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Systolic Versus Diastolic Failure Forms of Heart Failure Sytolic Failure • Inability of the ventricle to contract normally and expel sufficient blood • Inadequate cardiac output with weakness, fatigue, reduced exercise tolerance (hypoperfusion) Diastolic Failure • Inability to relax or fill normally (elevation of filling pressures) • Due to increased resistance to ventricular diastolic capacity, impaired ventricular relaxation, and myocardial fibrosis and infiltration Management Congestive Heart Failure • Patients With Reduced Left Ventricular Ejection Fraction – If with fluid retention: • Use diuretics (thiazides) – Medications that should be AVOIDED: • Anti-arrhythmics • Calcium channel blockers • NSAIDs Circulation; Journal of the AHA http://circ.ahajournals.org/cgi/content/full/119/14/1977 Congestive Heart Failure • Patients With Reduced Left Ventricular Ejection Fraction – Recommendations concerning aldosterone antagonists: • carefully selected patients with moderately severe or severe HF symptoms and recent decompensation or with LV dysfunction early after MI Circulation; Journal of the AHA http://circ.ahajournals.org/cgi/content/full/119/14/1977 Congestive Heart Failure • Patients With Refractory End-Stage Heart Failure (Stage D) – Intravenous Peripheral Vasodilators and Positive Inotropic Agents: • hospitalized frequently for clinical deterioration, and during such admissions, they commonly receive infusions of both positive inotropic agents (dobutamine, dopamine, or milrinone) and vasodilator drugs (nitroglycerin, nitroprusside, or nesiritide) Circulation; Journal of the AHA http://circ.ahajournals.org/cgi/content/full/119/14/1977 Congestive Heart Failure The Hospitalized Patient Common Factors That Precipitate Hospitalization for Heart Failure • Noncompliance with medical regimen, sodium and/or fluid restriction • Acute myocardial ischemia • Uncorrected high blood pressure • Atrial fibrillation and other arrhythmias Circulation; Journal of the AHA http://circ.ahajournals.org/cgi/content/full/119/14/1977 Congestive Heart Failure The Hospitalized Patient Common Factors That Precipitate Hospitalization for Heart Failure • Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem, beta blockers) • Pulmonary embolus • Nonsteroidal anti-inflammatory drugs Circulation; Journal of the AHA http://circ.ahajournals.org/cgi/content/full/119/14/1977 Congestive Heart Failure The Hospitalized Patient Common Factors That Precipitate Hospitalization for Heart Failure • Excessive alcohol or illicit drug use • Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism) • Concurrent infections (e.g., pneumonia, viral illnesses) Circulation; Journal of the AHA http://circ.ahajournals.org/cgi/content/full/119/14/1977