1. 1 Heart Failure William Chavey, MD, MS Associate Professor Department of Family Medicine University of Michigan

2. 2 Heart Failure Terms  Heart failure (HF) may be divided into two categories --- preserved ejection fraction and reduced ejection fraction  Systolic dysfunction (reduced ejection fraction) is defined by a reduced EF (< 40 - 45%), typically measured via echo, ventriculogram, radionuclide scan, or CT  Diastolic dysfunction is an echocardiographic finding representing poor filling. Heart failure with reduced ejection fraction is not necessarily the same as diastolic dysfunction and patients may have simultaneous systolic and diastolic heart failure

3. 3 HF Classification NYHA ClassNYHA Symptom Description NYHA Class IAsymptomatic NYHA Class IIMildly symptomatic NYHA Class IIIModerately symptomatic NYHA Class IVSymptoms at rest

4. 4 BNP  Prognosis  Diagnosis  Titration of therapy --- mixed results when compared to symptom management  Levels increased by age, female, renal insufficiency  Levels decreased by obesity

5. 5

6. 6 ROC Curves for BNP and ED Diagnosis Using All 250 Patients 0102030405060708090100 0 10 20 30 40 50 60 70 80 90 100 1 - Specificity (%) Sensitivity (%) 82 118 205 --- BNP--- ER diagnosis AUC0.8840.9790

7. 7 Identifying Heart Failure Using BNP

8. Treatment Recommendations for Heart Failure Patients with Left Ventricular Systolic Dysfunction

9. Device Referral Algorithm

10. Heart Failure with Preserved EF  Few clinical trials  Diuresis in decompensated state  Rate reduction can improve diastolic filling  BP control important 10

11. 11 Case 1  73 y/o male with h/o AF on verapamil, metoprolol, and warfarin; o/w healthy and active and travels the world performing  Presents with DOE  What is in differential diagnosis?  How would you work this up?

12. 12 Case 1 points  Role of BNP in assessing etiology of symptoms  Management of systolic vs diastolic dysfunction

13. 13 Case 1 points  Management of systolic vs diastolic dysfunction. If systolic dysfunction would: - d/c verapamil - add ACE

14. 14 Case 2  50 y/o AA female with EF 20% and dyspnea at rest plus h/o AFib, CVA, Type II DM, RA plus other co-morbid conditions  What is the appropriate medical regimen for her?  Is she eligible for a device?

15. 15 Case 2  ACE inhibitor?  Beta blocker?  Diuretic?  Aldosterone antagonist?  ARB?  Vasodilators?  Dig?

16. 16 Case 2  ACE inhibitor? Yes  Beta blocker? Yes  Diuretic? Yes  Aldosterone antagonist? Yes  ARB? Probably not  Vasodilators? If tolerated by BP  Dig - probably