Nuggets, Pearls, and Vignettes of Master Heart Failure Clinicians

Abstract

"The failing heart is not just an enlarged version of a normal heart." I know Dr. Louis Katz said it, but I never found out where. At any rate, he posthumously alerted me to recognize that patients with heart failure do not demonstrate the lower range of normal physiology, but rather their own special ranges. I recognize this in the exquisite load sensitivity of the failing heart or in noting how much atrioventricular synchrony contributes to the failing heart. I try to teach this all the time-I'll know it's time to retire when I overhear the medical students joking about me having them graph the relationship between cardiac output and vascular resistance. Nevertheless, it's a concept I use every day.-Marc A. Silver Similar to all disease states, the primary approach to and ultimate treatment of heart failure is prevention. For the entire human population, this means bringing systemic blood pressure into the currently recommended range, controlling the risk factors for atherosclerosis, aggressively managing ischemic syndromes, reversing valvular and congenital lesions before cardiac damage occurs, and so forth. Hopefully, over time, we'll be able to counter and reverse many of the predisposing genetic factors as well.-Carl V. Leier Ask patients to describe exactly how they take their medications. Heart failure patients are frequent victims of polypharmacy, and despite the best intentions of the health care providers and patients, inadvertent medication errors are common. For example, one of my patients mixed up his digoxin and isosorbide dinitrate; as a result, he was taking digoxin three times a day (and wondering why he was nauseated)! Ask routinely about the use of over-the-counter medications, especially cold preparations, "diet pills," and nonsteroidal anti-inflammatory drugs (NSAIDs). These widely available agents are frequently used by heart failure patients, who fail to recognize the potential for drug-drug and drug-disease interactions.-Michael W. RichThere are several things I routinely do for each patient who comes to see me. On the first visit, I examine current medications and simplify the regimen. I eliminate calcium channel blockers, NSAIDs, and albuterol (unless there is a pressing need to continue these). We routinely check digoxin levels and adjust the medication to keep the plasma level between 0.7 and 1.0 ng/mL. This is based on data from our laboratory showing that most of the benefit of this drug is at low dose (J Am Coll Cardiol. 1997;29:1206) and a post hoc analysis of the DIG study, which showed a relationship of plasma level and mortality with more toxicity at higher doses (Am Heart J. 1997;134:3). I optimize angiotensin-converting enzyme (ACE) inhibitor doses (in an attempt to use the doses shown to be efficacious in the clinical trials) and use a longer-acting, preferably once-a-day ACE inhibitor to simplify the patient's regimen. I often give this dose prior to bedtime so that any hypotension will be at night while the patient is sleeping. I also give nitrates to my heart failure pat...

La clínica en la hipertensión pulmonar del adulto

“…A medida que aumenta la PAPs, la intensidad de S 2p debería aumentar con respecto a S 2a . Según Bourge, 40 la intensidad relativa de S 2p igual o mayor que S 2a , se ausculta más lejos del foco pulmonar a medida que aumenta la PAPs. La intensidad de S 2p en comparación con S 2a se evalúa auscultando a lo largo del borde esternal izquierdo, comenzando en el segundo espacio intercostal izquierdo (foco pulmonar), luego los espacios intercostales paraesternales tercero, cuarto y quinto, continuar con el quinto espacio en un punto entre el borde esternal izquierdo y la línea medioclavicular y enseguida el quinto espacio intercostal en la línea medioclavicular (figura 2).…”

“…Si una enfermedad pulmonar es la causa de la HP, la presión de la arteria pulmonar no reflejará con precisión las presiones de llenado del ventrículo izquierdo. 40 Con el VD aún hipertrofiado y con una PAPm considerablemente elevada podría observarse una onda «A» yugular prominente, levantamiento sistólico del segundo espacio intercostal izquierdo, un movimiento oscilante www.medigraphic.org.mx esternal que combinado con la retracción simultánea del ápice cardíaco produce una apariencia de «balanceo», un choque de cierre de la pulmonar palpable, matidez mayor a 2.5 cm por fuera del borde paraesternal izquierdo a nivel del segundo espacio intercostal y un levantamiento palpable (con el talón de la mano) paraesternal bajo izquierdo que corresponde al área de proyección del VD (complejo de la pulmonar de Chávez). La auscultación percutoria o pleximétrica pudiera ser de ayuda en delimitar la silueta cardíaca colocando el estetoscopio en la parte baja del esternón y percutiendo de forma simultánea con el dedo medio desde el borde cardíaco izquierdo medialmente hacia el estetoscopio (de afuera hacia adentro).…”

“…Esta confusión se evita por el hecho de que el pulso carotideo es fácilmente palpable y no fácilmente compresible, mientras que las pulsaciones venosas son compresibles y por lo común no son palpables. 40 No obstante, estas pulsaciones venosas si pueden percibirse a la palpación en el hígado. El signo de Kussmaul es la elevación paradójica de la presión venosa central durante la inspiración.…”

Advanced Heart Failure: A Practical Management Algorithm and Therapeutic Options

“…When properly executed, these efforts will move most patients from functional class III–IV and transplant evaluation to functional class II–III, improved quality of life, and often, re‐employment. Considerations for treatment modifications are many, 7 but only a few will be addressed here (Table I); many of these suggestions evolved out of clinical experience and tribulations over the years, and most have not yet been or ever will be addressed by large trials.…”

“…Para‐cardiac conditions are extremely important in the management of advanced cardiac failure 7 . Sleep disorders are common in HF, usually exacerbate HF symptoms, and should be treated 18 .…”