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%
HFPEF 41-49% could be HFpEF borderline or could be HFpEF improved

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)
Inotrope is an agent that alters the force of energy of the muscular contractions. Negative inotropic agents weaken the force of the muscular contraction
Of course acute cardiovascular causes such as valve dz, endocarditis, myopericarditis, aortic dissection

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 NON-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 Bumex Metolazone and Diuril
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
Metolazone and Diuril
Torsemide also works: initial daily dose: mg once max 200 duration hours
Metolazone 2.5 mg -10 mg x 1 plus loop diuretic
Diuril: chlorothiazide ( ) usually start 500

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 mcg/kg/min
PDE Inhibitors:  CO and HR
Milrinone 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