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HeartfailureHeartfailureDiagnosisCase 160 y/o male with PMH of HTN and CHDLVEF%40%and LV enlargementw/o any symptoms or signsHeart failure?Yes?Or No?DiagnosisHF is defined as a clinical syndrome that is characterized by specific symptoms(dyspnea and fatigue)in the medical history and signs(edema,rales)on the physical examination.There is no single diagnostic test for HF because it is largely a clinical diagnosis that is based on a careful history and physical examinationStage:from A to DStage A and B:clearly not HF at risk for developing HF Stage C and D:HFDifferent stage,different treatmentStages vs NYHA functional classObjective and subjectiveProgressiveReverseAssessment:Are you sure?The same case60 y/o male with PMH of HTN and CHDp/w dyspnea,fatigue,lower extremities edemaPE detect rale on the bilateral lower lungDx?Further evaluationMedical historyLaboratory test imageHeart failure assessment详细的病史和查体病因的询问用药（加药，减药）日常活动耐量容量状态,既往出入量,体重变化颈静脉CBC/BUN/Cr/electrolytes/UA/FBG/TSH/lipid profile/liver functionECG/CXR/echocardiographyBNPDrugs:are you sureCase 260 y/o male w/PMH of OMILVEF 40%w/o symptoms and signsShall I use ACEI or B-blocker?Shall I use digoxin?Shall I use diuretics?Therapy:ACEIStage A:prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease,diabetes mellitus,or hypertension with associated cardiovascular risk factors(IIa A)Stage B:be used in all patients with a recent or remote history of MI regardless of EF or presence of HF(I A)/used in patients with a reduced EF and no symptoms of HF,even if they have not experienced MI(I A)Stage C:recommended for all patients with current or prior symptoms of HF and reduced LVEF,unless contraindicated(I A)Therapy:B-blockerStage A:No roleStage B:be used in all patients with a recent or remote history of MI regardless of EF or presence of HF(I A)/in all patients without a history of MI who have a reduced LVEF with no HF symptoms(I C)Stage C:recommended for all stable patients with current or prior symptoms of HF and reduced LVEF,unless contraindicated(I A)Therapy:DigoxinStage A:No roleStage B:should not be used in patients with low EF,sinus rhythm,and no history of HF symptoms(III C)=No roleStage C:can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF(IIa B)Therapy:SpironolactoneStage A:NO roleStage B:NO role eitherStage C:is reasonable in selected patients with moderately severe to severe symptoms of HF and reduced LVEF(I B)BNP(NT-proBNP)60 y/o male w/PMH of OMI HTNLVEF 40%p/w dyspnea,lower extremities edema and can not lie flatDx?Shall I order BNP?About:BNP and NT-proBNPDiagnosis:in the acute setting to rule out or confirm the diagnosis(I A)emphasize:among patients presenting with ambiguous signs and symptomscan be helpful to exclude the diagnosis of heart failure among patients with signs and symptoms suspicious of heart failure in the non-acute setting(IIa C)Routine testing for patients with an obvious clinical diagnosis of heart failure is not recommended(III C)About:BNP and NT-proBNPGuiding managementThe value of serial measurements of BNP to guide therapy for patients with HF is not well establishedRoutine blood BNP or NT-proBNP testing is not warranted for making specific therapeutic decisions for patients with acute or chronic heart failureConclusionDiagnosis:Are you sure?AssessmentThe role of BNP:Are you sure?Pharmacological therapy:Are you sure?Further learning:beyond todays scopeManagement of acute onset heart failureDevices:ICD and CRTRole of CCB and ARBEtiology/classificationPatients With HF and Normal LVEFBeyond scopeHeart failure!Too much,too hard,too complicated!I am not sure!I feel frustrated!Q and AAny questions?References2009 Focused Update:ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults.J Am Coll Cardiol,2009;53:1343-1382 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult.Circulation 2005;112;e154-e235Clinical Utilization of Cardiac Biomarker Testing in Heart Failure.2007
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