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How do I manage systolic heart failure?

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The management of systolic heart failure is based upon relieving symptoms of volume overload [congestion, dyspnea] and improving left ventricular function.

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HPI: Dyspnea on exertion or at rest, fatigue, weakness, diaphoresis.

PMH: Hypertension, coronary artery disease, hyperlipidemia, diabetes, atrial fibrillation.:

PSH: Smoking, alcohol.

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Peripheral edema, elevated jugular venous pressure, rales, laterally displaced apical impulse, S3 gallop.

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ECHO: LVEF <40%, LA and LV enlargement, wall motion abnormalities.

X-ray: Cardiomegaly, cephalization of pulmonary vessels [increased distribution of flow to apices], pleural effusion.

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S-HF = Patient with Systolic Heart Failure, LVEF <40%.

LVEF = Left Ventricular Ejection Fraction.

AFIB = Atrial FIBrillation.

FUROS = FUROSemide 40 mg IV load followed by 20 mg/hr.

ACEI = ACE-Inhibitor enalapril 10 mg BID. If patient unable to tolerate ACE inhibitors, give angiotensin II receptor blocker (ARB) valsartan orally 80 mg BID.

METO = Oral extended release METOprolol 25 mg QD.

DIG = DIGoxin 0.5 mg QD for 2 days followed by 0.25 QD maintenance dose.

HYD = HYDralazine 10 mg TID.

NIT = Isosorbide diNITrate 20 mg TID.

INTOL-ACEI = Patients who are INTOLerable to ACE Inhibitors or angiotensin II receptor blockers.

INEFF = INEFFective treatment with furosemide and enalapril, with patient exhibiting symptoms of heart failure (dyspnea, weakness, elevated BP).

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S-HF = FUROS + ACEI + METO

S-HF + INTOL-ACEI = FUROS + HYD + NIT + METO

S-HF + INEFF = FUROS + ACEI (or HYD+NIT) + METO + DIG

S-HF + AFIB = FUROS + ACEI + METO + DIG

S-HF + AFIB + INTOL-ACEI = FUROS + HYD + NIT + METO + DIG

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Digoxin is effective in increasing cardiac output, improving exercise capacity and left ventricular function in patients with systolic heart failure unresponsive to diuretics, ACE inhibitors, and beta blockers. While neurohormonal effects occur with doses of digoxin < 0.25 mg/day, positive inotropic actions usually require doses > = 0.25 mg/day.

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  • – DIG trial has shown digoxin therapy to significantly reduce hospitalization rates for patients with heart failure, but no benefits in overall mortality.

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  1. Hunt SA, et al. 2009 Focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults. Circulation. 2009;119:e391.

  2. Digitalis Investigation Group. Sex based differences in the effect of digoxin for the treatment of heart failure. N Engl J Med. 1997;336: 525–533.

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How do I manage a patient presenting with acute diastolic heart failure?

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Diastolic heart failure (DHF) is defined as heart failure (HF) with a preserved LVEF variably defined as LVEF >45% or 50%. The management of diastolic heart failure is based upon reducing congestive state, controlling heart rate, treatment and prevention of ischemia, and control of blood pressure.

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HPI: Dyspnea on exertion or at rest, fatigue, weakness, diaphoresis.

PMH: Hypertension, coronary ...

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