysfunction Stage C – Prior or current symptoms of HF Stage D – Advanced heart disease and severely symptomatic or refractory HF . ACC/AHA Guidelines Stage A – High risk of HF.
Correction of systemic factors Thyroid dysfunction Infections Uncontrolled diabetes Hypertension Lifestyle modification Lower salt intake Alcohol cessation Medication compliance Maximize medications Discontinue drugs that may contribute to heart failure (NSAIDS. calcium channel blockers) . antiarrhythmics.
3. 4. Loop diuretics ACE inhibitor (or ARB if not tolerated) Beta blockers Digoxin Hydralazine. 2.1. Nitrate Potassium sparing diuretcs . 6. 5.
and to help relieve symptoms Potassium-sparing diuretics Spironolactone. Loop diuretics Furosemide. buteminide For Fluid control. eplerenone Help enhance diuresis Maintain potassium Shown to improve survival in CHF .
25 mg po TID Lisinopril – 5 mg po QDaily If cannot tolerate. Begin therapy low and titrate up as possible: Enalapril – 2. Improve survival in patients with all severities of heart failure. may try ARB .5 mg po BID Captopril – 6.
Contraindicated: Heart rate <60 bpm Symptomatic bradycardia Signs of peripheral hypoperfusion COPD. metoprolol. Certain Beta blockers (carvedilol. bisoprolol) can improve overall and event free survival in NYHA class II to III HF. probably in class IV.24 sec. asthma PR interval > 0. 2nd or 3rd degree block .
Dosing: Hydralazine Started at 25 mg po TID. lower rates of hospitalization. . and improvement in quality of life. titrated up to 100 mg po TID Isosorbide dinitrate Started at 40 mg po TID/QID Decreased mortality.
dyspnea. exercise intolerance Shown to significantly reduce hospitalization for heart failure. . Given to patients with HF to control symptoms such as fatigue. but no benefit in terms of overall mortality.
Some studies have shown a possible benefit specifically in HF with statin therapy Improved LVEF Reversal of ventricular remodeling Reduction in inflammatory markers (CRP. TNF-alphaII) . IL-6. Statin therapy is recommended in CHF for the secondary prevention of cardiovascular disease.
and pioglitazone (Actos) Cause fluid retention that can exacerbate HF Metformin People with HF who take it are at increased risk of potentially lethic lactic acidosis . NSAIDS Can cause worsening of preexisting HF Thiazolidinediones Include rosiglitazone (Avandia).
NYHA class II to III HF. About one-third of mortality in HF is due to sudden cardiac death. and LVEF ≤ 35% have a significant survival benefit from an implantable cardioverter-defibrillator (ICD) for the primary prevention of SCD. Sustained ventricular tachycardia is associated with sudden cardiac death in HF. . Patients with ischemic or nonischemic cardiomyopathy.
or more) is relative indication. . while a VO2max < 10 mL/kg per min is a stronger indication. nitroglycerin Mechanical circulatory support: Intraaortic balloon pump Left ventricular assist device (LVAD) Cardiac Transplantation A history of multiple hospitalizations for HF Escalation in the intensity of medical therapy A reproducable peak oxygen consumption with maximal exercise (VO2max) of < 14 mL/kg per min. Inotropic drugs: Dobutamine. dopamine. milrinone. (normal is 20 mL/kg per min. nitroprusside.
Characterized by the transudation of excess fluid into the lungs secondary to an increase in left atrial and subsequently pulmonary venous and pulmonary capillary pressures. . Cardiogenic pulmonary edema is a common and sometimes fatal cause of acute respiratory distress.
IV fluids Non-compliance with diuretics. Causes: Acute MI Rupture of chordae tendinae/acute mitral valve insufficiency Volume Overload Transfusions. diet (high salt intake) Worsening valvular defect Aortic stenosis .
S4 or new murmur . Symptoms Severe dyspnea Cough Clinical Findings Tachypnea Tachycardia Hypertension/Hypotension Crackles on lung exam Increased JVD S3.
Chemistry. CBC EKG Chest X-ray May consider cardiac enzymes 2D-Echo .
mechanical ventilation if needed Loop diuretics Morphine Vasodilator therapy (nitroglycerin) (BNP) – can help in acute setting. daily weights Oxygen. for short term therapy . Treatment Strict I’s and O’s.
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