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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Diagnostic approach
Less common etiologies (i.e. non-ischemic):
• Familial dilated cardiomyopathy
• Genetic (HCM, ARVC, hemochromatosis)
• Drugs /toxins (alcohol, cocaine,
chemotherapy)
• Pregnancy (Postpartum cardiomyopathy)
• Inflammatory (myocarditis, sarcoid)
• Endocrine (pheochromocytoma, Cushing)
• Nutritional (thiamine deficiency / beriberi,
selenium deficiency)
• Infiltrative (amyloid, Fabry)
• Workup for non ischemic cardiomyopathy
– Good History
• Te st in g di re c te d by h is to ry ( eg ) ge ne ti cs i f fa mi ly
history
– Cardiac MRI for most with non-ischemic
cardiomyopathy
(If available)
• To h el p r ul e ou t i nf il tra ti ve , ARV C
49
Adapted from CCS HF 2017 Figure 2
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Classifying Non-Ischemic Cardiomyopathies
Hypertrophic
Dilated Restrictive
Arryhthmogenic
Right Ventricular CM
(ARVC)
Unclassified
Familial
Sarcomeric
Other
Non-familial
Obesity
Athletic training
Amyloidosis
Acromegaly
Familial
Sarcomeric
Other non-sarcomeric
Muscular dystrophies
Myotonic dystrophies
SCN5A mutation
Hemochromatosis
Non-familial
Idiopathic
Myocarditis
Eosinophilic
Toxin
Pregnancy
Endocrine
Nutritional
Tachycardia-induced
HIV
Heavy metals
Sarcoidosis
(ISCHEMIC)
Familial
Amyloidosis
Sarcomeric
Hemochromatosis
Anderson-Fabry
Gaucher’s
Non-familial
Idiopathic
Amyloidosis
Sarcoidosis
Scleroderma
Endomyocardial
diseases
Carcinoid
Radiotherapy
DM
Drugs
Familial
Intercalated disc
(desmosome)
Ryanodine receptor
TGF-beta3
Familial
LV non-compaction
Lamin A/C
Barth
Non-familial
Takotsubo (stressinduced)
Adapted from: Elliott P et al. Classification of the cardiomyopathies: a position
statement from the ESC Working Group on Myocardial and Pericardial Diseases.
European heart journal. 2008 Jan 1;29(2):270-6.
*** NOT an
exhaustive list
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Acute HF Management
– Establish Diagnosis ASAP
(
guidelines say <2h after contact in ED
)
– Start with ABCs, IV O2 Monitor (IOM)
– Focused history: dyspnea, fatigue, edema
– Focused physical: congestion, valvular dz,
perfusion
– CBC, lytes, urea/Cr, gluc, BNP, Tn
– ECG, CXR
– Echo (w/in 48h)
– Consult CCU/Cardiology
– Consider potential etiologies or triggers for
decompensation
• Ischemia, HTN, Anemia, rapid afib, infection,
med or diet non adherence, NSAIDs, PE, thyroid…
Cardiogenic Shock
• Clinical + biochem manifestations of tissue
hypoperfusion
• SHOCK trial definition used most
• Stop beta blocker, other antiHTN
• Pressors / inotropes usually needed
• May need mechanical support
Acute Pulmonary Edema
• Identify underlying etiologies (HTN, MR, arrhythmia)
• Aggressive diuresis
• If hypertensive or MR à short-acting vasodilators
(e.g. nitroglycerin infusion, spray, patch)
• NIPPV à invasive ventilation (reduces
preload/afterload)
Atrial Arrhythmia
• Determine if chicken or egg (often difficult)
• If overloaded, achieve euvolemia
• If on BB à continue unless in shock
• If not on BB à don’t start in shock or +++ overload
• Use short acting medications
• Digoxin can be helpful for rate control if soft BP
• If unstable à ACLS
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Shock Grid to Guide Therapy
Dry Wet
Warm
(Distributive shock)
Low PCWP
Normal/High CI
Low SVR
(Mixed shock)
High PCWP
Low CI
Low/normal SVR
Cold
(Euvolemic cardiogenic
shock)
Low PCWP
Low CI
High SVR
(Classic cardiogenic
shock)
High PCWP
Low CI
High SVR
CI = cardiac index = CO/BSA (cardiac output/body surface area)
PCWP = pulmonary capillary wedge pressure
SVR = systemic vascular resistance
• What is the pump
doing?
• What are the filling
pressures / volume
status?
• What are the blood
vessels doing?
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Inpatient or outpatient management?
• In your applied exam, consider safety and resource utilization when treating acute heart failure
– For oral situations, it should be obvious if the patient needs hospitalization (i.e. they are hypoxemic or unstable)
• Risk scores exist to estimate patient mortality when presenting to the ED with HF (e.g. Emergency Heart
Failure Mortality Risk Grade [EHMRG] score)
– Freely available at MDCALC.com – gives 7day risk of mortality
• *NEW* COACH-HF trial (NEJM, 2023) showed that the use of a risk score tool (EHMRG30-T), stratifying
patients into low risk patients that can be discharged with standard follow-up or high risk patients that
should be admitted, was associated with ↓ rates of overall death and hospitalization compared to a
time period where the tool was not used (12.1% vs. 14.5% at 30 days, HR 0.88)
– Therefore, use of a validated risk score improved patient outcomes
53
CCS 2017 HF
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Long-term Management of HFrEF
Establish etiology
Practically: Hx/PE/labs +
• Echocardiogram (r/o non-myocardial causes)
• BNP: 2017 CCS recommends BNP if diagnosis unclear and for prognosis
• Assess for CAD (very often coronary angiography)
• CMRI for non ischemic etiologies
Quantify degree of disability
NYHA classification (I-IV)
• Allows clinician to track progress
• Becomes important for therapy considerations
CCS 2017 HF
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Risk factor modification & lifestyle interventions
• Exercise (flexibility, aerobic, +/- resistance)
• Salt restriction (<2-3g/d) à SODIUM-HF trial 2022 showed that strict salt restriction <2g/day did not improve HF related
hospital visit or CV death
• +/- fluid restriction (<2L/d)
• Smoking cessation
• EtOH avoidance
• Discuss Driving Safety (see bonus slides)
Treat HF-associated comorbidities (see later)
Multidisciplinary care model
Early advanced care planning discussions
Interventional therapy considerations
• ICD, CRT (see later)
• Surgery / percutaneous treatment of functional MR (see later)
• Revascularization in ICM
Advanced HF
• Really low EF, ++hospitalizations, NYHA IV, organ dysfunction, cardiac cachexia, high 1-year mortality, bad CPET performance…
• May need: Mechanical circulatory support (eg) VAD, Transplant workup, or palliative care
Once stabilized, reassess at least annually with clinical assessment + LVEF assessment
CCS HF 2017
Long-term Management of HFrEF
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Revascularization and ischemic cardiomyopathy
• Controversial area where new evidence is emerging
• STICH trial (CABG + medical therapy vs. medical therapy) showed
improved long-term mortality with revascularization with CABG
compared to medical therapy alone
• Subsequent PCI trials, including the most recent REVIVED-BCIS,
looked at patients with LVEF <35% with multivessel disease and
viability on cardiac MRI, showed no improvement in outcomes/LVEF
with PCI
• If choosing an option for revascularization for ischemic
cardiomyopathy, CABG would likely lead to improved outcomes
compared to PCI with the available evidence. However, optimizing
medical therapy is paramount in ALL patients!
56
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Guideline recommended pharmacotherapy for HFrEF
“Backbone” of HFrEF therapy now QUADUPLE Tx
• ARNI ßà
ACEI/ARB
• MRA
• SGLT2i (
even if not diabetic!
)
• BB
[only start when euvolemic and
hemodynamically stable]
Other tips
• Goal for target doses by 3-6 months
• No preference for uptitration in parallel vs. sequentially, no preference order you start rx
– “initiate standard therapies and titrate every 2-4 weeks…”
• Avoid CCBs with LVEF < 40% (amlodipine ok for HTN)
• Do not start BBs on NYHA IV patients
• ARNI initiation requires 36h “washout period” after ACEI use
HFrEF Pharmacotherapy
CCS 2021/2020/2017 HF
ARNI in clinical practice:
Start ARNI: Hospitalized w new dx HFrEF
Switch to ARNI if:
- Hospitalized for HF on ACE/ARB
- Symptomatic (NYHA2+) despite max ACE/ARB
Not practical if: no drug plan
($7 per day vs $0.20 per day for valsartan only)
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Long-term
Management
of HFrEF
CCS 2021 HF
See bonus
material for
more Rx info
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