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
- Follow them on Day 3, Day 7. Close monitoring of volume status is needed.
- Spironolactone in HEpEF (TOPCAT) NEJM 2013
- More Hyperkalemia, more AKI
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- BiDil
- Iva... (SHIFT Trial)
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- Primary prevention of SCD after MI
- Late Post-MI Trials
- MADIT (1996)
- Prior MI
- NSVT on monitoring
- LVEF (≤35 percent)
- Inducible sustained monomorphic VT during electrophysiology study (EPS) that was also inducible after administration of intravenous procainamide
- MUSTT (1999)
- Prior MI (4 days post MI to 3 yrs prior)
- Asymptomatic NSVT (at least 4 days post MI )
- EF < 40
- Inducible Sustained VT during EPS in a patient with NSVT
- No history of Sustained VT or V tach (Secondary prevention)
- MADIT2 (2002)
- Prior MI (>30 days of MI or > 3 months of CABG
- EF <30
- CABG Patch Trial (1997 NEJM)
- Severe CAD requiring surgical revascularization
- LVEF <36 percent
- Abnormal signal-averaged electrocardiogram
- No history of sustained ventricular tachyarrhythmia or syncope
- SCD HeFT (2005 NEJM)
- > 40 days post MI
- NYHA II-III,
- EF < 35
- CHF present for at least 3 mth prior to randomization with optimal medical management
- Bottom line
- SCE HeFT criteria (No need to fulfill other electrical criteria of MADIT-I due to its absence in SCD HeFT and still had benefit)
- MUSTT Trial Data still valid due to EF < 40 % as inclusion criteria
- Vs. SCD HeFT: less severe patients but high risk on further Elecrophysiological Study
- MADIT - II still valid as it was for EF < 30 % and NYHA Class I patients
- Vs. SCD HeFT: Less symptoms but higher risk by EF
- Early POST-MI
- Non-MI
CRT / ICD 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
- 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:
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 Updating... desh bandhu Nepal, Feb 6, 2016, 9:40 PM
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