BNP (confirmatory and marker of response to therapy)
Stress testing (determine if CAD is a causative factor)
Cardiac cath (plan for possible re-vascularization or valve procedure)
Treatment of chronic CHF
Low sodium diet (improves diuresis and decreases fluid overload/edema)
Daily weight (best measure of fluid status; weight gain of 3 pounds in 2-5 days indicative of a problem)
O2 if needed (based on ABG or pulse ox)
Control hypertension (decrease SVR)
Correct CAD (improve myocardial performance)
Control or correct arrhythmias (cardioversion or medications to control rhythm and rate)
Correct Valve disorders (improves function)
MedicationsBi-ventricular pacing (improves synchronization of ventricles and CO)
Drug therapy for CHF
ACEI (proven reduction in morbidity and mortality; decreases preload, afterload and myocardial remodeling)
ARB (if ACE not tolerated)
Beta Blockers Carvedilol (Coreg), Metoprolol (Toprol XL) (decrease in myocardial contractility, morbidity and mortality; control BP and HR; prevent myocardial remodeling; start low and go slow)
Loop Diuretics (decrease preload; do not prolong survival, just symptom management)
Digoxin (positive inotropic action; increases contractility; decreases HR and conduction; low therapeutic index; watch for toxicity e.g. headache, nausea, vision changes, arrhythmias, heart block, "green-yellow halos" around eyes; monitor levels and serum electrolytes; no reduction in mortality; benefit to reduce hospitalization and symptoms)
Spironolactone (K sparing diuretic; helpful in severe CHF; must have adequate renal function; watch K with ACEI)
Nitrates (decrease preload; vasodilation)
Statins (to treat any underlying hyperlipidemia)BiDil® (Isosorbide and Hydralazine)
What is the risk of combining spironolactone with an ACEI?
Which drugs have been shown longer survival in heart failure?
IABP (intra-aortic balloon pump; inflates during diastole; improves coronary perfusion; decreased workload for LV)
VAD (ventricular assist device; surgically implanted pump; bridge to transplant; “Destination Therapy”.
Bridge to transplant (heart is in bad shape so are kept alive on VAD until transplant is available)
Destination therapy (patient is not a candidate for transplant but will try out VAD to help support ventricle and increase survival)
Intra-aortic Balloon Pump (IABP)
Group of diseases resulting in damage to heart muscle, structure, and function
3 Types (Dilated, Hypertrophic, and Constrictive)
Most common 90% (idiopathic)
Primary (alcohol, viral, Doxorubicin (Adriamycin), ischemia, drug abuse)
Secondary (cardiomegaly with ventricular dilatation; impaired systolic function; atrial enlargement; stasis of blood in LV; increased risk of thrombi and arrhythmias; patients often younger than CHF patients)
Pathophysiology (resembles CHF, but the walls of the ventricles do not hypertrophy)Treatment (same as CHF, +/- anticoagulants, +/- antiarrthymics)
Transplantation (accounts for 50% of heart transplants)
Idiopathic Hypertrophic Subaortic Stenosis (IHSS)
Overgrowth of myocardium that obstructs outflow of blood through aorta (impedes systolic outflow and diastolic filling)
Causes: genetic, congenital, aortic stenosis, HTN
Very poorly tolerate tachycardia (decreased time in diastole; left ventricular filling) and hypovolemia (don't adequately fill ventricle; need big bolus of blood to push past obstruction)
Hard to diagnose (ECHO)
Results in exertional dyspnea, syncope, angina, arrhythmias
Cause of sudden death in athletes
Treatment of hypertrophic cardiomyopathy
Beta Blockers and Calcium Channel Blockers (decrease contractility, improve outflow and ventricular filling)
Symptoms: exercise intolerance, angina, syncope, dyspnea on exertion
Cannot tolerate increased HR or increased CO to meet demand
Diagnosed via ECHO
Treatment: same as CHF; treat arrhythmias, transplant, avoid exertion and dehydration
Demand exceeds supply (half of candidates die waiting for organ)
Criteria (age restriction, must be younger than 67 years old; otherwise good health; able to comply with complex medical regimen; no active infection; no active or recent maligancy
Procedure: evaluated for place on wait list; must be matched; may require vasopressors or IABP
Life-long immunosuppresants (increases risk of infection and malignancy)
Same as CHF, treatarrhythmias, transplant, avoid exertion, dehydration.
Cardiac Transplant Demands
Demand Exceeds Supply
Half of candidates die waiting for organ.
CriteriaAge restriction > 67, otherwise good health, able to comply with complex medical regimen, no active infection, no active or recent malignancy.ProcedureEvaluated for place on wait list. Must be matched. If condition dteriorates may be hospitalized. May require pressors or IABP.Life Long Immunosuppressants.Increased risk of infection and malignancy
Cardiac Transplant Criteria
Age restriction > 67, otherwise good health, able to comply with complex medical regimen, no active infection, no active or recent malignancy.
Cardiac Transplant Procedure
Evaluated for place on wait list. Must be matched. If condition deteriorates may be hospitalized. May require pressors or IABP.
Risk of Life long Immunosuppressants with cardiac transplant...