Chronic Heart Failure

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Clinical-manifestations 5 Laboratory 6 Diagnostic-procedures 7 Radiology 8 Complications 9 Management 10 More General Terms 11 Additional Terms 12 References

More Specific Terms

• left ventricular diastolic dysfunction (diastolic heart failure)

Introduction

• A clinical syndrome characterized by either:
• signs & symptoms of intravascular & interstitial volume overload, including shortness of breath, rales, & edema
• manifestations of inadequate tissue perfusion, such as fatigue or poor exercise tolerance

Etiology

• myocardial infarction
• cardiomyopathy
• pharmacologic agents:

• beta blockers
• calcium channel antagonists
• estrogens
• non-steroidal anti-inflammatory agents

• indomethacin
• phenylbutazone
• naproxen
• piroxicam
• especially long-acting NSAIDs

• steroids
• mannitol
• minoxidil

Clinical-manifestations

• Framingham criteria for diagnosis of CHF*

• major criteria

• paroxysmal nocturnal dyspnea
• jugular venous distention
• rales
• cardiomegaly
• acute pulmonary edema
• S3 gallop
• increased venous pressure (> 16 cm H2O)
• positive hepatojugular reflex

• minor criteria

• edema of extremities
• cough at night
• dyspnea on exertion
• hepatomegaly
• pleural effusion
• vital capacity < 2/3 of normal
• tachycardia (> 120/min)

• weight loss > 4.5 kg over 5 days of diuresis
  

• * At least one major & two minor criteria are necessary for diagnosis of CHF.

Laboratory

• hyponatremia is a marker of advanced disease
• elevated norepinephrine, atrial natriuretic factor & renin (rarely measured)
• elevated serum BNP ( ventricular pressure overload)
• low or high serum estradiol is associated with increased mortality in men []

Diagnostic-procedures

• electrocardiogram

• asymptomatic, non- sustained ventricular tachycardia (> 3 onsecutive beats) reflects severity of disease & portends poor prognosis
• conduction system abnormalities
• non-specific ST segment & T wave changes
• left ventricular hypertrophy suggests diastolic rather than systolic dysfunction
• Q waves suggest prior myocardial infarction

• echocardiogram:

• most useful diagnostic procedure
• global hypokinesis versus segmental wall motion anormalities
• chamber dimensions
• ventricular wall thickness
• evidence of valvular heart disease

• assessment of coronary artery disease:

• exercise tolerance testing, myocardial perfusion study, cardiac catherization
• indications:

• history of myocardial infarction
• cardiac angina
• atherosclerosis or peripheral vascular disease
• high-risk for myocardial infarction

Radiology

• chest X-ray

• cardiomegaly
• pulmonary venous redistribution
• interstitial or alveolar edema is uncommon

Complications

• sudden cardiac death in 20-40% due to:

• ventricular tachycardia or fibrillation
• bradycardia
• electromechanical dissociation

• depression or antidepressant therapy associated with increased mortality & risk of hospitalization [9]
  
• disease interaction(s) of heart failure with urinary incontinence
• disease interaction(s) of obstructive sleep apnea (OSA) with heart failure

Management

• also see heart failure
• pharmacological agents

• ACE inhibitors

• symptomatic congestive heart failure ( NYHA class II- IV)

• doses of ACE inhibitors shown to provide survival benefit

• captopril 50 mg TID
• enalapril 20 mg BID
• lisinopril 10 mg QD

• optimal doses ()

• lisinopril 40 mg QD
• enalapril 20 mg QD

• asymptomatic left ventricular ( LV) dysfunction

• LV ejection fraction <40%

• post myocardial infarction

• angiotensin II receptor inhibitors

• symptomatic CHF in elderly
• patients intolerant of ACE inhibitors

• diuretics

• loop diuretic ( Lasix) for volume overload
• spironolactone 25 mg PO QD reduces mortality

• may be used in conjunction with ACE inhibitor [4]

• digoxin

• persistent symptoms of CHF despite therapy with ACE inhibitors in patients in sinus rhythm
• rate control in atrial fibrillation

• nitrates

• angina pectoris
• preload reduction for peristent congestive symptoms

• hydralazine with isordil or other nitrate ( BiDil)

• patients intolerant of ACE inhibitors with symptomatic CHF
• hydralazine 75 mg QID shown to be of benefit
• guideline for African Americans with symptoms that persist despite optimal medical therapy [11]

• oral anticoagulation

• previous embolic event
• chronic or paroxysmal atrial fibrillation
• left ventricular thrombus

• antiplatelet agents

• treat comorbid cardiovascular disease
• aspirin better than warfarin for patients in sinus rhythm [15]

• beta-blockers (symptomatic improvement)

• carvedilol ( Coreg): start 3.125 mg (survival benefit)
• metoprolol ( Toprol XL): start 12.5 mg QD
• bisoprolol ( Zebeta)

• avoid NSAIDs, especially those with long 1/2 life

• increased systemic vascular resistance
• reduced renal perfusion

• statin may be of benefit, even in non- ischemic heart failure [8], little benefit in elderly [10]
• severe refractory congestive heart failure

• dobutamine
• milrinone

• implantable cardioverter-defibrillator ( ICD)

• symptomatic ventricular tachycardia

• unresponsive to pharmacologic agents, or
• left ventricular ejection fraction < 35%
• antiarrhythmic therapy is often required to prevent frequent ICD misfirings
• does NOT prevent bradyarrhythmias

• cardiac resynchronization therapy ( NYHA class III or IV)
• nutritional counseling

• limit Na+ intake (< 2 g/day)
• limit fluid intake (< 1.5 L/day may be appropriate)

• lifestyle modification

• regular aerobic exercise [7]

• daily weights

• measure weight in AM, after awakening & voiding
• if weight increases by > 2 pounds, double dose of diuretic & K+ [5]

• cardiac transplantation

More General Terms

• heart failure (HF)
• chronic heart disease

Additional Terms

• anemia & heart failure
• cardiomyopathy
• left ventricular systolic dysfunction
• myocardial infarction (MI); heart attack
• New York Heart Association classification of heart failure

References

1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1291
3. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
4. Journal Watch, Mass Med Soc 20(1):7 (Jan 1) 2000 Pitt B et al The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 341:709, 1999 PMID: [1]
5. Watson K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
6. Prescriber's Letter 10(8):44 2003
7. Journal Watch 24(6):50-51, 2004 ExTraMATCH Collaborative, BMJ 328:189, 2004 PMID: [2]
   - ExTraMATCH Collaborative [3]
8. Sola S et al, Atorvastatin improves left ventricular systolic function and serum markers of inflammation in nonischemic heart failure. J Am Coll Cardiol 2006, 47:332 PMID: [4]
   - Ramasubbu K and Mann DL The emerging role of statins in the treatment of heart failure. J Am Coll Cardiol 2006, 47:342 PMID: [5]
9. Sherwood A et al, Relationship of depression to death or hospitalization in patients with heart failure. Arch Intern Med 2007, 167:367 PMID: [6]
10. Kjekshus J et al for the CORONA group Rosuvastatin in older patients with systolic heart failure. N Engl J Med 2007, Nov 5 [7]
11. Jessup M et al 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. PMID: [8]
12. Jankowska EA et al Circulating estradiol and mortality in men with systolic chronic heart failure. JAMA 2009 May 13; 301:1892. PMID: [9]
13. University of Michigan Health System (UMHS) Guidelines on heart failure - systolic dysfunction [10]
14. Prescriber's Letter 17(2): 2010 Target Doses of Heart Failure Medications Detail-Document#: [11] (subscription needed) [12]
15. Homma S et al Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm N Engl J Med, May 2, 2012 <PubMed> PMID: [13] <Internet> [14]
    - Eikelboom JW and Connolly SJ Warfarin in Heart Failure N Engl J Med, May 2, 2012 <PubMed> PMID: [15] <Internet> [16]
16. National Guideline Clearinghouse Congestive heart failure. (American College of Radiology) ngc-guideline: [17]
    - National Guideline Clearinghouse Guideline syntheses Diagnosis and Evaluation of Chronic Heart Failure (CHF) European Society of Cardiology (ESC) Heart Failure Society of America (HFSA) National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHFA/CSANZ Scottish Intercollegiate Guidelines Network (SIGN) ngc-guideline-synthesis: 36850

chronic heart failure; congestive heart failure (CHF)