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Congestive Heart Failure

Congestive Heart Failure. Stephen Gottlieb, MD Professor of Medicine Director, Cardiomyopathy and Pulmonary Hypertension University of Maryland. What is Congestive Heart Failure?.  Ejection Fraction  NYHA (New York Heart Association Class)  Cardiac Index

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Congestive Heart Failure

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  1. Congestive Heart Failure Stephen Gottlieb, MD Professor of Medicine Director, Cardiomyopathy and Pulmonary Hypertension University of Maryland

  2. What is Congestive Heart Failure? •  Ejection Fraction • NYHA (New York Heart Association Class) • Cardiac Index • Pulmonary Capillary Wedge Pressure • Cardiopulmonary exercise test (CPEX) • BNP • None of the above X

  3. Congestive Heart Failure is a Clinical Diagnosis! • Called heart failure, chronic heart failure, CHF, HF • It is not equivalent to cardiomyopathy • Often defined as inability to maintain adequate cardiac output (CO) at normal filling pressures, either at rest, with exercise or both - resulting in symptoms and / or signs. • All of the previous factors help the clinician decide if the patient has CHF

  4. Causes of Heart Failure • Ischemic heart disease • Myocardial infarction • Ischemic heart disease • Non-ischemic cardiomyopathy • Alcohol • Hypertension • Thyroid disease • Amyloid • HIV • Myocarditis • Idiopathic • Diastolic dysfunction • Normal ejection fraction heart failure

  5. Symptoms • Shortness of breath (dyspnea) • Fatigue, Weakness • Orthopnea (dyspnea lying flat) • Paroxysmal nocturnal dyspnea (episodes of waking from sleep by dyspnea) • Cough, chest discomfort

  6. Signs • Pulmonary • Rales, CXR abnormalities (may disappear with chronicity) • Fluid overload • Edema, hepatomegaly, ascites, increased jugular venous distention

  7. Diagnosis Clinical Does the patient have typical symptoms? Shortness of breath with exertion Orthopnea, PND Fluid overload Known cardiac disease Is it cardiac or pulmonary If cardiac, what is the cause?

  8. Dilated Cardiomyopathy:Diverse etiologies, Common pathology ?

  9. Ejection Fraction • What is it? • The % of blood coming out of the heart with each beat • Advantages • Objective • Tells if there has been myocardial damage • Prognostic • Disadvantages • Doesn’t reflect physiology • Doesn’t tell you about physical limitations of patient

  10. No Systolic (Diastolic?) Dysfunction • Normal cardiac function • Elderly • Hypertension • Infiltrative (Restrictive Cardiomyopathy) • Amyloid • Hemachromatosis • Hypertrophic (HCM) • With Obstruction = HOCM

  11. NYHA (New York Heart Association Class) • What is it? • A subjective indication of physical status • I - no limitations • II – dyspnea on moderate exertion • III – dyspnea on minimal exertion • IV – dyspnea at rest • Stages • A - Risk for CHF; B – LF dysfunction without symptoms; C- Symptoms of CHF; D – Advanced CHF • Advantages • Assesses physical limitation • Disadvantages • Subjective • Affected by depression, deconditioning, psychological status

  12. Predictors of Depression (BDI) From Gottlieb et al, HF-ACTION data, 2008

  13. Hemodynamics Cardiac Index (CI)Pulmonary capillary wedge pressure (PCWP) • What is it? • A catheter measures cardiac function • Advantages • Objective, shows cardiac function • Disadvantages • Poorly related to symptoms • A one time measurement • PCWP reflects fluid status

  14. Cardiopulmonary Exercise Test (CPEX) • What is it? • Can measure work-load, peak oxygen consumption • Advantages • Objectively measures functional status • Disadvantages • Affected by deconditioning • Affected by lung disease

  15. BNP • What is it? • Blood test of peptide released by heart when distended

  16. We Know: BNP Levels Higher in Patients with Cardiogenic Dyspnea N=139 N=14 N=97 Maisel, A. et al. JACC, 2001; 37

  17. We Know: BNP and NT-proBNP is Prognostic in CHF Below Median Above Median From Richards et al. J Am Coll Cardiol 2006;47:52

  18. BNP • Advantages • Objective • Reflects cardiac pressure • Disadvantages • Can change with fluid status • Affected by Obesity, Intensive Care, Renal Disease, Chronicity of CHF, Pulmonary disease, Age

  19. Conclusion

  20. Conclusions • Heart failure is common, the cause of many hospitalizations (the most for Medicare) and disability • There are many different types of heart failure with many causes • It can be very difficult to determine if someone has heart failure • Our tests all tell different information

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