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Heart Failure
William Chavey, MD, MS
Associate Professor
Department of Family Medicine
University of Michigan
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Heart Failure Terms
Heart failure (HF) may be divided into two categories --- preserved ejection fraction and reduced ejection fraction
Systolic dysfunction (reduced ejection fraction) is defined by a reduced EF (< 40 - 45%), typically measured via echo, ventriculogram, radionuclide scan, or CT
Diastolic dysfunction is an echocardiographic finding representing poor filling. Heart failure with reduced ejection fraction is not necessarily the same as diastolic dysfunction and patients may have simultaneous systolic and diastolic heart failure
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HF Classification
NYHA Class NYHA Symptom Description
NYHA Class I Asymptomatic
NYHA Class II Mildly symptomatic
NYHA Class III Moderately symptomatic
NYHA Class IV Symptoms at rest
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BNP
Prognosis Diagnosis Titration of therapy --- mixed results when
compared to symptom management Levels increased by age, female, renal
insufficiency Levels decreased by obesity
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BNP Concentration for theBNP Concentration for thePrediction of Clinical EventsPrediction of Clinical Events
Maisel A, et al. Annals of Emergency Medicine 2001 (in press)
0 20 40 60 80 100 120 140 160 1800%
5%
10%
15%
20%
25%
30%
35%
40%
45%
BNP < 230 pg/ml
BNP 230-480 pg/ml
BNP > 480 pg/ml
Death or Heart Failure Hospitalization
Days
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ROC Curves for BNP and ED
Diagnosis Using All 250 Patients
0 10 20 30 40 50 60 70 80 90 100
0102030405060708090
100
1 - Specificity (%)
Sen
siti
vity
(%
)
82118
205
--- BNP --- ER diagnosisAUC 0.8840.9790
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Identifying Heart Failure Using BNP
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Treatment Recommendations for Heart Failure Patients with Left Ventricular Systolic Dysfunction
ACC/AHA B C D
NYHA Classification
I II – III IV
Symptoms 1 Symptoms, Current or Prior
Asymptomatic Never Hospitalized History of
Hospitalization Recurrent or Ongoing
Rest Dyspnea
ACE Inhibitor2 Yes Yes Yes Yes
Beta Blocker Yes1 Yes Yes Yes3
Aldosterone antagonist
Yes Yes Yes
Isosorbide dinitrate-hydralazine
Selected patients4 Selected patients4 Selected patients4
Diuretic PRN congestion PRN congestion Yes
ARB PRN5 PRN5 PRN5
Digoxin PRN5 PRN5 PRN5
Consider AICD/Bi-V pacemaker
Selected patients6 Yes Yes Yes
HF Disease Management
Yes Yes
Referral to Advanced Heart Failure Program
Yes Yes7
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Device Referral Algorithm
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Heart Failure with Preserved EF
Few clinical trials
Diuresis in decompensated state
Rate reduction can improve diastolic filling
BP control important
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Case 1
73 y/o male with h/o AF on verapamil, metoprolol, and warfarin; o/w healthy and active and travels the world performing
Presents with DOE What is in differential diagnosis? How would you work this up?
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Case 1 points
Role of BNP in assessing etiology of symptoms
Management of systolic vs diastolic dysfunction
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Case 1 points
Management of systolic vs diastolic dysfunction. If systolic dysfunction would:- d/c verapamil- add ACE
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Case 2
50 y/o AA female with EF 20% and dyspnea at rest plus h/o AFib, CVA, Type II DM, RA plus other co-morbid conditions
What is the appropriate medical regimen for her?
Is she eligible for a device?
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Case 2
ACE inhibitor? Beta blocker? Diuretic? Aldosterone antagonist? ARB? Vasodilators? Dig?
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Case 2
ACE inhibitor? Yes Beta blocker? Yes Diuretic? Yes Aldosterone antagonist? Yes ARB? Probably not Vasodilators? If tolerated by BP Dig - probably