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How do I manage heart failure with reduced ejection fraction (HFrEF)?

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The management of 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, paroxysmal nocturnal dyspnea, orthopnea

PMH:

  1. Ischemic heart disease

  2. Nonischemic causes: HTN, HIV, connective tissue disease, substance abuse, infiltrative disease, myocarditis, doxorubicin, arrhythmias (e.g., Afib), valvular disease (aortic stenosis, mitral stenosis, aortic insufficiency, mitral insufficiency).

PSH: Smoking, alcohol.

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Elevated jugular venous pressure, rales, laterally displaced apical impulse, S3 gallop, peripheral edema.

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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 2.5 mg BID, captopril 6.25 mg TID, lisinppril 5–10 mg daily titrated to a maintenance dose. If patient unable to tolerate ACE inhibitors, give angiotensin II receptor blocker (ARB) valsartan orally 40 mg BID titrated to a maintenance dose of 80–160 mg BID.

BB = Carvedilol 3.125 mg BID titrated to 25 mg BID or oral extended release metoprolol 25 mg QD upto 100 mg QID.

DIG = DIGoxin 0.125 to 0.25 mg QD for 2 days followed by 0.25 od maintenance dose.

HYD = HYDralazine 25–50 mg 3–4 times daily up to 300 mg in divided doses.

NIT = Isosorbide diNITrate 20–30 mg 3–4 times a day.

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 + BB

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

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

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

S-HF + AFIB + INTOL-ACEI = FUROS + HYD + NIT + BB + 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.

  • – Furosemide and digoxin only provides symptomatic relief as opposed to aldactone which in addition to symptomatic relief, provides mortality benefit in patients with HFrEF.

  • – Avoid ACE-I and ARBs

  • – Start with loop diuretic in volume overloaded patients, ACE-I or ARB and then a BB.

  • – Start low dose and then titrate to maintenance.

  • – Check potassium levels with patients on ACE-I/ARB/furosemide/spironolactone 2 weeks ...

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