Best of heart failure

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Ambrosy AP, Khan H, Udelson JE, Ment SJ, Vaduganathan M, Subacuis HP, Ko Heart Fail Rev (2018) 23:597 – 607 recommended to be in reach the target 97/10 should not be given c to risk for angioedema, stopped for 36 h bef patients with eGFR < impairment, the starti daily and ARNI is not hepatic impairment [ 3 With the results of t ommendations have b HF Guidelines. First, ACE inhibitors or an strategy of RAS inhibit or ARB or ARNI. T strategy of i hibition of evidence: A), or A (level of evidence: B – beta-blockers and aldo is ecommended for p morbidity and mortalit In the 2017 Focuse with chronic symptom tole ate an ACE inhibit recommended to furth 36 •• ]. In those patie switched to ARNI fro to note that ARNI sho with ACE inhibitors or inhibitor due to angio should not be administ edem [ 1 •• ]. In the stu inhibition, blacks and angioedema [ 35 ]. It is be educated about rec ma and to lert health scription of ACE inhi In a phase II trial i served ejection fractio reater extent than di tolerat d [ 39 ]. The eff compensated HF, in a IV symptoms, or in p time and is bei g te te Ivabradine Ivabradine is a specifi channel. If ion channel in spontaneously activ node, the AV node, an is a mixed Na/K curre at voltages in the dia 39 Page 4 of 9 in the past few decades [ 4 – 6 ]. The current treatment algorithm for ADHF focuses on targeting signs and symptoms of con- gestion with diuretics and vasodilators. However, there are many more factors to consider during the three different phases of admission. During the initial phase in the emergency department, it is reasonable to use a more focused six-axis assessment model previously described by Gheorghiade et al. by determining de novo vs. chronic HF, clinical severity, precipitants, heart rate and rhythm, blood pressure, and comorbidities [ 7 ]. This can guide the triage and initiation of necessary immediate thera- pies that can be performed in the emergency department be- fore admission. Once patients are admitted, we propose a transition to a more thorough evaluation using a newly proposed eight-axis model depicted in Fig. 1 . This transition is demonstrated in Fig. 2 . In the inpatient setting, in addition to treating conges- tion, there are eight important cardiac and noncardiac entities that have been shown to contribute to the development and exacerbation of HFrEF specifically. These include coronary artery disease, hypertension, myocardial disease, pericardial disease, electrical abnormalities, valvular disease, medical noncompliance, and comorbidities including renal dis- ease, iron deficiency, lung disease, and diabetes. Thes conditions become equally important in the manageme t of heart failure with preserved ejection fraction (HFpEF) exacerbations as the cardiac pathophysiology is still oor- ly understood. Focus on comorbidity management in ad- dition to decongestion is suggested in thi cohort as a temporizing measure. As indicated in Fig. 1 , determi - tion of ejection fraction is crucial early during the second phase of hospitalization in order to guide assessment and therapies, with the three widely accepted categories being (1) HFrEF if ≤ 40%, (2) mid-range EF if between 41 an 49%, and (3) HFpEF if ≥ 50% [ 8 ]. A comprehensive cardiovascular assessment can be achieved by further imaging modalities t at are more readily available in the second phase of hospitalization. The e include echocardiography to determine systolic and diastolic unctio as well as valvular disease, cardiac MRI to evaluate for peri- cardial disease (for those without an implantable cardioverter defibrillator or permanent pacemaker), nuclear single-ph ton Fig. 1 Eight-axis algorithm for managing ADHF. HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; EF, ejection fraction; HTN, hypertension; CAD, coronary artery disease; CKD, chronic kidney disease; DM2, diabetes mellitus type 2; US, ultrasound; echo, echocardiogram; LHC, left heart catheterization; Dob Echo, dobutamine echocardiography; BIVA, bioelectrical impedance vector analysis; SPECT, single-protein emission computed tomography; ECG, electrocardiogram; EP, electrophysiology; BMP, basic metabolic panel; PFT, pulmonary function test; ACEI, ACE inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor – neprilysin inhibitor; MRA, mineralocorticoid receptor antagonist; ICD, implantable cardioverter defibrillator; FCM, ferrous carboxymaltose; BP, blood pressure; NPPV, noninvasive positive pressure ventilation; DAPT, dual anti-platelet therapy; PCI, percutaneous intervention; GDMT, guideline-directed medical therapy; Afib, atrial fibrillation; CRT, cardiac resynchronization therapy. Borderline EF (asterisk) is also known as HFmrEF, heart failure with moderately reduced ejection fraction. 598 Heart Fail Rev (2018) 23:597 – 607 i t e ast fe eca es [ ]. e c rre t treat e t al rit f r f c ses tar eti si s a s t s f c - esti it i retics a as ilat rs. e er, t ere are a re fact rs t c si er ri t e t ree iffere t ases f a issi . ri t e i itial ase i t e e er e c e art e t, it is reasonable to use a more focused six-axis assessment model re i sl escri e e r ia e et al. eter i i e s. c r ic , cli ical se erit , reci ita ts, eart rate a r t , l ress re, a c r i ities [ ]. is ca i e t e triage an i itiati f ecessar i e iate t era- ies t at ca e erf r e i t e e er e c e art e t e- f re a issi . ce atie ts are a itte , e r se a tra siti t a re t r e al ati si a e l r se ei t-a is el e icte i i . . is tra siti is e strated in i . . I t e i atie t setti , i a iti t treati c es- ti , t ere are ei t i rta t car iac a car iac e tities t at a e ee s t c tri te t t e e el e t a exacerbati f r s ecificall . ese i cl e c r ar arter isease, erte si , car ial isease, ericar ial isease, electrical a r alities, al lar disease, medical c lia ce, a c r i ities i cl di g renal dis- ease, ir eficie c , l isease, a ia etes. These c iti s ec e e all i rta t in the ma ageme t f eart fail re it reser e ejecti fr cti n (HFp F) e acer ati s as t e car iac at si logy is still poor- ly understood. Focus on comorbidity management in ad- iti t ec esti is s este in t is c ort as a te rizi eas re. s i icate in ig. , etermina- ti f ejecti fracti is cr cial earl uri t e sec d ase f s italizati i r er t ide assessment and t era ies, it t e t ree i el acce te categories b in ( ) r if , ( ) i -ra e F if et een a , a ( ) if [ ]. c re e si e car i asc lar assessme t can be achieved by further imaging modalities that are more readil a aila le i t e sec ase f s italizatio . T ese i clud ec car i ra t eter i e s st lic a iast lic functi as ell as valvular isease, car iac I t evaluate f r peri- car ial isease (f r t se it t a i pla table cardioverter efi rillat r r er a e t ace a er), n cl ar si le-p oto Fig. 1 ight-axis algorith for anaging . p , heart failure ith preserved ejection fraction; r , heart failure ith reduced ejection fraction; , ejection fraction; , hypertension; , coronary artery disease; , chronic kidney disease; 2, diabetes ellitus type 2; , ultrasound; echo, echocardiogra ; , left heart catheterization; ob cho, dobuta ine echocardiography; I , bioelectrical i pedance vector analysis; , single-protein e ission co puted to ography; , electrocardiogra ; , electrophysiology; , basic etabolic panel; , pul onary function test; I, inhibitor; , angiotensin receptor blocker; I, angiotensin receptor – neprilysin inhibitor; MRA, ineralocorticoid receptor antagonist; I , i plantable cardioverter defibrillator; , ferrous carboxy altose; , blood pressure; NPPV, noninvasive positive pressure ventilation; APT, dual anti-platelet therapy; I, percutaneous intervention; GDMT, guideline-directed edical therapy; fib, atrial fibrillation; , cardiac resynchronization therapy. orderline (asterisk) is also kno n as HFmrEF, heart failure ith oderately reduced ejection fraction. 598 eart Fail Rev (2018) 23:597 – 607