Heart Failure

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Epidemiology 5 Pathology 6 Clinical-manifestations 7 Laboratory 8 Diagnostic-procedures 9 Radiology 10 Complications 11 Management 12 More General Terms 13 Additional Terms 14 References

More Specific Terms

• acute heart failure (AHF)
• chronic heart failure; congestive heart failure (CHF)
• cor pulmonale (right heart failure, right ventricular failure)
• diastolic dysfunction
• left ventricular diastolic dysfunction (diastolic heart failure)
• left ventricular failure
• left ventricular systolic dysfunction
• systolic dysfunction

Introduction

• Heart failure ( HF) is the inability of the heart to maintain a cardiac output sufficient to meet the metabolic needs of the body. It is a common condition with high morbidity & mortality.

Etiology

• coronary artery disease

• intermittent myocardial ischemia
• myocardial infarction

• hypertensive heart disease

• diastolic dysfunction, left ventricular hypertrophy
• systolic dysfunction

• dilated cardiomyopathy

• idiopathic
• toxic

• alcohol
• doxorubicin
• cocaine

• infection

• viral
• parasitic

• collagen vascular disease

• valvular heart disease

• mitral stenosis
• aortic stenosis
• acute mitral regurgitation

• ischemic papillary muscle dysfunction
• rupture of papillary muscle
• rupture of chordae tendinae

• aortic or mitral regurgitation from endocarditis

• hypertrophic cardiomyopathy
• restrictive cardiomyopathy

• amyloidosis
• sarcoidosis
• hemochromatosis

• constrictive pericarditis
• high output heart failure

• chronic anemia
• atrioventricular shunts
• thyrotoxicosis
• beriberi

• precipitants or decompenstation of heart failure:

• myocardial ischemia or infarction
• hypertension
• cardiac arrhythmias ( atrial fibrillation)
• infection
• anemia
• pregnancy
• thyrotoxicosis
• volume overload - renal failure
• toxins

• alcohol
• doxorubicin

• drugs

• beta-adrenergic receptor antagonists
• non-steroidal anti-inflammatory drugs ( NSAIDs)
• calcium channel antagonists

• pulmonary embolism
• valvular failure
• ventricular septal defect
• aortic dissection
• dietary or medical non-compliance

• risk factors

• obesity [5]
• diabetes, ( hazzard ratio as large as 2.6) [17]

Epidemiology

• 1% of adults in their 50s; 10% > 70 years [26]
• 5-10% of all hospital admissions, 31-47% with diastolic dysfunction [15]
• deaths from heart failure are increasing

Pathology

• organ hypoperfusion

• reflexive arteriolar vasoconstriction
• inadequate oxygen delivery to tissues

• left ventricular diastolic dysunction

• left ventricular hypertrophy
• increased left ventricular filling pressures
• left atrial enlargement

• predisposes to atrial fibrillation

• pulmonary edema
• left heart failure leads to right heart failure

• peripheral edema

• left ventricular systolic dysfunction

• decreased left ventricular ejection fraction
• increased left ventricular filling pressure
• left atrial enlargement

• predisposes to atrial fibrillation

• pulmonary edema
• left heart failure leads to right heart failure

• peripheral edema

• increased systemic vascular resistance due to:

• enhanced sympathetic nervous system activity
• elevation of circulating catecholamines

• activation of renin/ angiotensin system
• increased vasopressin

Clinical-manifestations

• symptoms

• fatigue
• dyspnea on exertion - most common initial symptom
• orthopnea - most sensitive indicator of high left ventricular filling pressure
• cough
• nausea
• right upper quadrant abdominal pain
• paroxysmal nocturnal dyspnea
• nocturia
• confusion

• signs

• peripheral edema, especially ankles
• jugular venous distention
• pulmonary edema
• pleural effusion
• rales, crackles may not be present with chronic HF despite decompensated HF
• pericardial effusion
• hepatic congestion, hepatomegaly
• third heart sound (S3), four heart sound (S4)
• systolic murmur of mitral regurgitation
• tachycardia
• ascites

Laboratory

• chem 7 panel

• serum creatinine, serum urea nitrogen

• elevated BUN/creatinine

• serum Na+:

• persistent hyponatremia is poor prognostic indicator [19]

• liver function tests ( elevated serum transaminases)
• complete blood count ( CBC)
• serum thyroid-stimulating hormone ( serum TSH)
• serum BNP:

• elevated serum BNP is non-specific
• if < 50 mg/mL, excludes heart failure as cause of dyspnea
• if < 100 ng/mL, heart failure unlikely [3]
• patient-specific characteristics may affect serum BNP cutoff (see serum BNP)

• elevated urinary albumin/creatinine is associated with a poor prognosis [28]
• urinalysis [39]

Diagnostic-procedures

• electrocardiogram: (common findings)

• arrhythmias
• conduction delays
• non-specific ST-T changes

• echocardiography

• diastolic vs systolic dysfunction
• valvular heart disease
• regional wall abnormalities suggesting CAD
• repeat echocardiogram most useful if there has been a change in clinical status [3]

• stress testing to identify myocardial ischemia
• 6 minute walk test:

• ability to walk < 300 meters is associated to 3-4 fold increase in mortality ( chronic heart failure) [3]

• cardiac catheterization if indicated by stress testing
• endomyocardial biopsy if suspecting: hemochromatosis, sarcoidosis, amyloidosis

Radiology

• chest X-ray

• cardiomegaly
• pulmonary vascular redistribution
• pleural effusion
• pulmonary edema

• radionuclide ventriculography

Complications

• 
  
• disease interaction(s) of heart failure with urinary incontinence
• disease interaction(s) of obstructive sleep apnea (OSA) with heart failure

Management

• non-pharmacologic

• restriction of physical activity

• bedrest to reduce myocardial demand for symptomatic patients- DVT prophylaxis
• carefully guided cardiac rehabilitation & exercise
• regular aerobic exercise for stable heart failure [8]

• weight loss in obese patients
• dietary sodium restriction < 2 grams/day
• fluid restriction < 1.5 L/day if hyponatremia <130 meq/L
• consider discontinuation of medications with negative inotropic effects

• beta-adrenergic antagonists
• verapamil
• diltiazem
• disopyramide
• flecainide

• oxygen
• smoking cessation
• dialysis if fluid overload & renal failure

• pharmacologic therapy

• vasodilators

• first line treatment in heart failure
• ACE inhibitors

• indicated even in the absence of symptoms [3]
• counteract reflexive activation of renin-angiotensin system
• decrease ventricular filling pressures
• decrease systemic vascular resistance
• increase cardiac output
• little or no change in blood pressure
• little or no change in heart rate
• avoid initiation of ACE inhibitor in setting of hypovolemia

• angiotensin II receptor antagonist ( ARB)

• patients who cannot tolerate ACE inhibitor
• losartan may be as good as candesartan [35]

• hydralazine plus isordil ( BiDil) [9]

• inferior to ACE inhibitor in whites
• may be treatment of choice in blacks
• an adjunct to standard therapy in blacks [3]
• BiDil 1-2 tabs PO TID

• beta-blocker, in connection with ACE inhibitor

• treat of chronic, not acute heart failure
• carvedilol ( Coreg), Toprol XL & bisoprolol ( Zebeta) have been shown to improve outcomes [6]
• atenolol & metoprolol tartrate also of benefit [24]
• lower heart rate associated with lower mortality [27]

• diuretics

• spironolactone (stage 3,4 NYHA-HF)

• recent history of recurrent symptoms at rest
• NYHA class 3-4 heart failure
• eplerenone is alternative if spironolactone not tolerated
• check serum K+ & serum creatinine

• loop diuretics for patients with volume overload
• adjust dose by input/output records or daily weights
• diuretic resistance can be treated or augmented by

• fluid restriction
• Na+ restriction
• use of diuretic combinations

• statins

• treat comorbid cardiovascular disease
• may not benefit patients with heart failure [23]

• rosuvastatin does not diminish 4 year mortality [22]

• may benefit elderly (> 65) with heart failure [30]

• antiplatelet agents

• treat comorbid cardiovascular disease
• aspirin better than warfarin for patients in sinus rhythm [41]

• inotropic agents

• digitalis glycosides ( digoxin)

• digoxin loading dose 0.25 mg PO TID or QID for 1 day
• digoxin maintenance dose 0.125-0.25 mg PO QD
• may reduce symptoms & hospitalizatons, but does not reduce mortality

• testosterone replacement may be of benefit in men & women [34]
• anticoagulation if atrial fibrillation
• omega-3 fatty acids 1 g/day may diminish mortality & hospitalization [21,22,23] (2% absolute risk reduction)

• evalulate for ischemic heart disease if new onset or worsening heart failure [3]
• correct potential factors that may exacerbate heart failure

• hypertension
• myocardial ischemia
• arrhythmias
• obesity
• inappropriate medications
• dietary indiscretion
• iron-deficiency even in the absence of anemia [29];

• IV iron for patients with serum ferritin < 100 ng/mL with a transferrin saturation < 20% suggested
• Venofer 200 mg/week until iron stores are replete, then 200 mg/month for 4-6 months [31]

• venovenous ultrafiltration for volume overload
• mechanical circulatory support

• implantable cardioverter-defibrillator ( ICD)

• NYHA class 2 or 4 heart failure on optimal medical therapy &
• prognosis: > 1 year survival anticipated &
• ventricular tachycardia, syncope, sudden death, or
• ischemic or nonischemic cardiomyopathy with LVEF <35%

• cardiac resynchronization therapy ( CRT)

• NYHA class 3,4 heart failure, or
• LV ejection fraction <= 35%, or
• prolonged QRS duration > 120 msec, LBBB

• ICD/ CRT intrathoracic impedance data not only fail to improve outcomes, but increase hospitalizations due to heart failure [38]

• CPAP for obstructive sleep apnea
• cardiac transplantation or left ventricular assist device

• NYHA HF class 4 (see cardiac transplantation)

• wireless pulmonary artery sensor may provide early warning of worsening heart failure [36]
• transendocardial implantation of autologuous bone marrow mononuclear cells of no benefit [40]
• also see heart failure classification AHH/ACC
• prevention: see prevention of heart disease
• heart failure management programs of uncertain value [20]
• Telemonitoring of patients after hospitalization for heart failure of uncertain value [33]
• poor health literacy adversely effects outcomes [37]

More General Terms

• heart disease (cardiac disease)

Additional Terms

• anemia & heart failure
• cardiomyopathy
• depression & heart disease
• heart failure classification AHH/ACC
• New York Heart Association classification of heart failure
• prevention of heart failure
• screening questions for heart failure (FACES)
• Seattle heart failure model
• third heart sound (S3), S3 gallop

References

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3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
4. Watson K, in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
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6. Prescriber's Letter 10(8):44 2003
7. Prescriber's Letter 10(10):58 2003
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    - Myocarditis: current treatment: HFSA 2010 comprehensive heart failure practice guideline. Heart Failure Society of America, Inc ngc-guideline: [71]
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heart failure (HF)