Congestive heart failure classification

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Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

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Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

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History and Symptoms

Physical Examination

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Cardiac Catheterization

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Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Risk calculators and risk factors for Congestive heart failure classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

There are several classification schemes used to characterize the pathophysiology of heart failure as either systolic vs diastolic; left vs right; or low output vs high output.

Classification

There are several classification schemes used to characterize heart failure, which include:

Systolic versus Diastolic Heart Failure

Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation. These may also be labeled "heart failure with preserved ejection fraction" (HFpEF) and "heart failure with reduced ejection fraction" (HFrEF)[1].

Systolic Dysfunction

The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.

Diastolic Dysfunciton

The left ventricular ejection fraction is preserved in diastolic dysfunction and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

Left, Right and Biventricular Failure

Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).

Left Heart Failure

  • There is impaired left ventricular function with reduced flow into the aorta.

Right Heart Failure

  • There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.

Biventricular Failure

  • The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

High Output Versus Low Output Failure

Low Output Failure

High Output Failure

Chronicity of Heart Failure

Acute or Decompensated

Acute or decompensated heart failure is a term used to describe exacerbated or decompensated heart failure, and refers to an episode in which a patient sustains a change in heart failure signs and symptoms that necessitates urgent therapy or hospitalization.[4]

Chronic

There is stable symptomatology in chronic heart failure.

Assessing the Severity of Heart Failure: The New York Heart Association Criteria (NYHA)

  • NYHA I: No symptoms with ordinary activity.
  • NYHA IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency present at rest.

ACC/AHA Classification of Chronic Heart Failure Based on the Structural and Symptomatic Stages of the Syndrome

The ACC/AHA classification system was introduced to emphasize the natural history of the heart failure syndrome and to identify opportunities to intervene earlier and prevent disease progression.

Stage A

Patients “at Risk”

Stage B

Patients with structural heart disease, but no history of signs or symptoms of heart failure.

Stage C

Underlying structural heart disease and symptoms of heart failure.

  • Dyspnea or fatigue due to left ventricular systolic dysfunction.
  • Asymptomatic patients receiving treatment for prior symptoms of heart failure.

Stage D

Despite of maximal medical therapy, symptoms of heart failure at rest and advanced structural heart disease.

  • Being considered for advance options including LVAD and heart transplantation.
  • Requiring continuous inotropic or mechanical support.
  • Receiving or being considered for palliative care/end of life care.

Classification of Heart Failure Based on the Ejection Fraction (EF)

  • The 2013 ACC/AHA guidelines indicated that the EF is the most accurate way to classify heart failure rather than systolic vs diastolic. That is due to the variation in the definition of systolic dysfunction with some defines it as an EF < 35%, < 40% and <= 40%.
  • For 2013 guideline, HFrEF is defined as the clinical diagnosis of heart failure, with an EF less than or equal to 40%.
  • HFpEF is defined as symptoms of heart failure and EF= 40-50%.

Guidelines Resources

References

  1. 1.0 1.1 Aurigemma GP (2006). "heart failure--a common and lethal condition by any name". N Engl J Med. 355 (3): 308–10. doi:10.1056/NEJMe068128. PMID 16855273.
  2. Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  3. high-output heart failure at Dorland's Medical Dictionary
  4. Jessup. M, et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009 Apr 14;119(14):1977-2016. PMID 19324967
  5. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG 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
  6. Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 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 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967



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