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How to Save the Failing Heart

Learn about the diagnosis, treatment, and management of heart failure to effectively save failing hearts. Understand the risk factors, symptoms, diagnostic tests, and medications involved. Available in text language.

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How to Save the Failing Heart

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  1. How to Save the Failing Heart Subir Shah Assistant Professor in Cardiology

  2. Definition • Intern answer: Someone short of breath with fluid all over • Guideline answer: A Disease process that results from any structural or functional impairment of ventricular filling or ejection of blood

  3. Distinction of Kinds of HF • HFpEF= Heart Failure with a preserved ejection fraction. EF >50% • HFrEF= Heart Failure with a reduced ejection fraction. EF<40% • What about 41%-49%

  4. Classification

  5. Diagnosing it • Intern answer: CXR, BNP, BMP, Echo, ask the nurse what they think, call my senior resident • Guideline answer: There is no single diagnostic test for HF because it is largely a clinical diagnosis based on a careful history and physical exam • So…..

  6. It’s all on you...

  7. Stepwise Approach • Who gets it • History • Physical • Labs • Therapy • Breathe…. • Documentation • Sign it out and get the heck out of the hospital

  8. Who gets it: Epidemiology • Pts above age 40 have a 20% chance of developing HF • so you have a 20% chance of making the right diagnosis • African American men have the highest prevalence • Easier: Pt’s with a HF dx and a recent admission of CHF • CHF has a 25% readmission rate nationwide in the first 30 days

  9. Who gets it: HF risk factors • HTN (50% of pts admitted with HF have BP>140/90 • DM • Atherosclerotic Disease • Metabolic Syndrome • 3 of the following (abdominal adiposity, hypertriglyceridemia, low HDL, HTN, DM) • OSA • Medication noncompliance or Decreased Effect

  10. Subgroups of HF • Pts with ACS • Pts with Accelerated HTN • Pts with Acute decompensated HF • Pts with Shock • Pts with acutely worsening right HF • Pts after surgery

  11. Common Factors that precipitate Acute Decompensated HF • Non adherence to meds, sodium (<2 grams), or fluid restriction (<1.5-2 Liters) 1L=32 oz • Acute Myocardial Ischemia • Uncorrected HTN • Recent addition of negative inotropes (verapamil, diltiazem, Beta Blockers) • PE • Initiation of drugs that increase salt retention • Steroids, NSAIDS, TZDS • Excessive alcohol or drug use • Concurrent infections • Endocrine abnormalities (hyper,hypothyroid, DM)

  12. Picture to know!!!

  13. Types of Shock

  14. How to Diagnose it.. All about the HISTORY!!! • LETS FIGURE THESE OUT AS A GROUP 

  15. History • Anorexia, early satiety, weight loss • GI sx common in CHF • Rapid weight gain (suggests volume overload) • Palpitations, syncope, AICD shocks • Could be indicative of A fib or Vtach • Peripheral edema ascites • PND, orthopnea • Hx prior hospitalizations or frequent hospitalizations • Diet (high sodium diet) • Adherence to medications

  16. Physical • Obesity or cardiac cachexia • Blood pressure (HTN or hypotension in HF) • Width of pulse pressure would make u consider decreased cardiac output • JVP at rest and following abdominal compression • Most useful finding on PE to identify congestion • Extra heart sounds (S3 assoc with adverse prognosis in HFrEF) • Hepatomegaly and ascites • Peripheral edema • Temperature of lower extremities (cool lower extremities mean decreased cardiac output)

  17. Labs/Tests • BNP (Class Ia) to help establish dx of AECHF • Class IIB level C to guide therapy • Troponin(increase is assoc with worse prognosis) • CXR (Class I C) – to assess heart size and pulmonary congestion • EKG (view arrhythmias and chamber size) • Echo, RHC, and LHC

  18. Framingham Criteria

  19. BNP elevation causes • CARDIAC • CHF • LVH • ACS • Pericardial dz • Valvular dz • A fib • Cardioversion • Myocarditis • NON-CARDIAC • Advancing Age • Anemia • Pulmonary HTN • Severe PNA • Critical Illness • Bacterial Sepsis • Severe Burns • Chemotherapy

  20. Diuretics • Lasix • Initial daily dose: 20 to 40 mg qd or bid • Maximum daily dose: 600 mg • Duration of action 6-8 hrs • Bumex • Initial Daily dose: 0.5mg -1 mg qday or bid • Maximum daily dose: 10 mg • Duration of action: 4-6 hours • Metolazoneand Diuril

  21. Risks of Diuretics • Electrolyte and Fluid Depletion • Hypotension • Azotemia • Senior yelling at you

  22. Intravenous Inotropic Agents • Adrenergic Agonists:  CO and HR • Dopamine… initial dose 5-10 mcg/kg/min • Dobutamine… initial dose 2.5-5 mcg/kg/min • PDE Inhibitors:  CO and HR • Milrinone 0.125-.75 mcg/kg/min

  23. What about the maintenance meds? • Class 1 Indications • Pts on GDMT can be kept on it in acute exacerbations if thermodynamically stable • Starting a BB is recommended AFTER optimization of volume status and successful discontinuation of Intravenous diuretics, vasodilators, and inotropic agents. • BB should be started at low dose and only in stable pts. Caution when a pt was on inotropes

  24. Documentation • Take credit IN THE CHART • Describe Reasoning for treating the way you treated and describe if they responded • Proper Term: Acute on Chronic systolic/diastolic Heart failure • HFrEF and HFpEF is ALLOWED

  25. Initial Follow-Up • Actually follow up and see the patient • Recheck vitals • Strict I’s and O’s- may need catheter • Place them on the RIGHT amt of Oxygen • Bipap if necessary • Code status discussion • Sign it out

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