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Heart Failure (HF): Demand Shortfall Simplified

Ischemic heart disease, hypertension, and heart failure (HF) are all on the rise in America. This blog will be centered around simplifying heart failure. Like most complex medical topics, I like to break things down algorithmically and separate things into simpler parts whenever possible. ACLS and PALS utilize an algorithmic approach as well as innovative artificial intelligence (AI) and machine learning software which expands well beyond the realm of medicine. Stay tuned, AI in healthcare will be discussed in a future blog post. I think of heart failure and their related topics in bundles of "two (2)".

1.) Is it acute OR chronic?

Acute (sudden): causation can include an MI, a pulmonary embolism, or flash pulmonary edema.

Chronic (gradual or subtle): - these can be compensated patients.

2.) Is it a systolic OR a diastolic failure?

Systolic: impaired pumping or contractility - typical LVEF is < 40%, remember LVEF=SV/EDV x 100 and normal is around 65%. w/o disease- SV=70ml and EDV=110ml. Causation is most commonly tied to smoking, HTN, sedentary lifestyle, dilated cardiomyopathy or even a significant family history of early CAD.

Diastolic: impaired ability to fill where the LVEF is usually close to normal. Causation is most commonly tied to HTN, tamponade (trauma/medical origins), hypertrophic cardiomyopathies.

Source: Index of Sciences

3.) Is it left sided OR right sided?

Left: patient could c/o dyspnea - listen for adventitious lungs sounds and sit them up - on physician exam, it could also be related to a valvular issue.

Right: strongly tied to chronic lung disease. Remember cor pulmonale. Look for peripheral edema, ascites and many times clear lungs sounds. On physician exam, it could also be related to a valvular issue.

Heart Failure can also be biventricular (congestive) in nature, this is very common in ischemic heart disease. Keep in mind that most CHF patients are usually euvolemic so consider NTG before diuretics like furosemide.

4.) Is it a low output OR a high output failure?

Low: heart cannot generate an adequate cardiac output (CO)=HR x SV.

High: Circulation cannot be sustained even despite a normal/increased CO.

EMS + Hospital Diagnostics:

Abnormal CXR and echos with/without infiltrates

Abnormal labs (elevation of BNP) - typically > 250 pg/ml, can go well over 1,000 pg/ml in severe cases. This naturally rises with age and can be high in setting of renal ailment.

Blood Pressure changes (high or low)

EKG changes including axis deviations, arrythmias, hypertrophic issues

Management - not all HF is considered equal -- they actual stage/class this disease

Consider root causes or what is aggravating this event

Elevate their head

Consider oxygenation - even CPAP or BiPAP

High doses of NTG especially if SBP is extremely high

Consider pressor agents in setting of cardiogenic shock

Diuretics still have a place - just be wise around fluid status and kidney output

June 26, 2023

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

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