1. Heart Failure

2. S/S of Heart Failure ● Cardinal Symptoms: ● Fatigue ● Shortness of breath ● Signs ● Edema ● Rales

3. Systolic Dysfunction ● Characterized by: ● Decreased myocardial contractility ● Reduction in LVEF – <40% ● LV enlargement ● Fluid backup leads to pulmonary congestion ● Dilated Cardiomyopathy

4. Diastolic Dysfunction ● Characterized by: ● Abnormal LV filling ● Elevated filling pressures ● Ventricular hypertrophy ● LVEF > 40%

5. New York Heart Association Classification

6. American Heart Association

7. 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

8. 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

9. 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

10. 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

11. Beta Blocker ● Carvedilol (Coreg) – 3.125 mg BID ● Bisoprolol (Zebeta) – 1.25 mg Qday ● Metoprolol Succinate CR (Toprol-XL) – 1.25-25 mg Qday

12. 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

13. 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.

14. 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

15. 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

16. Vasodilators ● Nitroglycerin – 20 mcg/min ● Nitroprusside – 10 mcg/min ● Nesiritide – Bolus 2mcg/kg

17. Inotropes ● Dobutamine – 1-2 mcg/min ● Milrinone (Primacor) – Bolus 50 mcg/kg ● Dopamine – 1-2 mcg/kg per min

18. 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

19. 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,

20. PMH ● HTN ● Arthritis ● Chronic Kidney dz ● End stage ● DM ● CAD ● Severe Aortic Stenosis ● Osteomyelitis in L great toe

21. PSH ● Cataract removal ● Hernia repair ● Urological stents ● Amputation L great toe – Osteomyelitis

22. Family Hx ● Cancer ● Heart Dz ● Stroke ● DM

23. Social Hx ● Non-smoker ● No alcohol use ● Disabled

24. 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

25. Allergies ● Maxipime ● Bactrim ● Levaquin ● Pen G ● Sulfa ● Vanc

26. PE ● BP: 139/69, P: 67 ● Lungs: Diminished breath sounds ● CV: grade 3.6 murmur ● Pedal edema bilaterally

27. Assessment ● Severe Aortic Stenosis ● Acute Exacerbation COPD ● DM ● HTN ● End stage renal dz

28. Plan ● IV Bumex ● Consult Nephrology ● Sputum culture/sensitivity ● UA, culture/sensitivity

30. Day 3

31. 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

32. ● Nephrology: pt at baseline continue therapy, follow BUN/creatinine ● Aortic Stenosis likely cause for Edema/fluid overload

33. Day 3 ● Creatinine: 3.7 ● Bumex held, no IVF ● Avoid nephrotoxic drugs

34. Day 6 ● Cough and shortness of breath continue to worsen despite O2 and Q4 hr duoneb treatments ● V/Q Scan ● Consult Pulmonology

35. 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

36. Day 8 ● Suggest pt may have PE due to ongoing symptoms despite treatment. ● Pulmonology adds heparin SQ

37. Day 10 ● Pt symptoms begin to improve ● Pulmonology agrees high likelihood of PE ● Pt bridged to coumadin ● D/C day 15

38. References ● Fauci, Anthony S. et al. Harrison's Internal Medicine. Heart failure, 1443-1453. ● Up to date