- For hospitalized patients with acute decompensated heart failure, the initial dose of an intravenous (IV) diuretic should be 1 to 2.5 times the patient's total daily oral dose; if the patient is unresponsive, the IV dose should be increased by 50% to 100%.
pulse rate is 72/min with occasional irregularity; other vital signs are normal. On cardiac examination, heart sounds are regular, with occasional premature beats associated with cannon a waves on neck examination.
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Fasting and nonfasting total cholesterol and HDL cholesterol levels have fairly similar prognostic value and association with cardiovascular outcomes. Fasting samples are preferred in adults with an initial nonfasting triglyceride level of 400 mg/dL (4.52 mmol/L) or higher or with a family history of premature ASCVD or genetic hyperlipidemia.
Mitral regurgitation GDMT first
In patients with chronic severe secondary MR related to left ventricular systolic dysfunction who have persistent symptoms while receiving optimal GDMT, transcatheter edge-to-edge repair (TEER) is a reasonable option (class 2a recommendation), according to current guidelines. Surgical mitral valve repair (Option C) is also reasonable if the patient is undergoing concomitant coronary artery bypass graft surgery. Surgery also may be considered if the patient has unfavorable anatomy for TEER. However, this patient should undergo a trial of GDMT before mitral valve repair is considered.
Generally, patients with claudication have an ABI of 0.40 to 0.90, whereas patients with ischemic rest pain, ulceration, or gangrene have an ABI less than 0.40. A resting ABI greater than 1.40 indicates the presence of noncompressible, calcified arteries in the lower extremities and is considered uninterpretable. Between 19% and 31% of patients with typical claudication symptoms have a normal or borderline ABI. Because this patient with classic claudication symptoms and faint pulses has a nondiagnostic ABI, further testing is indicated. Exercise ABI testing is useful in patients with ABI values between 0.91 and 1.40 and high pretest probability of PAD. It requires ABI measurements at rest and after treadmill walking or plantar flexion exercises. A post-exercise ankle pressure drop of 30 mm Hg or more or significant decline in the ABI suggests PAD.
- In patients with a bicuspid aortic valve and aortic sinuses or an ascending aorta 4.0 cm or larger in diameter, lifelong serial imaging is reasonable
Aortic Regurgitation
> 4cm lifelong serial imaging, > 4.5cm surgical repair > 5cm > 5.5cm no surgical indications, surgical repair
Management of bicuspid aortic valve disease is determined by the predominant lesion type (stenosis or regurgitation) and its severity. In patients with a bicuspid valve undergoing surgery for severe aortic stenosis or regurgitation
surgical repair of the ascending aorta (Option A) is advised when the aortic diameter is greater than 4.5 cm
In the absence of surgical indications for a stenotic or regurgitant aortic valve, surgical repair of the ascending aorta or aortic sinuses is advised when the aortic diameter is greater than 5.5 cm or when the diameter is greater than 5.0 cm in a patient with additional risk factors for dissection (family history, rate of progression ≥0.5 cm/year). This asymptomatic patient does not have an indication for surgical intervention.
- Extending dual antiplatelet therapy (DAPT) beyond 12 months is reasonable in patients who have successfully tolerated 12 months of DAPT and remain at high risk for recurrent vascular events if the benefit exceeds the risk for increased bleeding.
β-Blockers are generally well tolerated but should not be started when the patient is acutely decompensated. These agents have negative inotropic properties and may exacerbate heart failure in patients with acute volume overload. β-Blockers should be initiated at low dosages and uptitrated slowly over weeks (not days) until the patient achieves the guideline-directed target dosage or maximum tolerable dosage. The target dosage for carvedilol is 25 mg twice daily (50 mg twice daily if weight >85 kg [187 lb])
- Spontaneous coronary artery dissection is the most common cause of pregnancy-associated myocardial infarction and occurs most commonly in the first month postpartum.
spontaneous coronary artery dissection
- Two key elements are associated with a successful transition to home following hospitalization for heart failure: a follow-up phone call within 2 to 3 days of discharge and an office visit within 7 to 14 days of hospital discharge.
small valve area (≤1.0 cm2), high peak velocity (≥4 m/s), and/or high mean gradient (≥40 mm Hg).
- Kussmaul sign and pericardial knock, if present, are helpful clues to the presence of constrictive pericarditis. The height of the waveform does not fall or may increase during inspiration (Kussmaul sign), reflecting the fixed diastolic volume of the right heart.
Takotsubo cardiomyopathy is a syndrome characterized by transient regional systolic ventricular dysfunction mimicking myocardial infarction (reduced ejection fraction, elevated cardiac enzymes, and signs of ischemia on ECG) in the absence of angiographic evidence of obstructive coronary artery disease.
- In patients with ascending aortic dissection, immediate open aortic repair is imperative to improve survival and reduce morbidity.
- Surgery for chronic primary severe mitral regurgitation is indicated in the presence of symptoms, left ventricular dilation, or reduced ejection fraction.
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