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Heart Failure
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S/S of Heart Failure ● Cardinal Symptoms: ● Fatigue ● Shortness of breath ● Signs ● Edema ● Rales
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Systolic Dysfunction ● Characterized by: ● Decreased myocardial contractility ● Reduction in LVEF – <40% ● LV enlargement ● Fluid backup leads to pulmonary congestion ● Dilated Cardiomyopathy
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Diastolic Dysfunction ● Characterized by: ● Abnormal LV filling ● Elevated filling pressures ● Ventricular hypertrophy ● LVEF > 40%
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New York Heart Association Classification
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American Heart Association
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Treatment for Chronic HF ● Modest exercise for class I-III – Euvolemic pt: walking or riding stationary bike reduces symptoms. – Increased exercise capacity and improved quality and duration of life. – Weight loss ● Diet – Restriction of Sodium ● 2-3 g daily – Fluid restriction unnecessary unless pt is hyponatremic
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Diuretic ● Furosemide (Lasix) – 20-40 mg Qday or BID ● Torsemide (Demadex) – 100-200 mg Qday or BID ● Bumetanide (Bumex) – 0.5-1 mg Qday or BID ● HCTZ – 25 mg Daily ● Metolazone (Zaroxolyn) – 5-20 mg Qday or BID
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ACEI ● Lisinopril – 2.5-5 mg Qday ● Captopril – 6.25 mg TID ● Enalapril – 2.5 mg BID ● Ramipril – 1.25-2.5 mg BID ● Trandolapril – 0.5 mg Qday
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ARB ● Valsartan (Diovan) – 40 mg BID ● Candesartan – 4 mg Qday – Double the dose Q2 wk max 32 mg ● Irbesartan (Avapro) – 75 mg Qday ● Losartan (Cozaar) – 12.5 mg -25 mg Qday
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Beta Blocker ● Carvedilol (Coreg) – 3.125 mg BID ● Bisoprolol (Zebeta) – 1.25 mg Qday ● Metoprolol Succinate CR (Toprol-XL) – 1.25-25 mg Qday
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Additional Therapies ● Spironolactone (Aldactone) – 12.5-25 mg Qday ● Eplerenone (Inspra) – 25 mg Qday ● Hydrolazine/Isosorbide Dinitrate (BiDil) – 10-25mg/10 mg Qday ● Digoxin – 0.125 mg Qday
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Device Therapy ● Cardiac Resynchronization – Depressed EF and symptomatic HF, QRS duration > 120 ms. ● Biventricular pacing/Cardiac resynchronization therapy (CRT) – Sinus rhythm with EF 120 ms and are still symptomatic with optimal medical therapy.
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Treatment of HF Asssess for fluid retention Fluid Retention No Fluid Retention Diuretic ACEI Beta Blocker ARB Aldosterone Antagonist Hydralazine/Isosorbide Digoxin ICD if NYHA Class II-III CRT if NYHA class III-IV and QRS >120 ms NYHA I-IV Persistent symptoms or special populations
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Treatment for Acute HF ● Stabilize hemodynamic derangements that provoked symptoms ● ID and treat reversible factors that precipitated decompensation ● Reestablish effective outpt medical regimen that prevent progression and relapse
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Vasodilators ● Nitroglycerin – 20 mcg/min ● Nitroprusside – 10 mcg/min ● Nesiritide – Bolus 2mcg/kg
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Inotropes ● Dobutamine – 1-2 mcg/min ● Milrinone (Primacor) – Bolus 50 mcg/kg ● Dopamine – 1-2 mcg/kg per min
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Vasoconstrictors ● Dopamine – 5 mcg/kg per min ● Epinephrine – 0.5 mcg/kg per min ● Phenylephrine – 0.3 mcg/kg per min ● Vasopressin – 0.05 units/min
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Case Study ● 70 yo F presents with Cough and wheezing ● Started 5 days ago and has been constant. ● + shortness of breath and rhinorrhea ● - fever, sputum,
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PMH ● HTN ● Arthritis ● Chronic Kidney dz ● End stage ● DM ● CAD ● Severe Aortic Stenosis ● Osteomyelitis in L great toe
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PSH ● Cataract removal ● Hernia repair ● Urological stents ● Amputation L great toe – Osteomyelitis
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Family Hx ● Cancer ● Heart Dz ● Stroke ● DM
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Social Hx ● Non-smoker ● No alcohol use ● Disabled
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Medications ● Prednisone 20 mg ● Epogen (epoetin alfa) 10,000 SQ Q2wk ● Novolog Sliding scale ● Isordil 30mg ● Coreg 6.25 mg ● Apresoline 50 mg ● Lyrica 50 mg ● Allopurinol 100 mg ● Ultram 50 mg ● Lasix 20 mg
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Allergies ● Maxipime ● Bactrim ● Levaquin ● Pen G ● Sulfa ● Vanc
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PE ● BP: 139/69, P: 67 ● Lungs: Diminished breath sounds ● CV: grade 3.6 murmur ● Pedal edema bilaterally
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Assessment ● Severe Aortic Stenosis ● Acute Exacerbation COPD ● DM ● HTN ● End stage renal dz
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Plan ● IV Bumex ● Consult Nephrology ● Sputum culture/sensitivity ● UA, culture/sensitivity
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Day 3
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LABS ● CBC: 7.5 ● HGB: 4.14 ● HCT: 10.9 ● PLT: 278 ● Na: 132 ● K: 4.6 ● Cl: 96 ● CO2: 31 ● BUN : 61 ● Creatinine: 2.70 ● Glucose: 198
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● Nephrology: pt at baseline continue therapy, follow BUN/creatinine ● Aortic Stenosis likely cause for Edema/fluid overload
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Day 3 ● Creatinine: 3.7 ● Bumex held, no IVF ● Avoid nephrotoxic drugs
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Day 6 ● Cough and shortness of breath continue to worsen despite O2 and Q4 hr duoneb treatments ● V/Q Scan ● Consult Pulmonology
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Day 7 ● V/Q scan – Low to intermediate risk of PE ● Pulmonology orders Duplex bilateral LE – Non occluding Thrombus L femoral fundus – Conclude No PE
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Day 8 ● Suggest pt may have PE due to ongoing symptoms despite treatment. ● Pulmonology adds heparin SQ
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Day 10 ● Pt symptoms begin to improve ● Pulmonology agrees high likelihood of PE ● Pt bridged to coumadin ● D/C day 15
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References ● Fauci, Anthony S. et al. Harrison's Internal Medicine. Heart failure, 1443-1453. ● Up to date
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