Risk factors
- HTN, Hyperlipidemia
- Ischemic or valvular heart dz
- DM
- Heavy EtOH, Smoking
- Chemotherapy
- Fam Hx of heart failure
Symptoms
- Breathlessness, orthopnea, PND
- Fatigue, Confusion (esp in elderly)
- Leg swelling
Signs
- Lung crackles, DVP, Positive HJR
- Displaced apex, S3, S4, heart murmur
- Low BP, HR >100
ECG
- Q wave, tachycardia
- LVH, LBBB
CXR
- Cardiomegaly
- pulmonary edema, pulmonary venous redistribution
- Pleural effusion
If CHF in doubt
BNP
- >500 pg/ml, HF likley
Echo
- dec LVEF
- inc LV end-systolic and end-diastolic diameter
- LVH, Diastolic dysfunction, wall motion abn
- Inc RV size & dysfunction
- Valve dysfunction
- Inc Pulmonary arterial Pressures
How often to follow
- Acute change in HF symptoms
- in 1-2 days
- After HF hospitalization
- in 2 weeks
- After addition of HF med or inc in dose
- 1 wk if unstable, 2 wk if stable, 4 wk if asymptomatic
- Stable on optimized Tx
- 3-6mo
- Check lytes, BUN, Cr if intercurrent illness (flu) could affect volume status
What to Follow
- HF symptoms – NYHA & new symptoms?
- Body Wt, HR, postural BP
- JVP, HJR, peripheral edema
- Auscultate heart & chest
- check meds
Only when there is clinical change:
- ECG, CXR, Echo
- BNP (if uncertain CHF contributes to S/Sx)
- Lytes / Cr Q7-14d after ACEi/ARB, spironolactone, diuretic change, until stable, then q1-3mo
Ref
- New onset HF or recent HF hospitalization
- HF associated with ischemia/infarction, HTN, valvular dz, syncope, renal dysfunction, multiple comorbidities
- Unknown etiology
- Family Hx of HF
- Intolerance to Tx
- Poor compliance with Tx
Education on HF syndrome,
- Warning S/Sx:
- Dyspnea when flat, during sleep, w/ less exertion.
- Fatigue with less exertion or symptoms at rest
- lightheadedness/faint
- Prolonged palpitations or usual angina pain
- Wt gain >2kg in 2 days or 3kg in 7 days
- self monitoring, Drug Tx, prognosis
- Lifestyle
- Reduce CV risk: salt <2g/d, control HTN/DM, smoking cessation
- No need to push oral fluid
- Lose Wt, regular physical activity as tolerated, daily wt if fluid retention
Tx
- Low LVEF – Rx ACEI +/- BB
- LVEF >40% with symptoms, Tx cause eg HTN, Ischemia – consider ACEI/ARB, BB
- Systolic HF (symptoms + LVEF <40%)
- Tailored diuretic
- ACEi + BB – titrate to target doses (ARB if intolerance ACI)
- Nitrate / Hydralazine if intolerant to ACEI & ARB
- NYHA 2-3a (persistent symptoms, High BNP, recent HF hospitalization)
- Add Mineralcorticoid Receptor Antagonist (MRA): Spironolactone, eplerenone
- NYHA 3b-4
- MRA, digoxin, nitrates, increase or combine diuretics
- If refractory, consider transplant or palliation
- LVEF <30% – ICD ref
- Ramipril 1.25-2.5mg bid –> 5mg bid
- Metoprolol 12.5-25mg od –> 200mg od
- Spironolactone 12.5mg od –> 50mg od
- Hydralazine 37.5mg tid –> 75mg tid
- Diuretics, nitrates, digoxin – improve symptoms
- ACEI/ARB, BB, spironolactone/epleronone – Improve survival in pt with low LVEF
- Drug combination is required, most req dose adjustment & used long term
- Device with low LVEF or wide QRS
Diastolic HF
- Control Vol with min effective diuretic dose
- Resting HR to 70 bpm, especially with A fib (anticoagulated unless C/I)
- Determine if contributing ischemia or valvular heart dz & Tx if necessary – vigilant of AS and MR
- Control HTN is critical
- ARC/ARB +/- BB (CCB can be considered)
- Loop diuretics, renal function may be vol dependant
SOB & LVEF >50%
Cardiac causes
- Diastolic HF, CAD
- Valvular dz, intracardiac shunt
- hypertrophic cardiomyopathy, restrictive cardiomyopathy
- constrictive pericarditis
Non-Cardiac causes
- Lung dz, pulm arterial HTN
- Obesity, deconditioning, hyperventilation
- Anemia, extracardiac shunt
- thyrotoxicosis
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