Heart failure
Congestive heart failure is defined as "defective cardiac filling and/or impaired contraction and emptying, resulting in the heart's inability to pump a sufficient amount of blood to meet the needs of the body tissues or to be able to do so only with an elevated filling pressure".[1]
Classification
Systolic dysfunction
Diastolic dysfunction
Diagnosis
History and physical examination
| Congestion†? (jugular venous distention and radiographic redistribution)[2] | |||
|---|---|---|---|
| No | Yes | ||
| Hypoperfusion‡? (proportional pulse pressure < 25%[3][4], cool extremities[5]) |
No | Warm and dry (46% mortality at one year) |
Warm and wet |
| Yes | Cold and dry | Cold and wet (33% mortality at one year[4]) | |
| Notes: Adapted from Figure 1 of Nohria et al.[6] | |||
The best findings for detecting increased filling pressure are jugular venous distention and radiographic redistribution. The best findings for detecting systolic dysfunction are abnormal apical impulse, radiographic cardiomegaly, and q waves or left bundle branch block on an electrocardiogram. [2]
The history and physical examination can also be used for patients with advanced heart failure to place the patient into a hemodynamic profile to guide management.[6][4][5] Patients in the "cold and wet" category may need to "warm up in order to dry out" by stopping beta-blockers and ACE inhibitors.[6]
Echocardiogram
The fractional shortening can estimate the left ventricular ejection fraction.[7][8][9]
Treatment
Medications
Angiotensin-converting enzyme inhibitors
Angiotensin-converting enzyme inhibitors (ACE inhibitors) should not be used if:[10]
- Baseline serum potassium is < 5.5 mmol per liter.
- No prior life-threatening adverse reactions (angioedema or anuric renal failure) during previous exposure to the drug
- They are not pregnant
- Systolic blood pressure less than 80 mm Hg
- Serum levels of creatinine greater than 3 mg per dL
- Bilateral renal artery stenosis is not present
Angiotensin-converting enzyme inhibitors combined with angiotensin-receptor blockers
This combination should be avoided due to increased azotemia, hyperkalemia, and symptomatic hypotension.[11]
Aldosterone antagonists
Aldosterone antagonists, initial dose of spironolactone 12.5 mg or eplerenone 25 mg, may be used as long as:[10]
- Serum creatinine 1.6 mg per dL or less and glomerular filtration rate or creatinine clearance exceeds 30 mL per minute.
- Baseline serum potassium is < 5.0 mEq per liter
Risk of hyperkalemia is increased if the following drugs are used:[10]
- Higher doses of ACE inhibitors (captopril greater than or equal to 75 mg daily; enalapril or lisinopril greater than or equal to 10 mg daily).
- Nonsteroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors
- Potassium supplements
After starting aldosterone antagonists:[10]
- Potassium levels and renal function should be checked in 3 days
- Potassium levels and renal function should be checked at 1 week
- Potassium levels and renal function should be checked monthly for the first 3 months.
- Diarrhea or other causes of dehydration should be addressed emergently
Implantable devices
Several implantable devices may help; however, it is not clear that implantable cardioverter-defibrillators (ICD) add benefit over cardiac resynchronisation therapy (CRT).[12]
Cardiac resynchronization therapy
According to a systematic review, cardiac resynchronization therapy (CRT), which is biventricular pacing, can reduce morbiity and mortality if the ejection fraction is less than 35%.[13] 30 patients must be treated to avoid one death (number needed to treat is 30). Cardiac resynchronization should only be used for patients with a QRS duration of at least 120 msec.[14]
Implantable cardioverter-defibrillator
Implantable cardioverter-defibrillators (ICD) can reduce mortality in patients who have an ejection fraction of less than 35%.[15]
Left ventricular assist devices
Left ventricular assist devices (LVADs) may be an option for patients with end stage heart failure.[16]
References
- ↑ National Library of Medicine. Heart Failure, Congestive. Retrieved on 2007-10-19.
- ↑ 2.0 2.1 Badgett RG, Lucey CR, Mulrow CD (1997). "Can the clinical examination diagnose left-sided heart failure in adults?". JAMA 277 (21): 1712-9. PMID 9169900. [e]
- ↑ Stevenson LW, Perloff JK (1989). "The limited reliability of physical signs for estimating hemodynamics in chronic heart failure". JAMA 261 (6): 884–8. PMID 2913385. [e]
- ↑ 4.0 4.1 4.2 4.3 4.4 Shah MR, Hasselblad V, Stinnett SS, et al (2001). "Hemodynamic profiles of advanced heart failure: association with clinical characteristics and long-term outcomes". J. Card. Fail. 7 (2): 105–13. DOI:10.1054/jcaf.2001.24131. PMID 11420761. Research Blogging.
- ↑ 5.0 5.1 5.2 Kaplan LJ, McPartland K, Santora TA, Trooskin SZ (2001). "Start with a subjective assessment of skin temperature to identify hypoperfusion in intensive care unit patients". The Journal of trauma 50 (4): 620–7; discussion 627–8. PMID 11303155. [e]
- ↑ 6.0 6.1 6.2 Nohria A, Lewis E, Stevenson LW (2002). "Medical management of advanced heart failure". JAMA 287 (5): 628–40. PMID 11829703. [e]
- ↑ Tortoledo FA, Fernandez GC, Quinones MA (1983). "An accurate and simplified method to calculate angiographic left ventricular ejection fraction". Catheterization and cardiovascular diagnosis 9 (4): 357-62. PMID 6627386. [e]
- ↑ Quinones MA, Waggoner AD, Reduto LA, et al (1981). "A new, simplified and accurate method for determining ejection fraction with two-dimensional echocardiography". Circulation 64 (4): 744-53. PMID 7273375. [e]
- ↑ Erbel R, Schweizer P, Krebs W, Meyer J, Effert S (1984). "Sensitivity and specificity of two-dimensional echocardiography in detection of impaired left ventricular function". Eur. Heart J. 5 (6): 477-89. PMID 6745290. [e]
- ↑ 10.0 10.1 10.2 10.3 Hunt SA, Abraham WT, Chin MH, et al (2005). "ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society". Circulation 112 (12): e154–235. DOI:10.1161/CIRCULATIONAHA.105.167586. PMID 16160202. Research Blogging. National Guidelines Clearinghouse
- ↑ Phillips CO, Kashani A, Ko DK, Francis G, Krumholz HM (2007). "Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials". Arch. Intern. Med. 167 (18): 1930–6. DOI:10.1001/archinte.167.18.1930. PMID 17923591. Research Blogging.
- ↑ Lam SK, Owen A (2007). "Combined resynchronisation and implantable defibrillator therapy in left ventricular dysfunction: Bayesian network meta-analysis of randomised controlled trials". BMJ 335 (7626): 925. DOI:10.1136/bmj.39343.511389.BE. PMID 17932160. Research Blogging.
- ↑ McAlister FA, Ezekowitz J, Hooton N, et al (2007). "Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: a systematic review". JAMA 297 (22): 2502–14. DOI:10.1001/jama.297.22.2502. PMID 17565085. Research Blogging. ACPJC summary
- ↑ Beshai JF, Grimm RA, Nagueh SF, et al (2007). "Cardiac-Resynchronization Therapy in Heart Failure with Narrow QRS Complexes". DOI:10.1056/NEJMoa0706695. PMID 17986493. Research Blogging.
- ↑ Bardy GH, Lee KL, Mark DB, et al (2005). "Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure". N. Engl. J. Med. 352 (3): 225–37. DOI:10.1056/NEJMoa043399. PMID 15659722. Research Blogging.
- ↑ Delgado RM, Radovancevic B (2007). "Symptomatic relief: left ventricular assist devices versus resynchronization therapy". Heart failure clinics 3 (3): 259–65. DOI:10.1016/j.hfc.2007.05.004. PMID 17723934. Research Blogging.