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    Congestive Heart Failure

    Michele Ritter, M.D.

    Argy – February, 2007

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    Heart Failure

    Results from any structural orfunctional abnormality that impairsthe ability of the ventricle to eectbloo! "Systolic Heart Failure# orto fill $ith bloo! "Diastolic HeartFailure#.

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    The Vicious Cycle of Congestive Heart

    Failure

    Decrease! %loo! &ressure an!Decrease! Renal perfusion

    'timulates the Releaseof renin, (hich allo$s

    conversion ofAngiotensin

    to Angiotensin II.  Angiotensin )) stimulates

    Aldosterone secretion $hichcauses retention of

    *a+ an! (ater, increasing filling pressure

    - Dysfunction causesDecrease! car!iac output

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    Types of Heart Failure

    Low-Output Heart Failure 'ystolic eart Failure/

    !ecrease! car!iac output Decrease! eft ventricular eection fraction

    Diastolic eart Failure/ levate! eft an! Right ventricular en!1!iastolic

    pressures May have normal -F

    High-Output Heart Failure 'een $ith peripheral shunting, lo$1systemic vascular

    resistance, hyperthryoi!ism, beri1beri, carcinoi!, anemia ften have normal car!iac output

    Right-Ventricular Failure 'een $ith pulmonary hypertension, large R- infarctions.

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    Causes of Low-Output Heart Failure

    Systolic Dysfunction 3oronary Artery Disease )!iopathic !ilate! car!iomyopathy "D3M#

    405 i!iopathic "at least 245 familial# 6 5 mycoar!itis "viral# )schemic heart !isease, perpartum, hypertension,

    )-, connective tissue !isease, substance abuse,!oorubicin

    ypertension -alvular eart Disease

    Diastolic Dysfunction ypertension 3oronary artery !isease ypertrophic obstructive car!iomyopathy "3M# Restrictive car!iomyopathy

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    Clinical Presentation of Heart Failure

    Due to ecess flui! accumulation/ Dyspnea "most sensitive symptom#

    !ema

    epatic congestion Ascites

    rthopnea, &aroysmal *octurnal Dyspnea"&*D#

    Due to re!uction in car!iac ouput/ Fatigue "especially $ith eertion"

    (ea8ness

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    easuring !ugular Venous Pressure

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    La" #nalysis in Heart Failure

    3%3 'ince anemia can eacerbate heart failure

    'erum electrolytes an! creatinine  before starting high !ose !iuretics

    Fasting %loo! glucose ;o evaluate for possible !iabetes mellitus

    ;hyroi! function tests 'ince thyrotoicosis can result in A. Fib,  an! hypothyroi!ism can results in F.

    )ron stu!ies ;o screen for here!itary hemochromatosis as cause of heart

    failure.

    A*A ;o evaluate for possible lupus

    -iral stu!ies )f viral mycocar!itis suspecte!

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    La"oratory #nalysis $cont%&

    %*&(ith chronic heart failure, atrial mycotes

    secrete increase amounts of atrial natriuretic

    pepti!e "A* an! brain natriuretic pepeti!e"%* in response to high atrial an!ventricular filling pressures

    m in patients $ith!yspnea !ue to heart failure.

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    Chest '-ray in Heart Failure

    3ar!iomegaly

    3ephali?ation of the pulmonary

    vessels @erley %1lines

    &leural effusions

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    Car(iomegaly

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    Pulmonary vessel congestion

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    Pulmonary E(ema (ue to Heart Failure

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    )erley * lines

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    Car(iac Testing in Heart Failure

    lectrocar!iogram/May sho$ specific cause of heart failure/

    )schemic heart !isease

    Dilate! car!iomyopathy/ first degree AVblock, LBBB, Left anterior fascicular block 

    Amyloi!osis/ pseudo-infarction pattern )!iopathic !ilate! car!iomyopathy/ LVH 

    chocar!iogram/ eft ventricular eection fraction'tructural>valvular abnormalities

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    Further Car(iac Testing in Heart Failure

    ercise ;esting 'houl! be part of initial evaluation of all patients

    $ith 3F. 3oronary arteriography

    'houl! be performe! in patients presenting $ithheart failure $ho have angina or significantischemia

    Reasonable in patients $ho have chest pain thatmay or may not be car!iac in origin, in $homcar!iac anatomy is not 8no$n, an! in patients $ith8no$n or suspecte! coronary artery !isease $ho !onot have angina.

    Measure car!iac output, !egree of left ventricular!ysfunction, an! left ventricular en!1!iastolicpressure.

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    Further testing in Heart Failure

    n!omyocar!ial biopsy *ot freuently use!

    Really only useful in cases such as viral1

    in!uce! car!iomyopathy

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    Classification of Heart Failure

    *e$ Bor8 eart Association "*BA#lass I – symptoms of F only at

    levels that $oul! limit normal

    in!ivi!uals.

    lass II – symptoms of F $ithor!inary eertion

    lass III – symptoms of F on lessthan or!inary eertion

    lass IV – symptoms of F at rest

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    Classification of Heart Failure $cont%&

    A33>AA Cui!elinesStage A – igh ris8 of F, $ithout

    structural heart !isease or symptomsStage ! – eart !isease $ith

    asymptomatic left ventricular!ysfunction

    Stage  – &rior or current symptoms

    of FStage D – A!vance! heart !isease an!

    severely symptomatic or refractory F

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    Chronic Treatment of +ystolic Heart

    Failure

    3orrection of systemic factors ;hyroi! !ysfunction )nfections

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    ,iuretics

    oop !iuretics Furose"ide# $ute"inide

    For Flui! control, an! to help relieve

    symptoms

    &otassium1sparing !iuretics Spironolactone# eplerenone

    elp enhance !iuresis

    Maintain potassium

    'ho$n to improve survival in 3F

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     #CE nhi"itor 

    )mprove survival in patients $ith allseverities of heart failure.

    %egin therapy lo$ an! titrate up aspossible/ nalapril – 2.4 mg po %)D

    3aptopril – E.24 mg po ;)D

    isinopril – 4 mg po Daily )f cannot tolerate, may try AR%

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    *eta *loc.er therapy

    3ertain %eta bloc8ers "car%edilol,"etoprolol, $isoprolol# can improveoverall an! event free survival in *BA

    class )) to ))) F, probably in class )-. 3ontrain!icate!/

    eart rate GE0 bpm

    'ymptomatic bra!ycar!ia

    'igns of peripheral hypoperfusion

    3&D, asthma

    &R interval : 0.2= sec, 2n! or 9r! !egree bloc8

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    Hy(rala/ine plus 0itrates

    Dosing/y!rala?ine

    'tarte! at 24 mg po ;)D, titrate! up to 00

    mg po ;)D

    )sosorbi!e !initrate 'tarte! at =0 mg po ;)D>)D

    Decrease! mortality, lo$er rates of

    hospitali?ation, an! improvement inuality of life.

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    ,igoxin

    Civen to patients $ith F to controlsymptoms such as fatigue, !yspnea,eercise intolerance

    'ho$n to significantly re!ucehospitali?ation for heart failure, butno benefit in terms of overall

    mortality.

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    Other important me(ication in Heart

    Failure -- +tatins

    'tatin therapy is recommen!e! in3F for the secon!ary prevention ofcar!iovascular !isease.

    'ome stu!ies have sho$n apossible benefit specifically in F$ith statin therapy

    )mprove! -F Reversal of ventricular remo!eling Re!uction in inflammatory mar8ers "3R&,

    )1E, ;*F1alpha))#

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    e(s to #VO, in heart failure

    *'A)D' 3an cause $orsening of preeisting F

    ;hia?oli!ine!iones )nclu!e rosiglita?one "Avan!ia#, an!

    pioglita?one "Actos#

    3ause flui! retention that can eacerbate F

    Metformin &eople $ith F $ho ta8e it are at increase!

    ris8 of potentially lethic lactic aci!osis

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    mplanta"le Car(ioverter-,efi"rillators

    for HF

    'ustaine! ventriculartachycar!ia is associate! $ithsu!!en car!iac !eath in F.

    About one1thir! of mortality inF is !ue to su!!en car!iac!eath.

    &atients $ith ischemic ornonischemic car!iomyopathy,*BA class )) to ))) F, an!-F H 945 have a significantsurvival benefit from animplantable car!ioverter1!efibrillator ")3D# for the

    primary prevention of '3D.

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    anagement of 1efractory Heart

    Failure

    )notropic !rugs/ Dobutamine, !opamine, milrinone,

    nitroprussi!e, nitroglycerin Mechanical circulatory support/

    )ntraaortic balloon pump eft ventricular assist !evice "-AD# 3ar!iac ;ransplantation

    A history of multiple hospitali?ations for F scalation in the intensity of me!ical therapy A repro!ucable pea& o'ygen consu"ption with

    "a'i"al e'ercise (VO)"a'* of + , "L&g per "in. "normal is 20 m>8g per min. or more#is relative in!ication, $hile a -2ma + ,/"L&g per "in is a stronger in!ication.

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     #cute ,ecompensate( Heart Failure

    3ar!iogenic pulmonary e!ema is acommon an! sometimes fatal causeof acute respiratory !istress.

    3haracteri?e! by the transu!ation ofecess flui! into the lungssecon!ary to an increase in leftatrial an! subseuently pulmonaryvenous an! pulmonary capillarypressures.

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     #cute ,ecompensaate( Heart Failure

    $cont%&

    3auses/ Acute 0I

    Rupture of chor!ae ten!inae>acute mitral

    valve insufficiency Volu"e O%erload

    ;ransfusions, )- flui!s

    *on1compliance $ith !iuretics, !iet "highsalt inta8e#

    1orsening %al%ular defect Aortic stenosis

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    ,ecompensate( Heart Failure

    'ymptoms 'evere !yspnea

    3ough

    3linical Fin!ings ;achypnea

    ;achycar!ia

    ypertension>ypotension

    3rac8les on lung eam )ncrease! I-D

    '9, '= or ne$ murmur

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    La"s2+tu(ies in #cute ,ecompensate(

    Heart Failure

    3hemistry, 3%3

    @C

    3hest J1ray May consi!er car!iac en?ymes

    2D1cho

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    ,ecompensate( Heart Failure

    ;reatment'trict )Ks an! Ks, !aily $eights

    ygen, mechanical ventilation ifnee!e!

    oop !iuretics "asiL#

    Morphine

    -aso!ilator therapy "nitroglycerin#*esiriti!e "%* – can help in acute

    setting, for short term therapy

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    Case 3 4

    A E41year ol! male $ith a history ofhypertension, DM, 3AD s>p M) an! three1vessel 3A%C in 2002, presents $ith

    $orsening !yspnea on eertion. estates that he occassionally has a !rycough, but !enies any recent chest pain,fevers, *>-. &atient states that he usuallycan get up a flight of stairs if he stops

    half1$ay, but over the last several !ays,has not been able to climb them at all.

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    Case 3 4 $cont%&

    &M/ 3AD – M) an! 3A%C in 2002 ypertension

    Diabetes Mellitus ypothyroi!ism

    Allergies/ *@DA

    utpatient Me!s/ 'ynthroi!Metformin *orvasc

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    Case 3 4 $cont%&

    &hysical am/ 67.E, E>72, 66, 2, 695 on RA

    Cen/ Alert an! oriente! 9, breathingrapi!ly

    3-/ RRR, no murmursN mo!. I-D

    Resp/ 3rac8les throughout lungs

    Ab!./ soft, nonten!er, *A%' t/ 2 + pitting e!ema bilaterally

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    Case 3 4 $cont%&

    abs/ gb/ 9.4

    (%3/

    &latelets/ 2=0 'o!ium/ 96

    &otassium/ 9.

    %

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    Case 3 4

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    Case 3 4

    (hat stu!ies $oul! you li8e tochec8 in this patientO

    (hat me!ications $oul! you li8e tostart>changeO

    (hat vital signs !o you $ant tomonitorO

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    Case 3 5

    n eamination her heart rate is 74>min an! herbloo! pressure is 4>69 mm g. %M) is 92.6.Iugular venous pressure is mil!ly elevate!. ungeamination reveals a fe$ bibasilar crac8les.

    3ar!iac eamination reveals regular rhythm,normal ' an! '2 an! the presence of an '9.;here is mil! peripheral e!ema. Anechocar!iogram is significant for left ventricularhypertrophy an! severely !ecrease! systolicfunction "left ventricular eection fraction, 205#

    An electrocar!iogram sho$s a previousanteroseptal M).

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    Case 3 5

    (hich of the follo$ing is the mostappropriate net !iagnostic testO

    "A#

    Measurement of plasma %*&"%# 'erum &rotein lectrophoresis

    "3# 3ar!iac 'tress ;est

    "D#

    3ar!iac catheteri?ation"# n!omyocar!ial biopsy