History Focused history - SOB analysis (SOCRATES ) = Associated syx like: PND, orhtopena, LL oedema. Chest pain, sweating - Fatigue, Presyncope, Effort intolerance, Hypotension - Edema, increased abdominal girth (ascites) © Quantify symptomatology — NYHA Functional Class © I: No limitation of activities; No symptoms from ordinary activities © Il: Slight, mild limitation of activity; Comfortable with rest or with mild exertion © Ill: Marked limitation of activity; Comfortable only at rest © IV: Any physical activity brings on discomfort; Symptoms occur at rest Ask about — PMHx (CHF; CAD/MI ) © Underlying causes ( © Precipitants + Cardiac (ischemia, IE, tachyarrhythmia, HTN, Valve), Anemia Infection, Resp (PE, COPD), Renal (ARF, Renal Artery Stenosis) Endocrine (thyrotoxicosis, phaeo, hyperaldosteronism) Drugs (NSAIDs, B-blockers, steroids, CCB, digoxin) Environment (non-compliance with meds/diet/salt) Physical Examination Focused Physical Examination * ABC's, vital signs, monitoring (IV, O2, BP, telemetry) © Hypotension; Narrow pulse pressure General © Assess for Cool extremities, cyanosis, slow cap refill (Cardiogenic shock) o Valsalva © Peripheral © Pulsus alterans, Edema * HEENT o (UVP (Positive AUR: Kussmaul's * Cardiovascular (JVP, pulses, precordial IPA) © Apex * Lateral to MCL for EF <50%, for increased LVEDV, for PCWP >12) + Diameter >4om in 45° LLD (for increased LVEDV) o §S3)S4, Murmur (. MR, TR) «Respiratory (PPA) © | Breath Sounds, Crackles, Wheeze * Abdominal (IPPA) © Ascites, Pulsitile hepatomegaly He is 55 years male known case of DM-II, diagnosed from long time, uncontrolled. He has recent Admission to outside hospital and found have CHF with EF = 35%. His final diagnosis was Ischemic related CMP. Currently on ASA, BB, diuretics. Statin, InsulinDifferential diagnosis Differential Diagnosis (Chronic HF) Myocardial Damage * CAD (65%), cardiomyopathy, myocarditis, Myocardial Infiltration * Sarcoid, amyloid, hemochromatosis Pressure Overload * HTN, OSA, AS, pHTN, coarct Volume Overload MR, AR, VSD, ASD, PDA Restriction/Obstruction + RV Infarct, MS, tamponade, constrictive pericarditis High-Output «AV fistula, peripartum, beriberi Infection * Chagas, Coxsackie, echovirus, HIV Drugs « EXOH, Adriamycin (400g/m2) + Radiation, catecholamine (cocaine, amphetamine) Idiopathic (20%) * Often DCM Congenital + Hereditary HOCM, Fredrich’s ataxia Endocrine/Metabolic «Hyperthyroidism, DM, acromegaly + Thiamine or selenium deficiency, uremia Investigations / Imaging CBCD, renal and liver profiles ECG, Echo, Cardiac enzymes, BNP AIC, lipid, ACR, CXR CHF with transudative Rt sided pleural effusionImportant points to remember ‘Admission Cardio consult Manage his CHF and optimize his cardiac medications Control his other risk factors... DM Evaluate the need for pig tail insertion/ chest tube By IR or thoracic surgery DVT prophylaxis Cardiac rehab Vaccinations for pneumococcal + annual influenzas RX: 1 2. 3. 4 5. 6. 7. 8. What is DM- Rx groups found to have CVS benefits? SGLT-2 GLP-1 Common side effects for these agents? What agents associated with decreased risk of HF admissions? SGLT-2