Maryland ACEP Chapter Educational Conference & Annual Meeting - PDF document

Maryland ACEP Chapter Educational Conference & Annual Meeting March 12, 2020 FACULTY: Tiffany C. Fong, MD, FACEP PRESENTATION HFrEF, HFpEF, what the (EF)? Point-of-Care Echo in the Evaluation of Heart Failure DESCRIPTION Decompensated heart failure is a commonly encountered clinical syndrome in the emergency department. Though emergency care providers have significant comfort with the diagnosis and management of patients with reduced ejection fraction, heart failure with preserved ejection fraction can be more enigmatic. This talk will provide an overview of the relevant pathophysiology, point-of-care echo findings, and management of HFrEF and HFpEF. OBJECTIVES • Recognize the clinical syndromes of heart failure with reduced and preserved ejection fraction (HFrEF and HFpEF). • Describe multiple techniques to estimate ejection fraction on point-of-care echocardiography. • Explain the basic physiology of left ventricular diastole. • Identify key sonographic findings in HFpEF. • Describe the management strategies for HFrEF and HFpEF. DISCLOSURE No significant financial relationships to disclose.

2/4/20 Tiffany Fong, MD FACEP 3/12/2020 1 2 HEART FAILURE 4 HFrEF and HFpEF Have NO significant differences in their physical exam findings JAMA 2005 6 1

2/4/20 7 8 9 10 10 First discrimination point in CHF: Determine preserved vs. reduced ejection fraction 11 2

2/4/20 EYEBALLING EF EPSS TO ESTIMATE EF 13 14 FRACTIONAL SHORTENING MAPSE 15 16 HFpEF 17 3

2/4/20 HFpEF WHY DOES DIASTOLIC DYSFUNCTION MATTER? HFpEF Lower mortality rate than HFrEF (3 vs 4%) but similar or higher morbidity (ICU, hospital LOS) 21 DIASTOLE 24 4

2/4/20 DIY: DIASTOLIC EVALUATION 26 KEY: Identify ↑LA pressure Greenstein & Mayo – Chest 2018;153(3) PW DOPPLER OF MITRAL INFLOW VELOCITY 29 30 5

2/4/20 TISSUE DOPPLER OF LATERAL MV ANNULUS Greenstein & Mayo – Chest 2018;153(3) 32 Figure: Liang 2010 NEJM 2004;351 33 34 SUPPORTING EVIDENCE OF DIASTOLIC EVALUATION 36 6

2/4/20 *EVOLVING THOUGHT: HFpEF IS NOT SIMPLY DIASTOLIC DYSFUNCTION 37 BASIC TREATMENT NEJM 2004 40 CORRECT DX PUTTING IT TOGETHER DECONGEST (Clinical Case) CONTROL HTN CONTROL AFIB 41 42 7

2/4/20 SUMMARY THANK YOU! tfong3@jhmi.edu 43 44 8