Heart Failure

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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 (lt 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

3
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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ROC Curves for BNP and ED Diagnosis Using All
250 Patients
82
118
205
Sensitivity ()

---
BNP
--- ER diagnosis
AUC
0.884
0.9790


1 - Specificity ()
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Identifying Heart Failure Using BNP
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Treatment Recommendations for Heart Failure
Patients with Left Ventricular Systolic
Dysfunction
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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