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Systolic Dysfunction
Coronary Artery Disease
Idiopathic dilated cardiomyopathy (DCM)
50% idiopathic (at least 25% familial)
9 % mycoarditis (viral)
Ischemic heart disease, perpartum, hypertension,
HIV, connective tissue disease, substance abuse,
doxorubicin
Hypertension
Valvular Heart Disease
Diastolic Dysfunction
Hypertension
Coronary artery disease
Hypertrophic obstructive cardiomyopathy (HCM)
Restrictive cardiomyopathy
Clinical Presentation of Heart Failure
BNP
With chronic 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.
Chest X-ray in Heart Failure
Cardiomegaly
Cephalization of the pulmonary
vessels
Kerley B-lines
Pleural effusions
Cardiomegaly
Pulmonary vessel congestion
Pulmonary Edema due to Heart Failure
Kerley B lines
Cardiac Testing in Heart Failure
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
Further Cardiac Testing in Heart Failure
Exercise Testing
Should be part of initial evaluation of all patients
with CHF.
Coronary arteriography
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, in whom
cardiac anatomy is not known, and in patients with
known or suspected coronary artery disease who do
not have angina.
Measure cardiac output, degree of left ventricular
dysfunction, and left ventricular end-diastolic
pressure.
Further testing in Heart Failure
Endomyocardial biopsy
Not frequently used
Really only useful in cases such as viral-
induced cardiomyopathy
Classification of Heart Failure
ACC/AHA Guidelines
Stage A High risk of HF, 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
Chronic Treatment of Systolic Heart
Failure
1. Loop diuretics
2. ACE inhibitor (or ARB if not
tolerated)
3. Beta blockers
4. Digoxin
5. Hydralazine, Nitrate
6. Potassium sparing diuretcs
Diuretics
Loop diuretics
Furosemide, buteminide
For Fluid control, and to help relieve
symptoms
Potassium-sparing diuretics
Spironolactone, eplerenone
Help enhance diuresis
Maintain potassium
Lisinopril 5 mg po QDaily
Dosing:
Hydralazine
Started at 25 mg po TID, titrated up to 100
mg po TID
Isosorbide dinitrate
Started at 40 mg po TID/QID
NSAIDS
Can cause worsening of preexisting HF
Thiazolidinediones
Include rosiglitazone (Avandia), 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
Implantable Cardioverter-Defibrillators
for HF
Sustained ventricular
tachycardia is associated with
sudden cardiac death in HF.
About one-third of mortality in
HF is due to sudden cardiac
death.
Patients with ischemic or
nonischemic cardiomyopathy,
NYHA class II to III HF, and
LVEF 35% have a significant
survival benefit from an
implantable cardioverter-
defibrillator (ICD) for the
primary prevention of SCD.
Management of Refractory Heart
Failure
Inotropic drugs:
Dobutamine, dopamine, milrinone,
nitroprusside, 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. (normal is 20 mL/kg per min. or more)
is relative indication, while a VO2max < 10
mL/kg per min is a stronger indication.
Acute Decompensated Heart Failure
Causes:
Acute MI
Rupture of chordae tendinae/acute mitral
valve insufficiency
Volume Overload
Transfusions, IV fluids
Non-compliance with diuretics, diet (high
salt intake)
Worsening valvular defect
Aortic stenosis
Decompensated Heart Failure
Symptoms
Severe dyspnea
Cough
Clinical Findings
Tachypnea
Tachycardia
Hypertension/Hypotension
Crackles on lung exam
Increased JVD
S3, S4 or new murmur
Labs/Studies in Acute Decompensated
Heart Failure
Chemistry, CBC
EKG
Chest X-ray
May consider cardiac enzymes
2D-Echo
Decompensated Heart Failure
Treatment
Strict Is and Os, daily weights
Oxygen, mechanical ventilation if
needed
Loop diuretics (Lasix!)
Morphine
Vasodilator therapy (nitroglycerin)
Nesiritide (BNP) can help in acute
setting, for short term therapy
Case # 1
A 65-year old male with a history of
hypertension, DM, CAD s/p MI and three-
vessel CABG in 2002, presents with
worsening dyspnea on exertion. He
states that he occassionally has a dry
cough, but denies any recent chest pain,
fevers, N/V. Patient states that he usually
can get up a flight of stairs if he stops
half-way, but over the last several days,
has not been able to climb them at all.
Case # 1 (cont.)
PMH:
CAD MI and CABG in 2002
Hypertension
Diabetes Mellitus
Hypothyroidism
Allergies:
NKDA
Outpatient Meds:
Synthroid
Metformin
Norvasc
Case # 1 (cont.)
Physical Exam:
97.6, 168/72, 99, 28, 93% on RA
Gen: Alert and oriented x 3, breathing
rapidly
CV: RRR, no murmurs; mod. JVD
Resp: Crackles throughout lungs
Abd.: soft, nontender, NABS
Ext: 2 + pitting edema bilaterally
Case # 1 (cont.)
Labs:
Hgb: 13.5 Trop. I 0.01
WBC: 8 CPK: 120
Platelets: 240
Sodium: 139
Potassium: 3.8
BUN: 18
Cr: 0.8
Case # 1
Case # 1