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Heart Failure
LV Dysfunction causes
Decreased cardiac output
Right-Ventricular Failure
Systolic Dysfunction
Hypertension
Valvular Heart Disease
Diastolic Dysfunction
Hypertension
Coronary artery disease
Hypertrophic obstructive cardiomyopathy (HCM)
Restrictive cardiomyopathy
S3 gallop
CBC
Iron studies
ANA
Viral studies
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.
Cardiomegaly
Cephalization of the pulmonary
vessels
Kerley B-lines
Pleural effusions
Cardiomegaly
Kerley B lines
Electrocardiogram:
May
Echocardiogram:
Left
Exercise Testing
Coronary arteriography
Endomyocardial biopsy
Not frequently used
Really only useful in cases such as viralinduced cardiomyopathy
I symptoms of HF only at
levels that would limit normal
individuals.
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
ACC/AHA Guidelines
Stage
Lifestyle modification
Thyroid dysfunction
Infections
Uncontrolled diabetes
Hypertension
Lower salt intake
Alcohol cessation
Medication compliance
Maximize medications
Order of Therapy
1.
2.
3.
4.
5.
6.
Loop diuretics
ACE inhibitor (or ARB if not
tolerated)
Beta blockers
Digoxin
Hydralazine, Nitrate
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
Shown to improve survival in CHF
ACE Inhibitor
Dosing:
Hydralazine
Isosorbide
dinitrate
Started at 40 mg po TID/QID
Digoxin
NSAIDS
Thiazolidinediones
Include rosiglitazone (Avandia), and
pioglitazone (Actos)
Cause fluid retention that can exacerbate HF
Metformin
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 cardioverterdefibrillator (ICD) for the
primary prevention of SCD.
Inotropic drugs:
Cardiac Transplantation
Causes:
Acute MI
Volume Overload
Aortic stenosis
Symptoms
Severe dyspnea
Cough
Clinical Findings
Tachypnea
Tachycardia
Hypertension/Hypotension
Crackles on lung exam
Increased JVD
S3, S4 or new murmur
Chemistry, CBC
EKG
Chest X-ray
May consider cardiac enzymes
2D-Echo
Treatment
Strict
Case # 1
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,
Case # 1 (cont.)
Labs:
Hgb: 13.5
WBC: 8
Platelets: 240
Sodium: 139
Potassium: 3.8
BUN: 18
Cr: 0.8
Trop. I 0.01
CPK: 120
Case # 1
Case # 1
Case # 2
Case # 2
Case # 2
(A)
(B)
(C)
(D)
(E)