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When supply < demand

Classification (NYHA) I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath) II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased Stages (American College of Cardiology / American Heart Association) A: high risk, no structural heart disease or sx B: structural heart disease, no signs or sx C: structural heart disease, prior or current sx D: refractory, specialized interventions needed Causes Causes of high output: anemia, pregnancy, hyperthyroidism, AV fistulas, wet beriberi, Pagets disease of bone, MR, AR Systolic failure: ischemic heart disease, HTN cardiomyopathy, valvular heart disease, myocarditis, EtOH, radiation, hemochromatosis, thyroid disease, DM, smoking, obesity Diastolic failure: HTN myocardial hypertrophy, AS, MS, AR, restrictive cardiomyopathy (amyloidosis, sarcoidosis, hemochromatosis) Clinical features L sided failure symptoms: dyspnea, orthopnea, PND, noctuenal cough, confusion and memory impairment, diaphoresis and cool extremities at rest, PMI displaced laterally, S3, S4, crackles/rales at lung bases, dullness to percussion and decreased tactile fremitues of lower lung fields, increased intensity of P2, narrow pulse pressure R sided failure symptoms: peripheral pitting edema, nocturia, JVD, hepatomegaly, ascites, RV heave Diagnosis CXR: cardiomegaly, Kerley B lines (These are short parallel lines at the lung periphery. These lines represent interlobular septa), interstitial markings, pleural effusion TTE: initial test of choice. EF, systolic vs diastolic ECG: nonspecific. Chamber enlargement, ischemia, past MI Nuclear ventriculography: LVEF, RVEF Cardiac catheterization: quantitiatve Stress testing: assesses dynamic responses of HR, heart rhythm, BP Lab tests: cardiac profile, CBC, BNP Framingham clinical criteria for the diagnosis for heart failure 2 major OR 1 major + 2 minor criteria Major : PND, orthopnea, elevated JVP, pulmonary rales, S3, cardiomegaly on CXR, pulmonary edema on CXR, weight loss 4.5 kg in five days in response to treatment Minor: bilateral leg edema, nocturnal cough, DOE, hepatomegaly, pleural effusion, tachycardia (120), weight loss 4.5 kg in five days Treatment Systolic o <4g Na/day, weight loss, smoking cessation, alcohol restruction, exercise, monitor weight daily o Diuretics: sx control only o Spironolactone: decreases M&M in class III and IV (RALES trial) o ACE inhibitors: decerase mortality, prolong survivial, alleviate sx (CONSENSUS, SOLVD trials) o ARBs: if ACE inhibitors cause cough

Beta blockers: decrease mortality in px with post-MI heart failure, carvedilol > metoprolol (COMET trial), decreases tissue remodeling, improves sx o Digitalis: for refractory CHF, improves sx o Hydralazine, isorbide dinitrate: improves mortality in some patients o Contraindications: metformin, thazolidinediones, NSAIDs, negative inotropes o ICD, CRT, VAD, cardiac transplant Diastolic failure o Beta blockers o Diuretics o ACE inhibitors, ARBs: unclear o Digoxin, spironolactone: contraindicated General treatment principles o Mild (Classes I to II): <4g Na/day, less physical activity, loop diuretic, ACE inhibitor o Mild to moderate (Classes II to III): loop diuretic + ACE inhibitor beta blockers o Moderate to severe (Classes III to IV): loop diuretic + ACE inhibitor digoxin spironolactone o