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11/18/2018 CHF Update 2018 Peter M. Lewis, DO FACC 1 1
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Which of the following is true?
11/18/2018 Which of the following is true? A. CHF incidence/prevalence is decreasing B. Incidence of CHF is the same in all populations C. Mortality has significantly decreased with newer treatment modalities D. HfpEF has similar mortality risk to HFrEF 2 2
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Which of the following is true?
11/18/2018 Which of the following is true? A. ECHO is a simple, easily obtainable test in the workup of CHF B. Provides significant data on systolic/diastolic parameters, valvular disease, pericardial disease C. Worse outcome in patients when not utililized in diagnosis and follow up D. All of the above 3 3
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CHF Update 2018 Definition Types Epidemiology Etiology Pathophysiology
11/18/2018 CHF Update 2018 Definition Types Epidemiology Etiology Pathophysiology Treatment strategies 4 4
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CHF Update 2018 5.8 million prevalence Men > women
11/18/2018 CHF Update 2018 5.8 million prevalence Men > women 1970s-1990s epidemic decreasing Majority >65 years and older accounting for >80% of mortality 5 5
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11/18/2018 CHF Update 2018 $ 31 billion in 2012 (80% direct costs from hospitalizations) Accounts for 1-2% of all health care cost in developed countries Costs expected to double by 2030 to over $70 billion 6 6
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CHF Update 2018 Incidence higher and earlier in AA men/women
11/18/2018 CHF Update 2018 Incidence higher and earlier in AA men/women Higher incidence of CAD, DM, HTN Obesity and CKI More prevalent before age 50 7 7
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CHF Update 2018 Incidence higher and earlier in AA men/women
11/18/2018 CHF Update 2018 Incidence higher and earlier in AA men/women Higher incidence of CAD, DM, HTN Obesity and CKI More prevalent before age 50 8 8
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11/18/2018 Update CHF 2018 9 9
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CHF Update 2018 Systolic and Diastolic HFrEF and HFpEF 13 13
11/18/2018 CHF Update 2018 Systolic and Diastolic HFrEF and HFpEF 13 13
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HFpEF Now accounts for >50%of all CHF cases
11/18/2018 HFpEF Now accounts for >50%of all CHF cases More prevalent in females Diastolic abnormalities invariably noted on ECHO Similar mortality compared to HfrEF No proven therapies to date to alter course 15 15
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Major Risk Factors Age Male HTN/LVH CAD/MI Valvular heart disease
11/18/2018 Major Risk Factors Age Male HTN/LVH CAD/MI Valvular heart disease Obeisity DM 16 16
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Minor Risk Factors Smoking Hyperlipidemia CKI Albumimuria OSA Anemia
11/18/2018 Minor Risk Factors Smoking Hyperlipidemia CKI Albumimuria OSA Anemia Tachycardia 17 17
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CHF 2018 Update Immune-mediated
11/18/2018 CHF 2018 Update Immune-mediated Peripartum cardiomyopathy, hypersensitivity Infectious Viral, parasitic (Chagas disease), bacterial Toxic risk precipitants Chemotherapy (anthracyclines, cyclophosphamide, 5-FU), targeted cancer therapy (trastuzumab, tyrosine kinase inhibitors), cocaine, NSAIDs, thiazolidinediones, doxazosin, alcohoSNP (e.g. α2CDel , β1Arg389), family history, congenital heart 18 18
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CHF Update 2018 Reduced Contractility------> decreased CO
11/18/2018 CHF Update 2018 Reduced Contractility------> decreased CO Increased preload/LAP BP maybe be decreased but SVR is increased Increased HR ( CO=HR x SV ) 19 19
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11/18/2018 CHF Update 2018 ECHO with depressed LVEF 23 23
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11/18/2018 CHF Update 2018 ECHO with LVH 24 24
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CHF Update 2018 Biomarkers BNP and proBNP
11/18/2018 CHF Update 2018 Biomarkers BNP and proBNP Utility in diagnosis and following response to treatment BNP levels responsive to ARNI Rx but not proBNP 25 25
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CHF Update 2018 BNP 32 amino acid peptide (134 AA NT-pro BNP)
11/18/2018 CHF Update 2018 BNP 32 amino acid peptide (134 AA NT-pro BNP) Secreted by cardiac myocytes Predominant cardiac/renal effects Decrease in SVR and CVP 26 26
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CHF Update 2018 Other causes for BNP elevations: ACS
11/18/2018 CHF Update 2018 Other causes for BNP elevations: ACS Atrial fibrillation Myocarditis Cardiac surgery 27 27
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CHF Update 2018 Secondary causes of increased BNP: Age Anemia
11/18/2018 CHF Update 2018 Secondary causes of increased BNP: Age Anemia Renal failure Sepsis Pulmonary hypertension Toxic/metabolic 28 28
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CHF Update 2018 ACC/AHA Classification Class A Class B Class C Class D
11/18/2018 CHF Update 2018 ACC/AHA Classification Class A Class B Class C Class D 29 29
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CHF Update 2018 Stage A Asymptomatic but with significant risk
11/18/2018 CHF Update 2018 Stage A Asymptomatic but with significant risk Risk factor modification to include BP control Rx of lipids/DM Reduction/abstinence from alcohol 30 30
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CHF Update 2018 Stage B Documented low EF but asymptomatic: ACEI/ARB
11/18/2018 CHF Update 2018 Stage B Documented low EF but asymptomatic: ACEI/ARB Beta blocker Surgery for any correctable disease 31 31
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CHF Update 2018 Stage C Symptomatic with signs/symptoms of CHF
11/18/2018 CHF Update 2018 Stage C Symptomatic with signs/symptoms of CHF Standard Rx Aldosterone antagonists Nitrates/hydralazine 32 32
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CHF Update 2018 Stage D Continued standard Rx Transplant
11/18/2018 CHF Update 2018 Stage D Continued standard Rx Transplant Resynchronization therapy LVAD Inotropic Rx 33 33
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CHF Update 2018 NYHA Classification Class I asymptomatic
11/18/2018 CHF Update 2018 NYHA Classification Class I asymptomatic Class II symptoms with significant activity Class III symptoms with minimal activity Class IV symptoms at rest 34 34
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CHF Update 2018 CBC UA CMP Fasting blood glucose levels Lipid profile
11/18/2018 CHF Update 2018 CBC UA CMP Fasting blood glucose levels Lipid profile Thyroid stimulating hormone (TSH) levels B-type natriuretic peptide levels/pro BNP N-terminal natriuretic peptide levels Electrocardiography 35 35
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CHF Update 2018 Electrocardiography Chest radiography
11/18/2018 CHF Update 2018 Electrocardiography Chest radiography Two-dimensional (2-D) echocardiography Nuclear imaging Maximal exercise testing Pulse oximetry or arterial blood gas 36 36
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CHF Update 2018 Diet/exercise Dietary consult Routine daily weights 37
11/18/2018 CHF Update 2018 Diet/exercise Dietary consult Routine daily weights 37 37
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CHF Update 2018 Standard Medical Therapy Diuretics ACEI/ARB
11/18/2018 CHF Update 2018 Standard Medical Therapy Diuretics ACEI/ARB Aldosterone antagonists Hyralazine/nitrates ARNI 38 38
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11/18/2018 CHF Update 2018 Digoxin Spironolactone Neseritide 40 40
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CHF Update 2018 Cardiac Resynchronization Therapy (CRT) Based on LVEF
11/18/2018 CHF Update 2018 Cardiac Resynchronization Therapy (CRT) Based on LVEF NYHA functional class QRS duration Concomitant need for ventricular pacing 44 44
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CHF Update 2018 CRT Simultaneous pacing of the RV/LV
11/18/2018 CHF Update 2018 CRT Simultaneous pacing of the RV/LV Acute hemodynamic benefits: Increased SBP Increased CO/CI Increased contractility 45 45
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CHF Update 2018 CRT Anatomic benefits: Decreased adverse LV remodeling
11/18/2018 CHF Update 2018 CRT Anatomic benefits: Decreased adverse LV remodeling Decreased LV size/spherical shape Increased LVEF 46 46
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CHF Update 2018 Device/ cardiac resynchronization therapy Class IA
11/18/2018 CHF Update 2018 Device/ cardiac resynchronization therapy Class IA NYHA II-IV class patients LVEF < 35% LBBB Other with QRS >140 msec 47 47
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CHF Update 2018 CRT Class IIB Non LBBB with QRS > 150 msec and NYHA
11/18/2018 CHF Update 2018 CRT Class IIB Non LBBB with QRS > 150 msec and NYHA III/IV QRS msec and NYHA II-IV 48 48
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CHF Update 2018 CRT CLASS III LVEF > 50% QRS <120 msecs
11/18/2018 CHF Update 2018 CRT CLASS III LVEF > 50% QRS <120 msecs Non-ambulatory NYHA Class IV Patients on inotropic Rx 49 49
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CHF Update 2018 Device Therapy
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Summary Treatment Guidelines
11/18/2018 Summary Treatment Guidelines 51 51
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