Heart failure with reduced ejection fraction (HFrEF)

Vignette says a 68 year old male with a history of hypertension, diabetes mellitus and coronary artery disease presents to the emergency department with progressive onset of shortness of breath over the past 2 weeks; He also reports increasing fatigue, orthopnea (i.e. difficulty breathing when lying flat), paroxysmal nocturnal dyspnea (i.e. waking up at night feeling short of breath) and bilateral leg swelling up to the knee; He also reports of unintentional weight gain of 2 kg in the past 4 weeks; He has a history of hypertension, diabetes mellitus and coronary artery disease and takes medications for hypertension, diabetes and dyslipidemia; Examination shows jugular venous distension, 2 + pitting edema; On auscultation bilateral crackles/rales along with S3 heart sound are heard; CXR shows cardiomegaly with bilateral pleural effusions; Laboratory studies show elevated BNP & NT pro BNP, elevated BUN & creatinine and hyponatremia; Echocardiogram shows dilated left ventricle, left ventricular ejection fraction (LVEF) of 35%, and enlarged left atrium; Diagnosis?

Diagnosis is Heart failure with reduced ejection fraction (HFrEF).

The American College of Cardiology (ACC) defines Heart Failure with Reduced Ejection Fraction (HFrEF) as a clinical syndrome characterized by:- 

1. Symptoms and/or signs of heart failure. 

2. Reduced left ventricular ejection fraction (LVEF) ≤ 40%. 

3. Elevated natriuretic peptides (e.g. BNP or NT-proBNP).

Diagnosis:­-

1. CBC, Serum electrolytes, Troponins, BNP/NT pro BNP, RFT, and LFT; (BNP>400 pg/mL, NT pro BNP> 450mg/dL if < 50 years of age, NT pro BNP> 900mg/dL if 50-74 years of age and NT pro BNP> 1800mg/dL if > 75 years of age indicates acute heart failure).

2. Chest x ray shows pulmonary edema, cardiomegaly, Kerley B lines and pleural effusion. 

3. ECG shows LVH, atrial enlargement, condition abnormalities (e.g. LBBB, RBBB), ischemic changes, and arrhythmias (e.g. atrial fibrillation, sinus tachycardia, premature ventricular ectopic, ventricular tachycardia).

4. Echocardiography shows reduced left ventricular ejection fraction, regional wall motion abnormalities, dilated LV & LA and valvular dysfunction.

5. Radionuclide ventriculography.

6. Cardiac MRI.

7. Coronary angiography.

Management of chronic HFrEF:-

1. ACE-i (e.g. Enalapril, Lisinopril) /ARBs (e.g. losartan, valsartan, telmisartan)/ ARNI (e.g. sacubitril-valsartan); The PARADIGM- HF showed that Sacubitril/valsartan is superior to enalapril in reducing mortality and HF hospitalizations.

2. Beta blockers (e.g. Metoprolol, Carvedilol).

3. MRA (e.g. Spironolactone); The RALES trial (Randomized Aldactone Evaluation Study) showed that spironolactone significantly reduced mortality and hospitalizations in patients with severe HFrEF (LVEF ≤ 35%), particularly those with symptomatic heart failure.

4. SGLT2i (e.g. empagliflozin. Dapagliflozin); The DAPA-HF trial showed that Dapagliflozin significantly improved outcomes in HFrEF patients (i.e. reduced CV death and HF hospitalization), even in those without diabetes.

5. Diuretics (e.g. Furosemide, Torsemide).

6. Hydralazine and Nitrates (decreases mortality and morbidity in HFrEF among African Americans, with NYHA class III-IV HF receiving optimal medical therapy (OMT) with ACEi and beta-blockers). 

7. Adjunctive therapies:- Anticoagulation (patients with AFib); ivabradine (HR >70 bpm on maximally tolerated beta blocker therapy); Iron therapy (serum ferritin <100, TSAT<20%), and Digoxin (decrease hospitalization of HFrEF).

8. Inotropes (e.g. Dobutamine, Milrinone) as a bridge therapy for cardiac transplantation or Ventricular Assist Devices (e.g. IABP, impella, tandem heart and ECMO) in patients with stage D HF refractory to Guideline Directed Medical Therapy (GDMT). 

9. CRT (EF< 35% and QRS > 130 ms). 

10. ICD (EF< 35% and QRS < 130 ms). 

11. Ventricular assist device (VAD). 

12. Heart transplantation.

Figure:- Tretament algorithm of HFrEF (ACC/AHA 2022 Guideline)

Admit to hospital for management of acute decompensated heart failure and includes oxygen therapy via noninvasive ventilation (i.e. CPAP/BiPAP), diuretics (e.g. furosemide), vasodilators (e.g. nitroglycerin) and inotropes (e.g. dobutamine, milrinone).

Acute pericarditis

Vignette says 30 year old male presents to the emergency department with central chest pain, which is aggravated by cough, inspiration and relieved by leaning forward, since the past few days; He also had fever, myalgia, sore throat for which he took analgesics from local pharmacy 2 weeks back and was gradually resolved; On auscultation pericardial friction rub is heard over the left parasternal region; Laboratory studies show increased CRP and ESR with normal cardiac troponins; ECG shows diffuse ST elevation and PR depression; Diagnosis? 

Diagnosis is acute viral pericarditis. 

Etiologies:-
1. Viral/idiopathic (80-90%): Coxsackievirus, influenza
2. Autoimmune: SLE, RA, post-MI (Dressler's syndrome)
3. Bacterial: TB (fibrinous), purulent (staph/strep)
4. Malignancy:-Lung/breast cancer metastases

Clinical Features:-
1. Severe retrosternal chest pain, pleuritic (aggravated by inspiration and cough), positional (worse when supine & relieved by sitting or leaning forward) that radiates to back, left ridge of trapezius, and neck. 
2. Pericardial friction rub (produced by the movement of the inflamed pericardial layers against one another).
3. Dyspnea.
4. Mild grade fever and myalgias (if viral etiology).

Diagnosis:-
1. ECG shows diffuse ST elevation and PR depression. 
2. Echocardiogram is used to assess for complications of acute pericarditis (effusion or tamponade); Isolated pericarditis shows normal in echocardiography. 
3. CT/MRI.
4. Inflammatory biomarkers (e.g. CRP, ESR) are elevated and Cardiac Biomarkers (usually negative, positive indicates concurrent myocarditis).

Management:-
1. First-line Therapy: NSAIDs (e.g. ibuprofen) + Colchicine along with PPI's cover. 
2. Refractory Cases: Corticosteroids (prednisone 0.5 mg/kg/day, taper over 4 weeks): Reserve for autoimmune pericarditis. Avoid in viral cases (↑ recurrence risk).

Deep venous thrombosis

Vignette says a 50 year old male presents to the emergency department with chief complaints of right calf pain and selling on the 3rd postoperative day; He recently underwent open cholecystectomy for acute cholecystitis 3 days back; He has a history of hypertension for which he takes amlodipine; Examination shows right calf tenderness on palpation; Vital signs show blood pressure of 120/80 mm of Hg, pulse rate of 88 bpm, respiratory rate of 18 breaths/min, oxygen saturation of 92% in RA and temperature of 97.9 F; D-dimer is positive; Duplex ultrasound of the right lower extremity shows thrombus, filling defects and lack of compressibility; Diagnosis?

Diagnosis is Deep venous thrombosis (DVT).

Presents with calf pain, tenderness and swelling; The patient might develop low grade fever, acute onset SOB, tachycardia, tachypnea and pleuritic chest pain if pulmonary embolism occurs secondary to deep venous thrombosis; Homans's sign is positive (i.e. calf pain at dorsiflexion of the foot).

Risk factors:-
1. Stasis
2. Endothelial injury
3. Hypercoagulability

Wells Score for DVT (used to stratify the likelihood of DVT):- A score of 3 or more suggests a high likelihood of DVT, whereas a score of 1 or 2 indicates moderate probability and a score of 0 suggests low likelihood.

Diagnosis:-
1. D-dimer is positive.
2. Duplex ultrasound of the lower extremity shows filling defects, lack of compressibility, thrombus and dilated veins.

Management:-
1. Anticoagulation (e.g. LMWH) followed by warfarin or direct oral anticoagulants (e.g. apixaban, rivaroxaban).
2. Compression stockings to prevent post-thrombotic syndrome and reduce swelling.
3. Thrombolytics (Symptomatic iliofemoral DVT).
4. IVC filters are indicated if anticoagulation is contraindicated or if emboli are occurring despite adequate anticoagulation.
5. Evaluate for underlying risk factors (e.g. malignancy, thrombophilia).
6. Prevention strategies of DVT includes:-
a. Pharmacologic: Prophylactic LMWH or fondaparinux. 
b. Mechanical: Sequential compression devices (SCDs) and graduated compression stockings. 
c. Early ambulation post-surgery is also an important strategy to reduce stasis.