Beruflich Dokumente
Kultur Dokumente
Failure
- Mini-Lecture-
Kristopher Huston MD, PGY2
Ali Ashtiani MD, PGY2
Arash Taghavi MD, PGY1
Heart Failure-Definition
“a complex clinical syndrome that can result from
any structural or functional cardiac disorder that
impairs the ability of the ventricle to fill with or
eject blood.”
HFrEF or Systolic HF
EF<40%
Aim of majority of therapies
ACCF/AHA Stages
A = No structural heart disease, risk factors for HF
B = Structural heart disease, no HF symptoms
C = Structural heart disease, with prior or current HF symptoms
D = Refractory HF requiring frequent interventions
The Major Causes
CAD (~70% of cases)
Hypertension
Valvular disease
Diabetes Mellitus
cardiomyopathy and progression of CAD
Less Common Causes
Myocarditis
Tachyarrhythmia
Congenital Heart Defects (HOCM)
Cardiomyopathy
Stress-induced
Toxins: Drugs (Cocaine, Methamphetamine, Chemotherapy, Radiation),
Alcohol
Pulmonary: OSA
Rheumatologic: Sarcoidosis, SLE
Infiltrative: Hemochromatosis, Amyloidosis
Chronic Disease
DM, HIV, Thyroid Disorders
How patients present
Clinical Symptoms
Dyspnea (100% sensitivity)
PND
Swelling/Dependent edema
Fatigue, Weight gain
Risk Factors:
Obesity, smoking, physical inactivity, lower
socioeconomic status factors.
Physical Exam
Pulmonary: Respiratory distress, Rales
Cardiac: Bradycardia/Tachycardia, Displaced
PMI, JVD, S3 gallop rhythm.
Abdomen: Ascites, Hepato-jugular Reflux
Extremities: cool, dependent edema, cyanosis,
pallor
Diagnosis
EKG (check for MI, PE, Arrhythmia, LVH)
CXR
Pulmonary venous congestion, interstitial edema
Cardiomegaly, pleural effusions
Labs
CBC, CMP, Troponin, ABG, Thyroid function tests
MORTALITY REDUCTION!
ACE-I/ARB, Beta-Blocker, Aldosterone Antagonist, Hydralazine plus
Isosorbide Nitrate
Management
ACE-Inhibitors
Decrease MORTALITY and hospitalizations
Initial baseline treatment in all patients with heart
failure, regardless of NYHA class
Enalapril Initial: 2.5 mg PO BID (Target:10-20 mg
BID)
Captopril Initial: 6.25 mg PO TID (Target: 50-100mg
TID)
Lisinopril Initial: 5 mg PO Daily (Target: 20- 40 mg
Daily)
**ARB’s have comparable mortality reduction, used
when ACE-I not tolerated**
Management
Beta-Blockers
Relative Contraindications
Symptomatic Hypotension or pressor requirement
HR < 60, 2nd or 3rd degree AV block, PAD with ischemia
Management
Aldosterone receptor antagonist
(Spironolactone)
NYHA Class II-IV, LVEF of 35% or less
Reduce morbidity and mortality
Monitor renal function, BMP
Creatinine 2.5mg/dl or less
Potassium 5.0 mEq/L or less
Diuretics
improve the symptoms and exercise tolerance
Anticoagulation
In the setting of Afib and additional cardio-embolic
risk factors
Management
Fish Oil
Conflicting evidence for this, however, not harmful
Consider 1g daily supplementation with OTC
Statins
No evidence for benefit in CHF
CCB
Peripheral vasodilators (Amlodipine, Felodipine) safe
to use in HF
No benefit, and possible harm, with Diltiazem or
Verapamil like drugs
Management
ICD
Primary Prevention
Prior MI (<40 days) and EF <30%
NYHA Class II, EF <35%
Have been on maximal medical therapy > 3 months
Syncope with structural heart disease and sustained VT/VF on EP
study
Cardiac Resynchronization
GRADE 1A Indication
1. SR, QRS > 150 ms, LBBB, EF < 35%, NYHA > III with optimal
therapy
GRADE 1B Indication
1. SR, QRS > 150 ms, LBBB, EF < 30%, NYHA > II with ICD placement
Nonpharmalogic
Treatment
Multidisciplinary Approach
Patient education and instruction
Appropriate hospital follow-up (within 7 days)
Management of comorbidities
Decreases hospitalizations and quality of life
Nishimura, RA et al. “2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease:
executive summary: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines.” Circulation. 2014 Jun 10;129(23):2440-92. doi: 10.1161/CIR.0000000000000029. Epub
2014 Mar 3.
MKSAP Question 1
A 74-year-old man is evaluated in the emergency department for a 7-day history of
progressive exertional dyspnea associated with a dry cough, increasing orthopnea
(from two to four pillows), and inability to buckle his belt. He has a 20-year history of
hypertension treated with diltiazem.
On physical exam, blood pressure is 162/86 mmHg, pulse rate is irregularly irregular
at 84/min, and respiration rate is 18/min. Estimated central venous pressure is 14 cm
H2O. Cardiac examination reveals an irregularly irregular rhythm and an S4. Bibasilar
crackles are heard on auscultation of the lungs. His liver is enlarged 2 cm below the
costal margin. His extremity examination reveals bilateral pitting edema.
Serum electrolyte levels and kidney function tests are normal. Serum B-type
natriuretic peptide level is 2472 pg/mL. ECG shows atrial fibrillation. Echocardiogram
shows a left ventricular ejection fraction of 60%, septal wall thickness of 1.5 cm, and
posterior wall thickness of 1.4 cm. Chest radiograph shows hazy bilateral infiltrates.
Answer: C Furosemide
This patient should be admitted to the hospital and given IV furosemide. His
presentation is characteristic for heart failure with preserved ejection fraction
(HFpEF). He has volume overload manifested by increasing abdominal girth,
increased exertional dyspnea, and progressive orthopnea. His left ventricular
ejection fraction is normal, but he has mild left ventricular hypertrophy and a
long history of hypertension. Additionally, he has a markedly elevated B-type
natriuretic peptide level. The etiology of his acute exacerbation into heart failure
is most likely acute atrial fibrillation, but because he is already on diltiazem and
has a normal heart rate, he may have been in atrial fibrillation for some time
and not noticed it.
Key point: Patients with HFpEF are often volume sensitive, and
careful use of diuretics to maintain euvolemia is important.
Question 2
A 56-year-old man with heart failure is admitted to the hospital with a 2-week history
of increasing exertional dyspnea and fatigue. He also has type 2 diabetes mellitus.
Medications are metformin, lisinopril, carvedilol, furosemide, metolazone, and
digoxin.
On physical examination, blood pressure is 88/60 mmHg, pulse rate is 95/min, and
respiration rate is 20/min. He is somewhat confused and inattentive. Jugular venous
distension is present to the angle of the jaw while sitting. Cardiac examination
reveals an S3. There are bibasilar crackles on pulmonary examination. He has edema
to the mid-thighs. Extremities appear mottled and are cool to the touch.
Serum creatinine level is 3.1 mg/dL; baseline value was 1.1 mg/dL. Serum sodium
level is 133 mEq/L. ECG shows no evidence of ischemia. Chest radiograph shows
cardiomegaly and vascular congestion.
This was her first hospitalization in 3 years, although she has skipped her diuretics
during other business trips without apparent ill effect. She had an implantable
cardioverter-defibrillator placed 3 years ago. An echocardiogram 1 month ago showed a
left ventricular ejection fraction of 15% (stable for the past 6 years). Medications are
captopril, metoprolol succinate, digoxin, furosemide, and spironolactone.
On physical examination, blood pressure is 110/72 mmHg, pulse rate is 56/min, and
respiration rate is 14/min. She has no jugular venous distension and no S3. Lungs are
clear, and she has no edema. ECG shows sinus rhythm, a QRS interval of 90 ms, and Q
waves in V1 through V4. There are no changes compared with the admission ECG
recorded 3 years ago.
On physical examination, blood pressure is 94/60 mmHg and pulse rate is 70/min.
Estimated central venous pressure is 5 cm H2O. There is no edema.
Serum electrolyte levels and kidney function are normal. ECG shows normal sinus
rhythm, a PR interval of 210 ms, QRS duration of 160 ms, and a new left bundle
branch block. His left ventricular ejection fraction 3 months ago was 25%.
This patient with symptomatic heart failure and a reduced left ventricular
ejection fraction with evidence of significant conduction system disease
should undergo placement of a biventricular pacemaker (cardiac
resynchronization therapy [CRT]). He has progressive heart failure symptoms
while on appropriate medical therapy and has New York Heart Association
functional class III symptoms. With his EF less than 35% and left bundle
branch block (LBBB), he is a candidate for a biventricular pacemaker, which
has been demonstrated to reduce mortality and symptoms in patients with
NYHA functional class III and IV heart failure by improving cardiac
hemodynamics.
The patient is fairly symptomatic but has not yet had optimal therapy, as
he has an indication for CRT and has not yet received it. Left ventricular
assist devices (LVAD) are reserved for patients with end-stage refractory
heart failure as a bridge to heart transplantation or as destination therapy
in selected patients who are not candidates for transplantation. However,
prior to being considered for either an LVAD or heart transplantation, a
patient must be on optimal medical therapy.
On physical examination, blood pressure is 134/72 mmHg and pulse rate is 66/min. BMI
is 35. She has no jugular venous distension. Cardiac examination reveals a grade 1/6
holosystolic murmur but is otherwise normal. There is no lower extremity edema. The
remainder of her examination is unremarkable.
Laboratory studies are significant for normal electrolyte levels and a serum creatinine
level of 1.5 mg/dL. ECG shows normal sinus rhythm, a QRS duration of 110 ms, and
nonspecific ST-T wave changes. Echocardiogram shows a left ventricular ejection
fraction of 38% and trace mitral regurgitation.