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Investigations
- Look for etiology
- Routine labs (CBC, creatinine, lytes)
- Troponin
- NT-pro BNP
- ECG
- CXR
- Echocardiogram
General management
- General principles
- Furosemide IV to decrease volume overloading
- Sodium restricted diet < 2 g Na
- Fluid restricted diet < 2 L
- Nitroglycerin infusion to decrease preload
- Respiratory therapy, 100 % FiO2 +/- non-invasive positive pressure ventilation
- If hypotensive
- Consult CCU stat
- Insert central line and arterial line for invasive monitoring and intiation of vasopressors and inotropes
2 kinds of heart failure:
- HFpEF – heart failure with preserved ejection fraction
- Diastolic heart failure (HFpEF – heart failure with preserved ejection fraction)
- Why is ejection fraction preserved in diastolic heart failure?
- Recall that LVEF = stroke volume / EDV
- In diastolic heart failure, there is an inability for the left ventricle to fill completely, so the EDV is reduced, but stroke volume is also reduced
As a result, ejection fraction remains preserved
- Management
- No medications have been shown to reduced mortality or morbidity in preserved ejection fraction heart failure
- HFrEF – heart failure with reduced ejection fraction
- Systolic heart failure (HFrEF – heart failure with reduced ejection fraction)
- At least half of the blood left in the left ventricle at the end of diastole should be pumped out by the heart during each cardiac cycle
- LVEF between 40 and 50 % is borderline systolic heart failure
- LVEF under 40 % is considered systolic heart failure
- Management
- Long term management includes
- ACE inhibitors or ARBs
- For black people and ethnic groups intolerant of ACE/ARBs use isosorbide dinitrate and hydralazine
- Beta blockers (carvedilol, bisoprolol, metoprolol)
- Only if LVEF < 40 %
- Triple therapy: add mineralocorticoid receptor antagonists (spironolactone) in addition to ACE/ARB and beta blockers
- Avoid most CCBs when LVEF < 40 %
- Even diltiazem and verpamil for arrythmia if LVEF < 40 %
- Reassess symptoms after triple therapy
- If NYHA class I
- If NYHA class II-IV, sinus rhythm, heart rate > 70 bpm
- Add ivabradine
- Switch ACE or ARB to ARNI
- If NYHA class II-IV, sinus rhythm, heart rate < 70 bpm or AF or pacemaker
- Switch ACE or ARB to ARNI
- Devices (both used in severe heart failure)
- Implantable cardioverter defibrillators (ICDs)
- Arrhythmias are a common cause for sudden death in HF
- We can prophylactically install this device so that if the person enters into a shockable rhythm, the device will automatically cardiovert or defibrillate the patient
- Biventricular pacemakers
- Artificial implanted pacemaker that helps both ventricles contract at the same time
Quick pearls of heart failure management
- Isosorbide dinitrate can be considered
- In addition to standard triple therapy for black patients with advanced symptoms
- Patients unable to tolerate ACEi or ARB because of renal dysfunction or hyperkalemia
- Ivabradine should not be added before BB is titrated to maximum evidence based and patient tolerated dose
- If converting a patient from ACEi to ARNI, must wait at least 36 h after last dose before starting ARNI to lower risk of angioedema
- ARNI should not be added before triple therapy has been attempted for at least 3 months
- Patients who are volume overloaded can be given IV furosemide 20-80 mg bolus
- If SBP < 100 and symptomatic can provide dopamine or dobutamine
- If SBP > 100 can consider adding nitroglycerin (IV/SL) or nitroprusside (IV)
- Flexible Diuretic Regimen (FDR) is a way for patients to adjust their lasix dose based on their own weight measurements
- If patient is volume overloaded provide lasix dose that results in 1 kg or 2 lbs weight decrease per day
- If > 1 kg weight decrease, reduce lasix diuretic by 25 – 50 %
- If < 0.5 kg weight increase, increase lasix diuretic by 50 % and consider adding metolazone 1 to 7 times per week
- ICD should not be considered for patients with life expectancy of less than 1 year of life
- CRT should only be considered for patients who have tried optimal medical therapy for 3 months, who have NYHA II-IV symptoms (or without symptoms if their HF is from an ischemic cause) and who show ECG sinus rhythm, QRS duration > 130 msec with LBBB morphology