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ASLAM

ASLAM. CHF. Symptoms and Statistics. Symptoms: fatigue, dyspnea, orthopnea, edema, ascites, JVD Statistics: 4.6 million affected in US; 1 million hospitalizations; 200,000 deaths

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ASLAM

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  1. ASLAM CHF

  2. Symptoms and Statistics • Symptoms: fatigue, dyspnea, orthopnea, edema, ascites, JVD • Statistics: 4.6 million affected in US; 1 million hospitalizations; 200,000 deaths • Fatality: pts with systolic dysfxn and no symptoms have 20% risk of death in 5 years; pt with class 4 has 50% risk of dying in 1 year (the point is, this is not just some lame chronic disease, it can KILL you)

  3. Classification • Correctable vs Non Correctable • Correctable: if you correct the underlying condition it will improve the CHF • HTN, CAD, valvular heart dz, thyroid heart dz, anemia, tachycardia • Non Correctable: occurs when fail to provide appropriate/timely treatment, damage is irreversible

  4. Classification • Systolic vs Diastolic • Systolic: EF < 40%, dilated heart, decreased contractility • Diastolic: EF > 40%, heart normal or enlarged, decreased compliance

  5. Classification • Functional • Class I:no limitation of physical activity, no SOB or tachycardia with normal activity • Class II: symptoms with ordinary activity • Class III: symptoms with little activity (ie walking across the room) • Class IV: symptoms at rest

  6. Diagnosis • H&P: symptoms • EKG • CXR: cardiomegaly, pulmonary congestion (kerley B lines) • Lab studies: hyponatremia (diluted/fluid overload) • Echocardiogram • Cardiac enzymes • Serum marker: BNP is diagnostic

  7. LEFT heart failure Displaced apical pulse S3 Decreased breath sounds Pulmonary rales RIGHT heart failure Peripheral edema Increased JVP Hepatojugular reflex Hepatomegaly ascites

  8. BNP (B type natriuretic peptide) • Diagnostic(and prognostic) serum marker for CHF • Secreted from ventricles • Levels correlate with EDP and EDV • BNP<100 is NOT CHF • BNP>500 is diagnostic

  9. Treatment of CHF • Non Pharmacologic: • Education/fluid restriction/weight maintenance • Pharmacologic Algorithm: • Start with diuretic, add ACE I • If ACE I tolerated, add B-blocker If ACE I not tolerated, add ARB, then add B-blocker • If B-blocker not tolerated, add aldactone If B-blocker tolerated continue therapy and adjust doses as needed

  10. Diuretics • MOA: Decrease volume by preventing Na+ and H2O reabsorption (makes you pee a lot) • If edema is resistant: increase dose/frequency, switch drugs, combo therapy, parental administration, hemodialysis/filtration • Consequences: lowers intravascular pressure, lowers CO, electrolyte imbalance, hearing loss, gynecomastia (“man boobies”)

  11. ACE Inhibitors • Sounds like “-pril” • MOA: block conversion of angI to angII (so blocks the effects of angII: decrease aldosterone, decrease NE levels)

  12. Digoxin (+ inotrope) • MOA of Digoxin: inh Na/K ATPase in cardiac cells….leads to increased Ca++…..leads to increased contractility • Other effects of Digoxin: decrease epi, decrease peripheral vascular resistence, increase parasympathetic effects • Recommended for use in class 2-4, particularly with diuretics/AceI/B blockers

  13. ARBs • MOA: block angII receptors • NOT first choice, only if AceI not tolerated

  14. Beta Blockers • MOA: up regulates B1 receptor density, increase inotropic sensitivity to catecholamines • Sounds like “-olol”

  15. Clinical Trials (for the gunners) • SOLVD: Enalapril decreases mortality 16%(compared to placebo) • VHeFT2: Enalapril decreases mortality 28%(compared to hydralazine and isosorbide) • RALES: Aldactone added to standard regimen reduces mortality by 30% and hospitalizations by 35% • Elite II: no difference between Captopril and Losartan • CIBIS II: Bisoprolol decreased mortality 34% • MERIT-HF: Metoprolol reduces mortality 34%(compared to placebo) • COPERNICUS: Carvedilol improves survival 35% • US Carvedilol Heart Failure Study: 65% reduction in mortality (compared to placebo) • MIRACLE: BiV pacing improves status by at least one class and decreases hospitalization • PATH-CHF: BiV pacing had best outcome (compared to RV or LV)

  16. Acute CHF • Treatment— “LMNOP” • Lasix (IV diuretics) • Morphine • Nesiritide (BNP)/Nitroglycerine • Oxygen • Positive Inotropic Agents

  17. BNP Effects • Increases diuresis and natriuresis • Decreases afterload, preload, aldosterone, endothelin, dyspnea, PCWP

  18. If drugs cannot control CHF, must consider Pacemaker therapy, Surgical management, and if nothing else works—heart transplant

  19. That’s It for Aslam!

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