Heart Failure: Etiology: 5 million ppl in US have HF.

Most frequent cause of hospitalization for ppl >65 300,000 deaths per year. -Common cause ischemia cardiomyopathy in Industrial countries, infection in underdeveloped countries. Risk factors: Some preventable African Men > Women 75% have HTN Diabetes (CAD) Cardiotoxic Americans age substance 45 64 2.5x than Alcohol (left white person of ventricular dysf) same age Smoking (CAD) Cocaine Chemotherapy drugs (Doxorubicin Adriamycin) Hyperlidemia Thyroid Tachycardia CAD (CAD) disorders (Afib, Hyper: Afib Supraventricular tachycardia) -Primary prevention meds Statin for lipids, ACE-I for diabetes, Beta blockers to mortality and future CV complications -2nd line prevention: Obesity control, treatment of obstructive sleep apnea, stop smoking, alcohol and bad drugs Diagnosis: Most people with CAD, valvular heart disease, longstanding HTN are asymptomatic but they can still have LV dysfunction. Symptomatic patients: dyspnea & cough fatigue, exercise intolerance, fluid retention Pulmonary congestion, edema - Dyspnea and cough misdiagnosed as bronchitis, pneumonia, asthma - BP, murmurs, fluid retention, JVD, pulmonary crackles, lower extremity edema - BNP and NTproBNP (N-terminal pro-B-type natriuretic peptide) with ventricular volume and pressure associated with overload *Older people, Renal disease, obese pts, acute MI ECG for anyone with history of heart disease, new onset or exacerbated heart failure. * Ventricular hypertrophy, Atrial abnormalities, arrhythmias, conduction issues, ischemia Echocardiography 2D with Doppler in anyone suspected of HF for LV cavity size and function, ejection fraction (normal >50%). Stress testing: for ischemia -Dipyrdamole, dobutamine, adenosine Cardiac catherization and endomyocardial biopsy when Echo cant define the severity of valvular heart disease. Rule out thyroid disease by measure TSH Lastly: CBC, serum electrolytes, BUN, Cr, chest radiography and pulmonary function tests

Treatment:

Determine functional capacity with NYHA (New York Heart Association) classification Class 1 mild: Asymptomatic LV dysfunction, normal physical activity with no symptoms such as fatigue, palpitation, SOB Class 2 mild: Fatigue, palpitation, SOB with normal physical activity Class 3 mod: SOB with minimal activity such as daily living. Clsss 4 severe: SOB at rest, unable to do physical activity without discomfort -6-minute walk test: Ask the patient to walk for 6 minutes in a straight line back and forth between 2 points
separated by 60 feet. Allow the patient to stop and rest or even sit, if necessary. At either end of the course, place chairs that can quickly be moved if the patient needs to sit. Note the total distance walked in 6 minutes, which correlates well with other measures of functional capacity.

Drugs: For left ventricular dysfunction *Early use of loop diuretics (no mortality) to relieve volume overload and end organ damage. -Combo hydralazine and isosorbide dinitrate with ACE-I (in all patients with LV dysfunction) or ARBS and Beta-blocker for African Americans. -Warfarin for AFib anticoagulation -Combo ACE-I and ARBs reduction LV size, prevent heart remodeling *monitor for hyperkalemia and renal dysfunction *Hydralazine and long acting nitrates for those who cant tolerate ACE-I or ARBS -DOES NOT decrease mortality -B-blockers used in all NYHA classes if pt is stable on ACE-I and is not volume overloaded *reduce heart failure symptoms, improve ejection fraction *carvedilol, bisoprolol, long term metoprolol -slowly titrate upward every 2 to 4 weeks to the highest therapeutic dose *watch for bradycardia hypotension, -Aldosterone antagonists for pts that stage 3 or 4 NYHA symptoms. *Eplerenone (more selective) > Spironolactone (causes gynomastia in men) decrease mortality in patients with EF <40% after acute MI *Side effects: hyperkalemia just like ACE-I (DONT COMBO THEM). Need weekly serum electrolytes for potassium. -Diuretics: no mortality, Furosemide first then 2nd line toresemide or bumetanide *Combo with low Na diet(2g/day) to control volume overloadimprove NYHA 2 -4 classification of HF. *Thiazides (use on a sliding scale) added if Furosemide along not enough *Always monitor renal function and electrolytes (potassium) -Digoxin: reserved for NYHA class 2 -4, combo with B-blocker for rate control in atrial fibrillation *Ensure good renal function to ensure good therapeutic levels -Anticoagulants (Warfarin): Thrombotic events: dilated cardiomyopathy with EF <35%, mitral stenosis, atrial fibrillation -Intracardiac device to monitor HR and rhythm to correct arrhythmia for people with LV dysfunction and EF <30% only in class 1-3, class 4 symptoms do not benefit from ICDs. *Biventricular pacemaker can improve quality of life and hospitalization

-Hospitalization for severe class 4 HF w/ dyspnea at rest, severe fatigue, volume overload (diuretic resistant), atria and ventricular arrhythmias that could worse symptoms and cause cardiac death, new ECG changes to r/o MI. Consult cardiologists when symptoms worsen despite optimum medical therapy. -Adjust inotropic drug treatment -Catheterization, ICDs, pacemakers, transplantation. -Consult pulmonogists for those with COPD or sleep apnea