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Heart Failure

Heart Failure: Address Following 4 points in Assessment of Heart Failure 

Type 
    • HFrEF / HFpEF / HFpEF, borderline / HFpEF, improved; 
    • Ischemic vs Non-Ischemic
    • Lowest EF …Last EF
Volume Status
    • Compensated / Decompensated 
    • Acute / Acute on Chronic / Chronic 
      • Classification of Acute Decompensation
Functional Status (NYHA I/II/III/IV) 
Worsening 2/2 – ACS/Uncontrolled HTN / Noncompliant to Salt or Med (with reasons for non-compliant) – Rx
 
Treatment:
    • Goal of Acute HF management: No benefit seen on long term survival 
    • Diuretics (2-3 X their home dose, initially IV)
    •  
       
    • ACEI or BB (if already on it, and reasonably good BP) or Aldo ants (see reference)
    • No need to put in Foley cath in floor; daily in/out and weight MUST
 
Goal of Chronic HF management: GDMT (Guideline directed medical therapy)
  • Relieving Congestion
    •  
  • Slowing progression
    • BB
      • Carvedilol Dose_response trial (MOCHA) 1996 Circulation
      • Reverse remodeling is time dependent. 
      • Not much diff between Met S vs Carvedilol. Carv CR is not to be used. 
    • ACEI
    • Aldosterone Antagonist
      • Eplerenone (EMPHASIS-HF; NYHA 2) 
        • EF < 30 or 31-35 with wide QRS
        • Effective at high risk subgroups
          • >75
          • DM
          • eGFR <60
          • SBP <123 
        • Follow them on Day 3, Day 7. Close monitoring of volume status is needed. 
      • Spironolactone in HEpEF (TOPCAT) NEJM 2013
        • More Hyperkalemia, more AKI 
        •  
           
    • BiDil
    • Iva... (SHIFT Trial)
    •  
  • CRT in heart failure 
    • Who benefits with CRT? 
      • Symptomatic patients: NYHA III - IV 
        • Who are symptomatic patients?
          • Typically Low EF : < 35 %
          • Who have ventricular desynchronization: QRS > 150; QRS > 120 could also be considered as desynchronized ventricle 
    • Typically these patients also qualify for ICD criteria's
  • SCD and its prevention in heart failure: please see http://www.imreference.com/cardiology/misc-cardiology
HFpEF
  • TOPCAT (spirinolactone)
  • Control BP
  • Releif of volume overload
  • Coronoary revascularization (IIc)
 
Prevention of HF
  • Post-MI: ACEI or ARB, BB, Statin
  • BNP vs NT-proBNP
    • Normal BNP: around 30
  • BNP Causes of elevation
    • Cardiac Cause
    • Non-cardiac cause: Advancing age, Anemia, Renal Failure, Hypoxia, Toxic-Metabolic insults, Endocrinopathies, Critical Illness, Bacterial Sepsis, Severe burns, Cahectic Syndromes
  • 2013 Guideline has included BNP as a tool to include and exclude diagnosis. It also helps in prognosis.
    • >30 % fall prior to discharge is associated with good prognosis
    • > 30 % rise in outpatient set up in concern for worsening HF 
  • Refe: 
    • Yancy et al, Circ 2013, 
    • Moe et al Can J Cardio 2015
  • Newer biomarker
    • Galectin-3 (IIb) : released by activated macrophages
    • ST-2 (IIb) : soluble ligands of IL-33 which counteracts cardioprotective effects 
    • Does not get affected by age, body habitus, renal function
    • BNP itself may be a marker of preclinical HF diseases 
Non-pharmacoligical 
  • OSA evaluation and CPAP use
  • Exercise
  • Salt restriction
 
Reference:      

2013 ACCF/AHA Guideline for the Management of Heart Failure: DEFINITIONS of HFpEF and HFrEF

 
Heart Failure References
 
Other case based readings on Heart Failure:
 
 
DILATED CARDIOMYOPATHY
 
  • Etiology NEJM 2000:
    • Idiopathic – 50 percent
    • Myocarditis – 9 percent (direct damage, or autoimmune mediated)
      • parvovirus B19, HHV 6, coxsackievirus, influenza virus, adenovirus, echovirus, CMV, HIV
      • Chagas Disease (LV apical aneurysms is pathognomonic)
      • Lyme Disease (mostly conduction abnormalities, at times DCM)e
    • Ischemic heart disease – 7 percent
    • Infiltrative disease (and Storage Disease)– 5 percent  Case 11-2011
      • Amyloidosis (Associated proteinuria, neuropathy, Low ECG Voltage, Normal SPEP dose not rule out, Endomyocardial Biopsy with Congo Red is useful)
      • Fabry's Disease: (a/k/a angiokeratoma corporis diffusum,  X-linked recessive disease,  deficiency of the lysosomal enzyme α-galactosidase results in accumulation of glycosphingolipids in the skin, kidneys, and heart)  
    • Peripartum cardiomyopathy – 4 percent
    • Hypertension – 4 percent
    • Human immunodeficiency virus (HIV) infection – 4 percent
      • drug toxicity, secondary infection (CMV, EBV, Coxackie), HIV virus itself, or autoimmune process
    • Connective tissue disease – 3 percent
    • Substance abuse – 3 percent
    • Doxorubicin – 1 percent
    • Other – 10 percent
      • Transient left ventricular apical ballooning or takotsubo cardiomyopathy, or broken heart syndrome (has been reported in increasing number in last few years)
      • Sarcoidosis
      • ESRDs
      • Celiac Disease
      • OSA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Landmark Trials for Congestive Heart Failure







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