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what is the anatomical problem with HFrEF?
- dilated ventricle
- decreased ability to eject blood from ventricle
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What is the other name for HF with Reduced Ejection Fraction (HFrEF)?
Systolic heart Failure
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What is the ejection fraction with HFrEF?
<40%
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What are the common causes of HFrEF?
- Ischemic CAD (66% of cases)
- Non-ischemic (HTM, valvular dz, thyroid dz, mycarditis, med-induced)
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What is the typical pt with HFrEF?
Post MI
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What is another name for HF with Preserved Ejection Fraction (HFpEF)?
Diastolic heart failure
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What is the EF in HFpEF?
>40%
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What are the anatomical problems of HFpEF?
- hypertrophied ventricle
- impaired ventricular relaxation/ability to fill
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What are the common causes of HFpEF?
- HTN
- age related changes to elastic properties of the heart (more in women)
- hypertrophic/restrictive cardiomyopathies
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What is the typical pt for HFpEF?
- elderly with long-standing hypertension
- more in women
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What are some odd causes of heart failure?
- drugs of abuse (cocaine, EtOH, amphetamines)
- drug induced chemotherapy
- takotsubo cardiomyopathy (broken heart dz or stress cardiomyopathy)
- peripartum
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What is the role of BNP?
to rule out HF exacerbation
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What is BNP released in response to and what are the levels?
- stretch of cardiac muscles
- <100 - unlikely CHF
- >500 - likely CHF
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What are the symptoms for Class 1?
- no limitation of physical activity
- ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea
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what are the symptoms of Class 2?
- slight limitation of physical activity
- comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea
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what are the symptoms for class 3?
- market limitation of physical activity
- comfortable at rest, but less that ordinary activity causes fatigue, palpitation or dyspnea
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what are the symptoms of Class 4?
- unable to carry out any physical activity without discomfort
- symptoms of cardiac insufficiency at rest
- if any physical activity is undertaken, discomfort is increased
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what is the drug of choice in a warm and wet pt?
loop diuretics
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what is the bioavailability of a po form of loop diuretics?
50% (20 mg iv = 40 mg po)
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why is ethacrynic acid rarely used? and what is the niche?
- ototoxicity
- used in pts with sever sulfa allergy (anaphylaxis, not rash)
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how do you dose loop diuretics in diuretic naive pt?
if they are already on a diuretic?
- furosemine 20-40 mg iv
- at least twice the usual oral dose
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How much should the urinary output by within two hours of a diuretic dose?
>500 ml
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What are the three additional agents to improve diuresis?
- chlorothiazide
- metolazone
- spironolactone
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What is the benefit for using metolazone and what must you be cautious of?
- CrCl <30
- watch electrolytes - only dosed 2-3 times per week
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what are the classes of medications that have evidence for improvement in symptoms of HF?
- beta blockers
- acei
- arbs
- digoxin
- diuretics
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what are the classes of medications that have evidence for improvement in mortality in HF?
- beta blockers
- acei
- arbs
- aldosterone antagonists
- vasodilators (hydralazine/nitrates)
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what are the two group to "avoid" statins in?
- CHF
- hemodialysis
- only avoid if that is there only disease state and they have no indications for a statin
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when do you initiate a beta blocker for a CHF pt?
- once stable on an oral diuretic dose
- no longer in acute decompensation or receiving IV inotropes
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what pain medications are ok to use in CHF?
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What are the classes that are most appropriate to start when diuretics fail?
- vasodilator (before the inotrope?)
- inotrope
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What are the three criteria for adding an IV vasodilator?
- severe pulmonary edema
- hypertensive emergency
- persistent symptoms despite aggressive diuretics
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What are the three criteria for starting an inotrope?
- evidence of cardiogenic shock (cold and wet)
- hypotension (SBP< 90, MAP <50)
- bridge in end-stage dz until transplantation
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