HEART FAILURE. Ali Mehr, MD, FACC
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1 HEART FAILURE Ali Mehr, MD, FACC Advanced Heart Failure and Transplant Cardiologist Director, Echocardiography Lab Phoenix VA Health Care System Associate Professor of Medicine University of Arizona, COM, Phoenix
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7 HEART FAILURE America s Silent Epidemic HFSA
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14 Only about 30 million is committed in research dollars for heart failure annually. In comparison lung cancer research receives $132 million annually.* *: HFSA.org
15 EDUCATION
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20 HFpEF Aortic Stenosis and Regurgitation Mitral Stenosis and Regurgitation Tricuspid Regurgitation Obstructive Sleep Apnea Pulmonary Arterial Hypertension Cardiac Amyloidosis Cardiac Sarcoidosis Constrictive Pericarditis Hypertensive Cardiomyopathy Hypertrophic Cardiomyopathy
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53 Which patient has lower blood pressure? 1) A forty year-old man with EF:20% 2) A sixty year-old woman with EF:55% 3) A twenty year-old woman with EF:70% 4) A seventy year-old man with EF:30% 5) None of the above
54 Formula to Remember Blood flow is cardiac output (CO) BP ~ CO x SVR CO = HR x SV SV = EDV-ESV EF = EDV-ESV/EDV
55 Week 1 You are seeing a 60 year-old African American patient with HFrEF (LVEF:20%) who has been discharged 5 days ago. This is his first f/u visit after two weeks of hospitalization and IV diuresis for ADHF. His weight upon discharge was 220 lbs. Meds: Lisinopril: 5mg daily. Carvedilol 3.125mg BID, Furosemide: 80mg BID On exam, BP:120/70mmHg, HR:84bpm, JVP:14CmH20 Weight: 210 lbs (7 lbs below his dry weight). Serum Cr: 2.1 (discharge Cr:1.9); K:4.2
56 1) Continue the same dose of medications 2) Decrease furosemide to 80mg daily 3) Decrease furosemide to 40mg BID 4) Hold furosemide 4) Keep furosemide at the same dose; decrease lisinopril to 2.5mg daily
57 DRY WEIGHT IS A MYTH! Same Person Same Scale Same time Same cloths
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61 Week 2 Patient is back to your clinic, he feels great. He is ambulatory and is back to his baseline DOE at NYHA class II. Exam: BP:110/66mmHg, HR:84bpm, JVP:8CmH20, Weight:204 lbs Serum Cr:2; K:3.8
62 1) Increase carvedilol to 6.25mg BID 2) Increase lisinopril to 10mg daily 3) No change in his medications, as he is back to his baseline and feels great. 4) Decrease his furosemide in preparation for uptitration of his HF medications. 5) It does not really matter whether you increase lisinopril or carvedilol, but you should start uptitration.
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64 Week 4 You increased carvedilol to 6.25mg BID and he has tolerated it well. His weight has remained stable at 205 lbs and has stable DOE at NYHA class II. On exam: BP:106/64mmHg, HR:80bpm, JVP:8Cm H20 Serum Cr:2; K:3.6.
65 1) Start Spironolactone at 25mg daily 2) Start Hydralazine/nitrate 3) Decrease furosemide due to borderline low serum potassium 4) Add KCl at 20mEq daily 5) No change in his medication in this visit
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67 Week 6 He has been doing well, Completely asymptomatic during performing his ADLs. Stable DOE at NYHA class II. His weight has remained stable at 203 lbs. On exam: BP:90/62mmHg, HR:80 bpm, JVP:6Cm H20 Serum Cr:2.1; K:4.4.
68 1) Decrease furosemide to 80mg daily 2) Hold furosemide 3) Increase carvedilol to 9.375mg BID 4) Decrease spironolactone to 12.5mg daily 4) No change in his medication as he is doing well and borderline low BP
69 Formula to Remember Blood flow is cardiac output (CO) BP ~ CO x SVR CO = HR x SV SV = EDV-ESV EF = EDV-ESV/EDV
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71 The keyword is: OPTIMIZATION
72 Week 40 Patient loses follow-up and 9 months later presents to the ED and is admitted for IV diuresis for ADHF. What is the most common precipitating factor for hospital readmission?
73 1) Pneumonia/Respiratory process 2) Medication non-compliance 3) Diet non-compliance 4) Worsening renal failure 5) Uncontrolled hypertension 6) Ischemia/ACS
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75 WHO SHOULD ADMIT THEM?
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77 WHERE TO ADMIT THEM?
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81 HOW LONG TO KEEP THEM?
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83 Let s get an echo to know the EF It is very difficult to assess cardiac function when HR:130 bpm! It is very difficult to interpret very poor echo images Right chambers are usually not well visualized They have already had WMA and depressed systolic function.
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86 WHAT STRATEGY TO USE FOR DIURESIS?
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89 MY PATIENT IS NOT RESPONSIVE TO LASIX
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93 I MAXED OUT THE DOSES OF ALL DIURETICS, BUT STILL NOT GETTING ENOUGH DECONGESTION
94 DON T LET IT FAIL! Thank You! Ali.Mehr@va.gov
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