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Definition Congestive Heart Failure

Is defined as a clinical syndrome that results in cardiac dysfunction from myocardial loss or dysfunction and is characterized by left ventricular hypertrophy, dysfunction, or both.

HF stimulates a cascade of neurohormonal and circulatory responses that are reflected in the signs and symptoms commonly associated with HF: shortness of breath, fatigue, reduced exercise tolerance, and fluid retention

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The mortality rate for Medicare

The mortality rate for Medicare patients with HF remains at 50% after an HF hospitalization The cost burden associated with this prevalence is estimated to increase from $21 billion to $53 billion in direct costs during this period

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Key of reducing hospitalization and improving QOL

Managing HF symptom exacerbation in the primary care setting is paramount to improving quality of life and reducing hospitalizations for this population.

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2. List the signs and symptoms commonly associated with CHF. (Article)

• shortness of breath. • Fatigue. • Reduced exercise tolerance. • Fluid retention.

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3. What are the two elements that lead to HF

Disminución en el cardiac output o fallo de bomba

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4. In CHF Describe the pathophysiology of HF

a. Primary factors in pump dysfunction leading to ventricular dilation cause by endothelial dysfunction in the cardiac, coronary vascular, and peripheral vascular systems,

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b. In CHF What is the consequence of pump dysfunction

•leading to ventricular dilation.

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c. In CHF What happens after ventricular dilation?

The remodeling (which occurs as a consequence of neurohormonal stress, cytokine activation, and hemodynamic compromise) may be halted or reversed through medications and therapeutic interventions such as cardiac resynchronization therapy and left ventricular assist devices.

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d. In CHF What can stop remodeling?

El remodeling puede interrumpirse (halted) o revertirse mediante medicamentos e intervenciones terapéuticas, como: • Terapia de resincronización cardíaca. • Dispositivos de asistencia ventricular izquierda. (Left ventricular assist devises.)

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5. What are the comorbid conditions that affect how a patient responds to treatment for CHF?

a. Hypertension (HTN) b. Diabetes. c. Sleep apnea: El pte de fallo no responde bien al to casi siempre porque no corrige, sino que usa el C-pap. d. Atrial fibrillation. e. Coronary heart disease (CHD). f. Gout. g. Dyslipidemia. h. Reactive airway disease.

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6. List the common triggers of HF

Common triggers include: • Consumption of foods with high sodium content. • Excessive fluid intake. • Non-adherence to medical therapy. • Recurrent ischemia. • worsening valvular heart disease.

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7. Classification of HF according to 2013 ACCF/AHA guidelines

HF and EF Reducido el EF <40 % HF pEF >50% p=preservada Borderline 41-49% Improved> 40%

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Classification of HF: HF and EF Reducido

el EF <40 % También se conoce como HF sistólica. Los ensayos clínicos aleatorios han incluido principalmente pacientes con HFrEF y sólo en estos pacientes se han demostrado terapias eficaces hasta la fecha.

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Classification of HF Heart Failure with Preserved Ejection Fraction (HFpEF)

EF ≥50% También se conoce como HF diastólica. Se han utilizado varios criterios diferentes para definir mejor el HFpEF. El diagnóstico de HFpEF es un reto porque es en gran medida una de excluir otras posibles causas no cardiacas de síntomas sugestivos de IC. Hasta la fecha, no se han identificado terapias eficaces.

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Classification of HF . HFpEF, Borderline

EF : 41% to 49% Estos pacientes caen en un grupo límite o intermedio. Sus características, patrones de tratamiento y resultados parecen similares a los del paciente con HFpEF.

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Classification of HF : HFpEF, Improved

EF: >40% Se ha reconocido que un subconjunto de pacientes con HFpEF previamente había HFrEF. Estos pacientes con mejoría o recuperación en EF pueden ser clínicamente distintos de aquellos con EF persistentemente conservado o EF reducido. Se necesitan más investigaciones para caracterizar mejor a estos pacientes.

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ACCF/AHA stages of HF vs NYHA funcional cathegory A vs None

ACCF /AHA: A- At High risk for HF but without structural heart disease or symtoms of HR NYHA : None

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ACCF/AHA stages of HF vs NYHA funcional cathegory B vs I

ACCF /AHA: B = Structural heart disease but without sign s or symtoms of HF NYHA : I = no limitation of physical activity. ordinary physical activity does not cause symptoms of HF

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ACCF/AHA stages of HF vs NYHA funcional cathegory C vs 1-IV

ACCF/AHA C= Structural heart disease with prior or current symptoms of HF NYHA : I= no limitation of physical activity. ordinary physical activity does not cause symptoms of HF II= Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity result in symptoms of HF III= Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. IV= Unable to carry on any physical act. without symptoms of HF, or symptoms of HR at rest.

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ACCF/AHA stages of HF vs NYHA funcional cathegory D vs IV

ACCF /AHA D= refractory HF requiring specialized interventions NYHA IV= Unable to carry on any physical act. without symptoms of HF, or symptoms of HR at rest.

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9. What should be included in the H&P of a patient with HF?

Recomendation level B 

  1. A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF (Identificar trastornos o comportamientos de condiciones cardiacas y no cardiacas que pueden causar o acelerar el desarrollo de la HF. )
  2. In patient with idopatic DCM a 3-generational family history should be obtained to aid in establishing the diagnosis of familial DCM. Hx familiar de condiciones cardiacas. En paciente con DCM (disease congestion miocardic). Se debe obtener el family history de hasta 3 generaciones para ayudar en el establecimiento del diagnostico de DCM.
  3. Volume status and vital signs should be assessed at
    each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venouspressure and the presence of peripheral edema or orthopnea.
    1. (En cada encuentro con el paciente se tiene que medir el estatus de volumen y los vital sings: • Se pesa en cada visita • Se mide presión venosa yugular • Se evalúa por ortopnea • Edema periferal • Signos vitales.) 

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What is the initial lab evaluation of patients with HF? (Slide presentation)

  1. CBC, U/A.
  2.  Serum electrolito: Magnesio y calcio.
  3. Urea Nitrógeno
  4. Creatinina serum
  5. Glucosa.
  6. Fasting lipid profile (FLP)
  7. Pruebas de función hepática
  8. TSH.

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List the other diagnostic tests for HF and the areas that are evaluated with each

De acuerdo con la guía de 2013, la ecocardiografía bidimensional con doppler sigue siendo el método preferido para la evaluación diagnóstica de la fracción de eyección del ventrículo izquierdo (FEVI), el tamaño del VI, el espesor de la pared y la función de la válvula. 

Como alternativa, la ventriculografía con radionucleidos es también un instrumento diagnóstico Es útil para medir volúmenes de LVEF y LV.

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Efectos 2rios de de medicamentos 

Los ARB te ocasionan hypercalemia , no tanta tos

Los antagonistas de aldosterana hypercalemia

Beta blocker –enmascara los signos de hypoglisemia, vigilar los ptees diabético  

Los diuréticos de tipo Loop son tóxicos en oído.

Los thiazidas se administran 30 minutos antes de los loop y se potencia el efecto diurético de la droga. (en pacientes con overload)

Los nitratos no los puedo usar junto con los resucitadores del miembro (cialis, levita)

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CHF Tx : Angiotensin converting enzyme inhibitors (ACE-I)

Names: 

Enalapril (Vasotec)

Ramipril (Altace)

Captopril (Capoten)

Lisinopril (Zestril/Prinivil)

Trandolopril (Mavik)

Quinapril (Accupril)

Benazepril (Lotensin)

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Mecanismo accion: 

Angiotensin converting enzyme inhibitors (ACE-I)

Blocks the conversion of angiotensin I to angiotensin II (potent vasoconstrictor) enhancing vasodilation, reducing fluid volume, and reducingperipheral vascular resistance After myocardial infarction,reduces ventricular remodeling

 

 

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ACE - I adverse effects and key points in monitoring 

Volume depletion Worsened kidney function Cough Hypotension *Angioedema (mouth or lip edema) with or without anaphylaxis (a rarebut serious side effect). 

 

Blood pressure (BP)— evaluate for orthostasis if patient is symptomatic.  Serum electrolytes to evaluate kidney function (potassium, BUN, and creatinine)

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Angiotensin II Receptor Blockers names 

  1. Candesartan (Atacand)
  2. Irbesartan (Avapro)
  3. Losartan (Cozaar)
  4. Valsartan (Diovan

Similar act

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ARB  Mechanims of action 

                          Similar action to ACE-I, resulting in vasodilation, reduced blood
volume, and prevention of ventricular remodeling

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ARB Adverse effects and key points to monitor 

  1. Worsened kidney function
  2. Hyperkalemia
  3. Not likely to cause a cough
  4. Less likely to cause angioedema

Monitor :

Blood pressure (BP)— evaluate for orthostasis if patient is symptomatic 

Serum electrolytes to evaluate
kidney function (potassium, BUN,
and creatinine)