Gina G. Mentzer, MD Cardiologist, Heart Failure & Transplant Advanced Integrated Medicine & Surgery (AIMS) Program for Heart Failure April 18 th,

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1 Gina G. Mentzer, MD Cardiologist, Heart Failure & Transplant Advanced Integrated Medicine & Surgery (AIMS) Program for Heart Failure April 18 th, 2015

2 Heart Failure (HF) Describe the natural course of HF Identify the HFpEF patient Identify HFpEF phenotypes Describe therapies for HFpEF

3 1 in 5 Americans over 40 years old are at risk for HF In US, ~6 million people have clinical HF >650,000 new cases a year Mortality of 50% within 5 years (even with medical therapy) 30 days post-discharge fatalities reach 10%

4 Classification EF% HF r EF HF with reduced Ejection Fraction HF p EF HF with preserved Ejection Fraction HF p EF, borderline HF p EF, improved to 49 > % ACC/AHA HF Guidelines Yancy et.al.

5 Sarah J. Goodlin, et al. JACC 2009.

6 Symptoms: Dyspnea, LE edema, fatigue, Exercise intolerance Typically older woman with HTN, DMII, CAD, obesity, afib, HLD (HTN is most prominent 60-89%) Chemotherapy High blood pressure (>200/100) Clinical findings: JVD, loud P2, S4, rales, edema Laboratory findings: BNP typically normal

7 Nohria 2005 Circulation

8 Structural and functional evaluation with imaging Complete family history Ischemic evaluation Laboratory assessment (CBC, BNP, LFTs, INR, chem panel, SPEP/UPEP, iron studies, A1C, TSH/FT4) Hemodynamic assessment clinically and invasively if indicated (pulm htn freq found) Endomyocardial biopsies are rarely indicated (amyloid, infiltrative, eos)

9 Clinical signs and symptoms Preserved EF >50% Diastolic dysfunction by Doppler echo or cath (E/A ratio>2; LVEDP >12 mmhg and higher CVP) Diagnosis of exclusion Get a hemodynamic study if clinical presentation does not correlate to therapeutic response.

10 HFpEF 1--Hypertrophic CMP HFpEF 2 Infiltrative CMP HFpEF 3 Idiopathic CMP, non-lvh HFpEF 4 Secondary to other diseases (HTN, ischemic, valvular, obesity, CKD, sleep apnea)

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16 No therapy found to improve morbidity and mortality. Diuretics for symptom control. Be cautious with diuresis. Focus on treatment of co-morbid conditions Don t miss primary pulmonary hypertension

17 Drug Initial Daily dose Max Dose Notes Furosemide (loop) mg 120 mg bid BID~effective; IV >PO due to bioavailability and 2:1potency Torsemide (loop) mg 100 mg bid 1:2 furosemide: torsemide Bumetanide (loop) 0.5 mg-1 mg 5 mg bid 80% absorbed; 1:40 furosemide: bumex potency HCTZ (thiazide) 12.5 mg 50 mg Monitor Na Metolazone (thiazide) Spironolactone (aldosterone antag) Eplerenone (aldosterone antag) Triamterene (K sparing) 2.5 mg 2x/week 5 mg 3-4 x/week Monitor K, Na closely 12.5 mg daily 25 mg daily Monitor K & renal function 25 mg daily 50 mg daily 50 mg daily 100 mg BID Typically in combo

18 JNC-8 guidelines Use medications based off of co-morbid conditions Careful with CCB secondary to fluid retention Always counsel of low Na diet

19 Very sensitive to arrhythmias AHA/ACC/HRS Guidelines Cardiovert or control rates for afib esp with exercise Ablate aflutter over 95% success rate

20 BMI less than 30 is ideal Wt loss alleviates symptoms of HF Refer to cardiac rehabilitation Bariatric Medicine consult Gastric bypass surgical program

21 Get a sleep study Screen with overnight trend ox at home if indicated Helps with HTN, weight loss, dyspnea and fatigue

22 Advanced surgical therapy or transplant Ineffective therapy, unprepared death & readmissions Maximal medical therapy and palliative care

23 Earlier detection of HF exacerbations in the outpatient setting Triage RN HF clinic Monitoring Patient self-monitoring Device monitoring Telemonitoring Increased surveillance with clinic visits Hospital discharge follow-up and surveillance Earlier evaluation for advanced therapies. Partnership of patient and care providers to identify gate-keepers

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25 Left Atrial Decompression Pump For low cardiac output states especially with exercise High Pulmonary Capillary Wedge Pressures Improves exercise tolerance

26 Gina G. Mentzer, MD Cardiologist, Heart Failure & Transplant Advanced Integrated Medicine & Surgery (AIMS) Program for Heart Failure April 18 th, 2015

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