A 74-year-old man with a history of hypertension and

myocardial infarction that occurred 5 years

previously presents with breathlessness on exertion.
His current medications include a statin and aspirin.
On examination, his pulse is 76 beats per minute and
regular, and his blood pressure is 121/74 mm Hg.
There is jugular venous distention, lateral
displacement of the apex beat, and edema in his lower
limbs. The lung examination is normal.
An echocardiogram shows left ventricular dilatation,
globally reduced contractility, and an ejection
fraction of 33%. How should his case be managed?
Cuanto es lo normal de la F. de
Eyeccion
>60%
Falla cardiaca sistolica es
<40%
Diastolica es F. de Eyeccion mayor de
>50%

No usar digoxina en falla cardiaca diastólica

c. restrictivas (enarm)
 Diastolic Heart Failure
EF > 50%
It is estimated that 20 to 50 percent of
patients with heart failure have
preserved systolic function or a normal
left ventricular ejection fraction.
Although such hearts contract normally,
relaxation (diastole) is abnormal.
La principal causa de falla cardiaca es:

A) htas
B) enf. Coronaria
C) diabetes
d) c. dilatada
E) a y c
Coronary artery disease is the cause of
approximately two thirds of cases of systolic
heart failure,
although hypertension and diabetes are likely
to be contributing factors in many cases.
Dilated cardiomyopathy may also result from a genetic cause, previous viral
infection (recognized or unrecognized), alcohol abuse, or occasionally,
chemotherapy (e.g., doxorubicin or trastuzumab).
2
Estadio A: factores de riesgo: principales coronarios,
fumar, hipertensión el principal factor de riesgo es:
pathologic remodeling of the left ventricle,
with dilatation and impaired contractility

Principal factor contribuyente es:

notably activation of the sympathetic and

renin–angiotensin–aldosterone systems
Angiotensina importante elevacion en
I.C. descompensada (linea azul)
Tratamiento ideal 2019
Tx base de Iccv
Hb glicosilada debe esta abajo de ;
Con que presión arterial se debe evitar
Tx;
Peptido natriuretico; protector
 Mortalidad a 5 años es:
Before 1990, as many as 60 to 70% of
patients died within 5 years after the
diagnosis of systolic heart failure,
Effective treatment has improved both
outcomes, with a relative reduction in
mortality in recent years of 20 to 30%
Clasificación heart failure
Los principales síntomas en el Dx de
falla cardiaca son:
dyspnea and fatigue and peripheral
edema of heart failure

Cierto o falso

are nonspecific
Los signos mas específicos son:
Other symptoms (e.g., orthopnea and
paroxysmal nocturnal dyspnea)

and signs (e.g., jugular venous

distention, cardiac enlargement, and a
third heart sound) have 70 to 90%
specificity
A 43-year-old man presented to the emergency room in respiratory distress after a 3-week illness

Gyorik S and Menafoglio A. N Engl J Med 2006;355:e10

Existe laboratorio para el Dx?
A) cpk
B) troponina
C) dimero D
D) petido natriuretico
E) ninguna de las anteriores
Measurement of natriuretic peptides is
recommended,

a normal concentration virtually rules

out a diagnosis of heart failure (although this
observation may not hold true in the case of obese persons).10
BNP
El estudio de gabinete de eleccion es

A) Ecocardiograma
B) TAC
C) tele de tórax
D) resonancia magnetica
E) angiografía coronaria
Transthoracic Doppler echocardiography allows
for confirmation of the diagnosis, provides
information on myocardial and valvular structure
and function, and may reveal other important
findings, such as the presence of a thrombus
Cardiac magnetic resonance imaging is an
alternative to echocardiography in difficult cases,
such as those in which the quality of the
ultrasonic image is poor, or in cases in which
characterization of the tissue is particularly
important (e.g., when myocarditis or an
infiltrative myocardial disease is suspected)
Ins. Cardiaca diastolica:
El tratamiento que ayuda a sobrevida en
insuficiencia cardiaca diastolica o con
función sistolica preservada es?
A) digoxin
B) calcio antagonistas
C) diuréticos
D) IECAS
e) BB
F) ninguno
Insuficiencia cardíaca AGUDA
Inotropicos
Falla cardiaca sistolica

Fracción eyección
<40%
 Pharmacologic Therapy
Los diureticos (de asa o tiazidas)

A) mejoran la sobrevida únicamente

B) mejoran sobrevida y síntomas
C) mejoran solo los síntomas
relief of symptoms only (i.e., diuretics)

Diuretics provide rapid relief of dyspnea

and fluid retention
El tratamiento de eleccion es:
A) digoxina
B) BB como metoprolol
C) calcio antagonistas como nifedipino
D) IECAS como enalapril
e) bloqueadores de angiotensina II como
candesartan
F) inotropico en general como digoxina o
milrinona
Guías Europeas 2016
 ACE inhibitors
ACE inhibitors are the first-line therapy
for patients with systolic heart failure;
therapy should be initiated promptly
after diagnosis and continued
A) solo 6 meses, 1 año, solo mientras
halla sintomas
Indefinitely
IECAs cual es el de elección?
ACE inhibitors also reduce the risk of myocardial
infarction.
ACE inhibitors is recommended for all, irrespective of
the cause of the condition or the severity of the
symptoms (i.e., whether they are in NYHA class I, II, III,
or IV).
 Adverse Effects Related to Kinin
Potentiation (iecas)
1. Cough.
the most common, nonproductive

2. Angioedema.
in fewer than 1% of patents taking an ACE inhibitor but
is more frequent in blacks
 A 75-year-old man presented to the emergency
department with diffuse swelling of his tongue that
had begun a few hours earlier. He had no known
history of allergies. He had been taking 25 mg of
captopril twice daily. He had a large, swollen,
protuberant tongue and was breathing through his
nose. Angioedema was diagnosed, and the patient was
treated with epinephrine, antihistamines, and
corticosteroids;.
Quienes son de elección IECAS o Bloqueadores de
angiotensina II (enalapril vs losartan)

The efficacy of ARBs is similar to that of

ACE inhibitors,

as an alternative to ACE inhibitors

primarily in patients in whom a cough
develops as a result of ACE-inhibitor
Que receptor bloquea el antagonista de angiotensina II?
Elevacion de creatinina con IECAS;si
ocurre, suspender Iecas o Aras?
Cuanto esperar que se eleve creatinina
con Iecas?

Máximo el 35% del basal de creatinina

0.3 mg de elevación de creatinina

Aliskiren es:
Adverse reactions IECAs:Adverse Effects
Related to Angiotensin Suppression

Hypotension.
Worsening renal function.
Hyperkalemia
 Medicamento de elección en
insuficiencia cardiaca Es:
IECAS

Enalapril
 Hay otro mejor? 2017
????
Sacubitrilo Valsartan
 Beta-Blockers

Along with ACE inhibitors, beta-blockers

are essential first-line therapy

Los BB son inotropicos negativos y por

tanto No pueden elevar la F. de Eyeccion
Cierto o Falso
 carvedilol
Carvedilol a non-selective agent blocks
ß1, ß2 and α1 receptors;
Carvedilol *(dilatrend 25mg) also
possesses non-adrenergic properties
including antioxidant antiproliferative
actions, as well as favorable effects on
insulin resistance not seen with ß1
selective agents.
 COMET
Interpretation Our results suggest that
carvedilol extends survival compared
with metoprolol.
Lancet 2003; 362: 7-13
beta-blockers improves systolic function,
resulting in an increase in ejection
fraction of 5 to 10%, and reduces
symptoms
Question: In patients with chronic heart failure (CHF) doing well on
atenolol, should we consider switching them to carvedilol or

stable heart failure patientsmetoprolol?

on
atenolol should indeed be
changed to carvedilol or to
metoprolol CR/XL. Only
carvedilo, bisoprolol and
metoprolol CR/XL are currently
approved for use in heart failure
by the U.S. Food and Drug
Administration.

Cardiosource, american collegue of

cardiology
No todos Beta bloqueadores son iguales Buccindolol no
disminuye igual niveles de nor-epinefrina
 Aldosterone Antagonists
with severe systolic heart failure (NYHA class ll, III or IV)
´
Ejemplos de antagonista s de aldosterona son:
A) amilorida
B) triamtereno
risk of renal dysfunction and
C) espirinolactona
hyperkalemia)
D) eplerenona
E) tiazidas
F) solo a, b, c y d
E) solo d y e
G) ninguna de las anteriores
 La principal diferencia entre
espironolactona y eplerenona es;
Principal riesgo con bloquadores de
aldosterona es:
A) hipokalemia
B) hiperkalemia
C) falla renal
D) hipercalcemia
E)hiperglicemia

risk of hyperkalemia
Isorbid + hidralazina util especialmente
en raza negra (nejm 2005)
 Digoxina
Que hace en la mortalidad?
digoxina
Digoxina
La digoxina mejora la sobrevida?

digoxin, had no effect on mortality but

reduced the risk of hospitalization
El mecanismo de accion de la digoxina
es;

A) Inhibición de canales de sodio

B) inhibición de canales de potasio
C) inhibición de canales lentos de calcio
E) inhibición de bomba sodio potasio
Digoxin binds Na+/K+ ATPase pump in the
membranes and decreases its function.
This causes an increase in the level of
sodium ions in the myocytes, which then
leads to a rise in the level of calcium ions
Digoxina actua ;
 Intoxicación digital
Risk Factors Hypokalemia Symptoms
Hypomagnesemia Nausea
Hypercalcemia Vomiting
Medication use Yellow vision
interfering with Digoxin (xanthopsia)
excretion
Quinidine
Verapamil
Amiodarone
 Intox digital
Electrocardiogram

Paroxysmal Atrial Tachycardia with 2:1 AV Block

Atrial Fibrillation with low ventricular rate
Nodal rhythm
Ventricular Tachycardia
PR interval increased

La Clave es que baja la frecuencia por disminuir la

conduccion en nodo A-V
 digoxina
Digoxina claramente
indicada si hay
fibrilación auricular
con FC elevada
 Digoxina No usar

Si hay C. restrictiva o
insuficiencia cardiaca
diastólica (F. de E. mayor del
50%)
Digoxina; se puede usa en ins. Cardiaca
en ritmo sinusal?
Ivabradina
Ivabradina disminuye hospitalizaciones,
No mortalidad (como digoxina)
Ivabradina; efectos secundarios;
 Ivabradina
Taquicardia SINUSAL inapropiada

Angina estable

Insuficiencia Cardiaca si la FC > 70 a

pesar de BB o no puede recibir estos
(disminuye hospitalizaciones)
Tx 2019 FE<40%
2019 Resincronizador
Desfibrilador
Guías México 2020
Enfermedades más comunes
Sal: 2-3 gr.
 Las vacuna como influenza o
neumococo
A) no se deben aplicar pues los pacientes
con falla cardiaca estan
inmunodepirmidos
B) se deben aplicar
C) estan contraindicadas por los
medicamentos admisnistrados

Pneumococcal and influenza vaccinations are recommended

 La causa de muerte es
half the deaths that occur among patients
with systolic heart failure are attributed to
ventricular arrhythmias;

La mejor forma de prevenir la muerte subita

por arritmias ventriculares es con:
A) antiarritmicos como amiodarona
B) antiarritmicos como propafenona o
quinidina
C) ninguna de las anteriores
An implantable cardioverter–defibrillator
reduces the risk of sudden death
Stored Ventricular Electrogram from an Asymptomatic 35-Year-
Old Man Who Received a Defibrillator Prophylactically

The data were recorded at 1:20

a.m. while the patient was
asleep. After four beats of sinus
rhythm, ventricular tachycardia
begins abruptly, at a rate of 200
beats per minute (Panel A). The
defibrillator discharges
appropriately (a 20-J shock
denoted by the bar, Panel D)
during ventricular fibrillation and
restores sinus rhythm.

Maron, B. J. et al. N Engl J Med 2000;342:365-373

Mejor antiarritmico para prevenir
muerte subita:
Amiodarona

Pero……
Amiodarona; cuando la arritmia esta
C…… Amiodarona!!
Efectos secundarios:
Hipo e hipertiroidismo
Fibrosis pulmonar (tos seca IECAS)
Depositos corneales
Elevacion de enzimas hepaticas y daño
hepatico
Neuropatia periferica
Bradicardia
 Indicaciones de desfibrilador interno;

implantable cardioverter–defibrillator is
indicated for secondary prevention, in the
case of any patient who survives an
unprovoked episode of ventricular fibrillation or
sustained ventricular tachycardia,7,8 (sincope)
and for primary prevention, in the case of
patients in NYHA functional class II or III who
have an ejection fraction that is persistently
35% or less despite optimal medical therapy
cardiac-resynchronization therapy

current guidelines recommend cardiac-

resynchronization therapy for patients
with ejection fraction that is persistently
35% or below, sinus rhythm, and a QRS
duration of 120 msec or more with left
ventricular block
A 74-year-old man with a history of
hypertension and myocardial infarction that
occurred 5 years previously presents with
breathlessness on exertion.
His current medications include a statin and
aspirin.
There is jugular venous distention, lateral
displacement of the apex beat, and edema in his
lower limbs. The lung examination is normal.
Although systolic dysfunction is the likely
diagnosis, given the patient's previous
myocardial infarction, confirmation by
echocardiography (or other imaging) is
essential. In cases in which heart failure
is a less likely diagnosis, measurement of
natriuretic peptides may be useful as a
first step, since a normal concentration
suggests an alternative diagnosis.
A diuretic will quickly alleviate the patient's dyspnea
and edema, but it is insufficient therapy alone.
Both an ACE inhibitor and a beta-blocker should be
prescribed
if symptoms persist, an aldosterone antagonist
I would expect the patient's ejection fraction to
improve over the course of 3 to 6 months, but if it
remains at 35% or below, an implantable cardioverter–
defibrillator should be considered. If the patient's 12-
lead electrocardiogram shows QRS prolongation, I would
consider a device that provides both cardiac-
resynchronization therapy and implantable
cardioversion–defibrillation instead
 Diastolic H F
Unfortunately, unlike heart failure due to
systolic dysfunction, diastolic heart failure
has been studied in few clinical trials, so
there is little evidence to guide the care of patients
with this condition.
Physiological principles used in the treatment
of such patients include the control of blood
pressure, heart rate, myocardial ischemia, and
blood volume.
Nejm may 2003
Braunwald 2014
2017
2017
Guias Europeas 2016
 Guias americanas 2016
Indicaciones de DAI y resincronisador
Resincronisador
JP is a 60-year-old woman with NYHA class II systolic
dysfunction. Her medications at home include enalapril
(Vasotec) 20 mg BID, furosemide (Lasix) 40 mg daily,
and aspirin 81 mg daily. Her vital signs are BP 120/80
mm Hg and heart rate 80 bpm. She is without
complaints. Which of the following is the best
management for this patient?
A. No change in therapy is needed because the patient
is stable.
B. Add valsartan (Diovan) to enalapril (Vasotec) because
an ACE inhibitor in combination with an angiotensin-
receptor blocker (ARB) has demonstrated mortality
reduction.
C. Add digoxin (Lanoxin) 0.125 mg daily.
D. Start carvedilol (Coreg) 3.125 mg BID
The correct answer is D
ICCV y ejercicio?
Digoxina
DM e insuf. Cardiaca; Hipoglucemiante
de elección
Contraindicado;
Cuales BB
Antagonistas de aldosterona