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Heart Failure with Reduced Ejection Fraction

Etiology

  • 1) Ischemic Heart Disease/Cardiomyopathy (Impaired Contractility)
    • IHD/CAD = 60-75% of HF cases in developing world
      • Decreased cardiac output due to impaired contractility
      • A compensatory rise in NE, Renin, and ADH
      • Increases SVR
    • Coronary Artery Disease (CAD)
    • Chronic Volume Overload (MR, AR, Shunting)
    • Chronic Lung Disease (Cor pulmonale, Pulmonary vascular disorders)
  • 2) Dilated Cardiomyopathies (Impaired Contractility)
    • 30%, Defect in force generation, transmission, myocyte signaling
      • Genetic (20-50%) (Cytoskeleton mutation)
      • Non-Genetic (Myocarditis, Peri-partum, Toxic (alcohol), Idiopathic)
      • Infiltrative Disorders
  • 3) Valvular Heart Disease
    • 15%
    • Toxic/drug-induced damage (Metabolic disorder, Viral)
    • Chagas disease
    • Rate and Rhythm disorders (Chronic Arrythmias)
  • 4) Hypertension
    • 10%

General

  • 80% die from Cardiovascular Causes (MC Cause of death)
    • Worsening HF (Cardiogenic Shock, Low Output State)
    • 40% Sudden Cardiac Death (VTach (most common), Bradyarrhythmia)
  • Hypertension contributes to 75% of patients, also DM
  • Valvular heart disease also contributes (EtOH, Hypertension, Drugs) - Systolic Heart Failure (Contractile Failure)
  • Compliance (C) = EDV/EDP
    • EDV not easily measured, thus use EF = SV/EDV measured via TTE
  • Characterized by decreased CO/CI, increased SVR, and increased LVEDV
  • Decreased CO (insufficient ventricular contractility, EF will be low)
  • Decrease in SV and Increase in EDP
    • Decreased CO, increases A-a O2 and decreases renal perfusion
  • Increased EDP associated with Increase in EDV
    • Decreased Compliance (EF ≤40%), Increased HR

Poor Prognostic Factors for HFrEF

  • 30-40% die within 1 year of diagnosis and 60-70% die within 5 years
  • Higher NYHA functional Class
  • Exam
    • Resting Tachycardia
    • Presence of an S3 gallop
    • Elevated JVP
    • Hypotension: BP <100/60
  • Labs:
    • Hyponatremia
    • Elevated pro-BNP levels, high NE and catecholamines, elevated troponins
    • Renal insufficiency
    • Low maximal oxygen consumption (peak VO2)
  • ECG: QRS >120ms, LBBB pattern
  • Echocardiography
    • Moderate to severe mitral regurgitation
    • Severe LV dysfunction
    • Concomitant diastolic dysfunction
    • Reduced RV function
    • Pulmonary Hypertension
  • Other:
    • Anemia
    • Atrial Fibrillation
    • Diabetes Mellitus

Treatment to improve long-term survival:

Other Management