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what is the anatomical problem with HFrEF?
- dilated ventricle
- decreased ability to eject blood from ventricle
What is the other name for HF with Reduced Ejection Fraction (HFrEF)?
Systolic heart Failure
What is the ejection fraction with HFrEF?
What are the common causes of HFrEF?
- Ischemic CAD (66% of cases)
- Non-ischemic (HTM, valvular dz, thyroid dz, mycarditis, med-induced)
What is the typical pt with HFrEF?
What is another name for HF with Preserved Ejection Fraction (HFpEF)?
Diastolic heart failure
What is the EF in HFpEF?
What are the anatomical problems of HFpEF?
- hypertrophied ventricle
- impaired ventricular relaxation/ability to fill
What are the common causes of HFpEF?
- age related changes to elastic properties of the heart (more in women)
- hypertrophic/restrictive cardiomyopathies
What is the typical pt for HFpEF?
- elderly with long-standing hypertension
- more in women
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)
What is the role of BNP?
to rule out HF exacerbation
What is BNP released in response to and what are the levels?
- stretch of cardiac muscles
- <100 - unlikely CHF
- >500 - likely CHF
What are the symptoms for Class 1?
- no limitation of physical activity
- ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea
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
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
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
what is the drug of choice in a warm and wet pt?
what is the bioavailability of a po form of loop diuretics?
50% (20 mg iv = 40 mg po)
why is ethacrynic acid rarely used? and what is the niche?
- used in pts with sever sulfa allergy (anaphylaxis, not rash)
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
How much should the urinary output by within two hours of a diuretic dose?
What are the three additional agents to improve diuresis?
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
what are the classes of medications that have evidence for improvement in symptoms of HF?
- beta blockers
what are the classes of medications that have evidence for improvement in mortality in HF?
- beta blockers
- aldosterone antagonists
- vasodilators (hydralazine/nitrates)
what are the two group to "avoid" statins in?
- only avoid if that is there only disease state and they have no indications for a statin
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
what pain medications are ok to use in CHF?
What are the classes that are most appropriate to start when diuretics fail?
- vasodilator (before the inotrope?)
What are the three criteria for adding an IV vasodilator?
- severe pulmonary edema
- hypertensive emergency
- persistent symptoms despite aggressive diuretics
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