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Systolic Dysfunction
Coronary Artery Disease
Idiopathic dilated cardiomyopathy (DCM)
50% idiopathic (at least 25% familial)
9 % mycoarditis (viral)
Ischemic heart disease, perpartum, hypertension,
HIV, connective tissue disease, substance abuse,
doxorubicin
Hypertension
Valvular Heart Disease
Diastolic Dysfunction
Hypertension
Coronary artery disease
Hypertrophic obstructive cardiomyopathy (HCM)
Restrictive cardiomyopathy
Clinical Presentation of Heart Failure
Cardiomegaly
Cephalization of the pulmonary
vessels
Kerley B-lines
Pleural effusions
Cardiomegaly
Pulmonary vessel congestion
Pulmonary Edema due to Heart Failure
Kerley B lines
Cardiac Testing in Heart Failure
Electrocardiogram:
May show specific cause of heart
failure:
Ischemic heart disease
Dilated cardiomyopathy: first degree AV
block, LBBB, Left anterior fascicular block
Amyloidosis: pseudo-infarction pattern
Idiopathic dilated cardiomyopathy: LVH
Echocardiogram:
Left ventricular ejection fraction
Structural/valvular abnormalities
SUGAR LAND
Endomyocardial biopsy
Not frequently used
Really only useful in cases such as viral-
induced cardiomyopathy
Algorithm for the diagnosis of heart failure
Classification of Heart Failure
ACC/AHA Guidelines
Stage A – High risk of HF, without
structural heart disease or symptoms
Stage B – Heart disease with
asymptomatic left ventricular
dysfunction
Stage C – Prior or current symptoms
of HF
Stage D – Advanced heart disease and
severely symptomatic or refractory HF
Chronic Treatment of Systolic Heart
Failure
Lifestyle changes
Medications
Surgery
TREATMENT: Lifestyle choices
General recommendation: 30
minutes most days of the week
Specifics may be different for
different people (check with doctor
about what type and how much)
Always want to start slow
and build up gradually
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Order of Therapy
1. Loop diuretics
2. ACE inhibitor (or ARB if not
tolerated)
3. Beta blockers
4. Digoxin
5. Hydralazine, Nitrate
6. Potassium sparing diuretcs
Diuretics
Loop diuretics
Furosemide, buteminide
For Fluid control, and to help relieve
symptoms
Potassium-sparing diuretics
Spironolactone, eplerenone
Help enhance diuresis
Maintain potassium
Lisinopril – 5 mg po QDaily
Dosing:
Hydralazine
Started at 25 mg po TID, titrated up to 100
mg po TID
Isosorbide dinitrate
Started at 40 mg po TID/QID
Angioplasty
Coronary artery bypass graft
Heart pump
Transplant
Meds to AVOID in heart failure
NSAIDS
Can cause worsening of preexisting HF
Thiazolidinediones
Include rosiglitazone (Avandia), and
pioglitazone (Actos)
Cause fluid retention that can exacerbate HF
Metformin
People with HF who take it are at increased
risk of potentially lethic lactic acidosis
Implantable Cardioverter-Defibrillators
for HF
Sustained ventricular
tachycardia is associated with
sudden cardiac death in HF.
About one-third of mortality in
HF is due to sudden cardiac
death.
Patients with ischemic or
nonischemic cardiomyopathy,
NYHA class II to III HF, and
LVEF ≤ 35% have a significant
survival benefit from an
implantable cardioverter-
defibrillator (ICD) for the
primary prevention of SCD.
Prognostication
I 5-10%
II-III 15-30%
IV 50-60%
Summary