How to Save the Failing Heart Subir Shah Assistant Professor in Cardiology

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

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

Classification

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…..

It’s all on you...

Stepwise Approach Who gets it History Physical Labs Therapy Breathe…. Documentation Sign it out and get the heck out of the hospital

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

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

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

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

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Types of Shock

How to Diagnose it.. All about the HISTORY!!! LETS FIGURE THESE OUT AS A GROUP 

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

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)

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

Framingham Criteria

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

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: 10 -20 mg once max 200 duration 12-16 hours Metolazone 2.5 mg -10 mg x 1 plus loop diuretic Diuril: chlorothiazide (250-1000) usually start 500

Risks of Diuretics Electrolyte and Fluid Depletion Hypotension Azotemia Senior yelling at you

Intravenous Inotropic Agents Adrenergic Agonists:  CO and HR Dopamine… initial dose 5-10 mcg/kg/min Dobutamine… initial dose 2.5-5 mcg/kg/min PDE Inhibitors:  CO and HR Milrinone 0.125-.75 mcg/kg/min

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

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

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