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| {{Infobox_Disease | | | __NOTOC__ |
| Name = Heart failure |
| | {| class="infobox" style="float:right;" |
| Image = |
| | |- |
| Caption = |
| | | [[File:Siren.gif|30px|link= Heart failure resident survival guide]]|| <br> || <br> |
| DiseasesDB = 16209 |
| | | [[Heart failure resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| ICD10 = {{ICD10|I|50|0|i|50}} |
| | |} |
| ICD9 = {{ICD9|428.0}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000158 |
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| eMedicineSubj = med |
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| eMedicineTopic = 3552 |
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| MeshID = D006333|
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| }}
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| {{SI}} | | {{Congestive heart failure}} |
| {{WikiDoc Cardiology Network Infobox}}
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| {{WikiDoc Cardiology News}}
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| {{CMG}}
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| '''Associate Editor-In-Chief:''' {{CZ}}
| | {{CMG}}; {{AE}} {{LG}}, {{Mitra}} {{MehdiP}} {{HK}} [[User:Edzelco|Edzel Lorraine Co, D.M.D., M.D.]] [Mailto:efco@alum.up.edu.ph] |
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| {{Editor Join}} | | {{SK}} CHF; pump failure; left heart failure; chronic heart failure; acute heart failure; LV dysfunction; LV failure; impaired filling; reduced cardiac output; HFpEF; HFrEF; heart failure preserved ejection fraction; heart failure reduced ejection fraction; decompensated heart failure; acute decompensated heart failure; ADHF |
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| '''''Synonyms and Related Key Words:''''' CHF, pump failure, left heart failure, right heart failure, chronic heart failure, acute heart failure, flash pulmonary edema, congestion, systolic dysfunction, LV dysfunction, LV failure, impaired filling, reduced cardiac output, pulmonary edema
| | == [[Congestive heart failure overview|Overview]] == |
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| ==Overview==
| | == [[Congestive heart failure classification|Classification]] == |
| ===[[Congestive heart failure overview|Overview]]===
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| ===[[Congestive heart failure epidemiology and demographics|Epidemiology and Demographics]]===
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| ==[[Congestive heart failure pathophysiology and etiology|Pathophysiology and Etiology]]== | | == [[Congestive heart failure pathophysiology|Pathophysiology]] == |
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| ==Diagnosis==
| | [[Congestive heart failure pathophysiology#Systolic dysfunction|Systolic dysfunction]] | [[Diastolic dysfunction pathophysiology|Diastolic dysfunction]] | [[Congestive heart failure with preserved EF|HFpEF]] | [[Congestive heart failure with reduced EF|HFrEF]] |
| ===[[Congestive heart failure clinical assessment|Clinical Assessment]]===
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| ===[[Congestive heart failure differential diagnosis|Differential Diagnosis]]===
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| ==Treatment==
| | == [[Congestive heart failure causes|Causes]] == |
| ===[[Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)|Treatment of Patients at High Risk for Developing Heart Failure (Stage A)]]===
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| ===[[Congestive heart failure treatment of patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)|Treatment of Patients with Cardiac Structural Abnormalities or Remodeling who have not Developed Heart Failure Symptoms (Stage B)]]===
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| ===[[Congestive heart failure treatment of patients with current or prior symptoms of heart failure (Stage C)|Treatment of Patients with Current or Prior Symptoms of Heart Failure (Stage C)]]===
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| ===[[Congestive heart failure treatment of patients with refractory end-stage heart failure (Stage D)|Treatment of Patients With Refractory End-Stage Heart Failure (Stage D)]]===
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| ===[[Congestive heart failure treatment of special populations|Treatment of Special Populations]]===
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| ===[[Congestive heart failure treatment patients who have concomitant disorders|Treatment of Patients with Heart Failure who have Concomitant Disorders]]===
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| ==Classification Schemes of Heart Failure== | | == [[Congestive heart failure differential diagnosis|Differentiating Chronic Heart Failure from other Diseases]] == |
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| ===Framingham Criteria === | | == [[Congestive heart failure epidemiology and demographics|Epidemiology and Demographics]] == |
| ==== Major Criteria ====
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| * [[Paroxysmal nocturnal dyspnea]]
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| * [[Jugular vein|Jugular vein distention]]
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| * [[Rales]]
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| * [[cardiomegaly|Radiographic cardiomegaly]]
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| * [[pulmonary edema|Acute pulmonary edema]]
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| * [[S3]]
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| * [[Central venous pressure]] > 16 cmH2O
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| * Circulation time ≥ 25 sec
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| * [[Hepatojugular reflux]]
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| * [[Pulmonary edema]]
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| * [[Anasarca|Visceral congestion]]
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| * [[Cardiomegaly]] at [[autopsy]]
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| * [[Weight loss]] ≥ 4.5 kg in 5 days in response to treatment of heart failure
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| ==== Minor Criteria ==== | | == [[Congestive heart failure risk factors|Risk Factors]] == |
| * [[ankle edema|Bilateral ankle edema]]
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| * [[cough|Nocturnal cough]]
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| * [[Dyspnea|Dyspnea on ordinary exertion]]
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| * [[Hepatomegaly]]
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| * [[Pleural effusion]]
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| * [[vital capacity|30% decrease in baseline vital capacity]]
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| * [[Tachycardia]]
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| ===Boston Criteria of Congestive Heart Failure=== | | == [[Congestive heart failure natural history|Natural History, Complications and Prognosis]] == |
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| *'''Category I''': '''History'''
| | == Diagnosis == |
| :*[[dyspnea|Rest dyspnea]] 4 points
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| :*[[Orthopnea]] 4 points
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| :*[[Paroxysmal nocturnal dyspnea]] 3 points
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| :*[[Dyspnea]] on walking on level ground 2 points
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| :*[[Dyspnea]] on climbing 1 point
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| *'''Category II''': '''Physical Examination'''
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| :*[[Heart rate|Heart rate abnormality]] (1 point if 91 to 110 bpm; if >110 bpm, 2 points)
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| :*[[Jugular venous pressure|Jugular venous pressure elevation]] (2 points if >6 cm H<sub>2</sub>O; 3 points if >6 cm H<sub>2</sub>O and [[hepatomegaly]] or [[edema]]))
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| :*[[rales|Lung crackles]] (1 point if basilar; 2 points if more than basilar)
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| :*[[Wheezing]] 3 points
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| :*[[S3|Third heart sound]] 3 points
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| *'''Category III''': '''Chest Radiography'''
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| :*[[pulmonary edema|Alveolar pulmonary edema]] 4 points
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| :*[[pulmonary edema|Interstitial pulmonary edema]] 3 points
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| :*[[pleural effusion|Bilateral pleural effusion]] 3 points
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| :*Cardiothoracic ratio >0.50 (posteroanterior projection) 3 points
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| :*Upper zone flow redistribution 2 points
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| No more than 4 points are allowed from each of three categories; hence the composite score (the sum of the subtotal from each category) has a possible maximum of 12 points.
| | [[Congestive heart failure clinical assessment|Clinical Assessment]] | [[Congestive heart failure history and symptoms|History and Symptoms]] | [[Congestive heart failure physical examination|Physical Examination]] | [[Congestive heart failure laboratory tests|Laboratory Findings]] | [[Congestive heart failure electrocardiogram|Electrocardiogram]] | [[Congestive heart failure chest x ray|Chest X Ray]] | [[Congestive heart failure echocardiography|Echocardiography]] | [[Congestive heart failure cardiac MRI|Cardiac MRI]] | [[Congestive heart failure exercise stress testing|Exercise Stress Test]] | [[Congestive heart failure myocardial viability study|Myocardial Viability Studies]] | [[Congestive heart failure cardiac catheterization|Cardiac Catheterization]] | [[Invasive hemodynamic monitoring]] |
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| The diagnosis of heart failure is classified as "definite" at a score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a score of 4 points or less.
| | == Treatment == |
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| ===New York Heart Association Criteria (NYHA) ===
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| *'''NYHA I''': No symptoms with ordinary activity.
| | === Treatment of Heart failure with reduced ejection fraction === |
| *'''NYHA II''': Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in [[fatigue]], [[palpitation]], [[dyspnea]], or [[angina]]. | | : '''[[Congestive heart failure Pharmacological treatments for patients with heart failure with reduced ejection fraction|Pharmacological treatments for patients with heart failure with reduced ejection fraction]]''': |
| *'''NYHA III''': Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in [[fatigue]], [[palpitation]], [[dyspnea]], or [[chest pain|anginal pain]]. | | *'''In all patients:''' [[Congestive heart failure Angiotensin-converting enzyme inhibitors|Angiotensin-converting enzyme inhibitors]] | [[Congestive heart failure beta blockers|Beta Blockers]] | [[Congestive heart failure aldosterone antagonists|Aldosterone Antagonists]] | [[Congestive heart failure angiotensin receptor-neprilysin inhibitor|Angiotensin Receptor-Neprilysin Inhibitor]] | [[Congestive heart failure Sodium-glucose co-transporter 2 inhibitors|Sodium-glucose co-transporter 2 inhibitors]] |
| *'''NYHA IV''': Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency present at rest.
| | *'''In selected patients:''' [[Congestive heart failure diuretics|Diuretics]] | [[Congestive heart failure angiotensin receptor blockers|Angiotensin receptor blockers]] | [[Congestive heart failure If-channel inhibitor|I<sub>f</sub>-channel inhibitor]] | [[Combination of hydralazine and isosorbide dinitrate]] | [[Congestive heart failure Digoxin|Digoxin]] | [[Congestive heart failure iron|Iron]] |
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| ===ACC/AHA Classification of Chronic Heart Failure === | | Guideline-recommended medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) can be suggested by the [https://decisionalgorithm.shinyapps.io/heartfailure/ Heart Failure Educational Decision Aid] medication optimization algorithm<ref name="DorschSifuentesCordwin2023">{{cite journal | last1 = Dorsch | first1 = Michael P. | last2 = Sifuentes | first2 = Aaron | last3 = Cordwin | first3 = David J. | last4 = Kuo | first4 = Rachel | last5 = Rowell | first5 = Brigid E. | last6 = Arzac | first6 = Juan J. | last7 = DeBacker | first7 = Ken | last8 = Guidi | first8 = Jessica L. | last9 = Hummel | first9 = Scott L. | last10 = Koelling | first10 = Todd M. | title = A Computable Algorithm for Medication Optimization in Heart Failure With Reduced Ejection Fraction | journal = JACC: Advances | date = April 2023 | page = 100289 | issn = 2772-963X | doi = 10.1016/j.jacadv.2023.100289 | pmid = | url = }}</ref>. |
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| ==== Classification System based on structural and symptomatic stages of the syndrome. ====
| | : '''Cardiac rhythm management for patients with heart failure with reduced ejection fraction''': [[Congestive heart failure Antiarrhythmic drugs|Antiarrhythmic drugs]] | [[Congestive heart failure Implantable cardioverter defibrillator|Implantable cardioverter defibrillator]] | [[Cardiac resynchronization therapy]] |
| Stage 1: patients at risk of developing heart failure but who have no structural heart disease at present.
| | : '''[[Congestive heart failure Nutritional supplements and hormonal therapies|Nutritional supplements and hormonal therapies]]''' |
| Stage 2: patients with structural heart disease but no symptoms.
| | : '''[[Congestive heart failure Exercise training|Exercise training]]''' |
| Stage 3: patients with structural heart disease and symptomatic heart failure.
| | : '''[[Congestive heart failure Drugs to avoid|Drugs to avoid]]''' |
| Stage 4: patients with severe refractory heart failure.
| | : '''[[Congestive heart failure Drug interactions|Drug interactions]]''' |
| | : '''[[Congestive heart failure Treatment of underlying causes|Treatment of underlying causes]]''' |
| | : '''[[Congestive heart failure Treatment of associated conditions|Treatment of associated conditions]]''' |
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| ==== Stage 1 ==== | | === [[Congestive heart failure Treatment of Heart failure with preserved ejection fraction| Treatment of Heart failure with preserved ejection fraction]] === |
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| Patients “at Risk”
| | === [[Congestive heart failure Management of Acute heart failure | Management of Acute heart failure]] === |
| * [[Hypertension]]
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| * [[Diabetes mellitus]]
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| * [[Coronary artery disease]]
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| * Exposure history to [[cardiac toxins]]:
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| * History of [[cardiotoxic drug]] therapy.
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| * History of [[alcohol abuse]].
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| * Familial history of [[cardiomyopathy]]
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| ==== Stage 2 ==== | | ===[[ Management of Advanced heart failure]] === |
| | [[Congestive heart failure Ultrafiltration|Ultrafiltration]] | [[Congestive heart failure Mechanical circulatory support| Mechanical circulatory support]] | [[Heart transplantation]] |
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| Patients with structural heart disease, but no history of signs or symptoms of heart failure.
| | == ACC/AHA Guideline Recommendations == |
| * [[Left ventricular hypertrophy]] ([[LVH]])
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| * [[fibrosis|Myocardial fibrosis]]
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| * Left ventricular dilatation or dysfunction
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| * Asymptomatic [[valvular heart disease]]
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| * [[acute myocardial infarction|Previous myocardial infarction]]
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| ==== Stage 3 ==== | | === [[Congestive heart failure AHA recommendations for hospitalized patient|Hospitalized Patients]] === |
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| Underlying structural heart disease and symptoms of [[heart failure]].
| | ===[[Congestive heart failure AHA recommendations for patients with a prior MI|Patients With a Prior MI]]=== |
| * [[Dyspnea]] or [[fatigue]] due to left ventricular systolic dysfunction.
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| * Asymptomatic patients receiving treatment for prior symptoms of [[heart failure]].
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| ==== Stage 4 ==== | | ===[[Congestive heart failure sudden cardiac death prevention|Sudden Cardiac Death Prevention]]=== |
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| Despite of maximal medical therapy, symptoms of heart failure at rest and advanced structural heart disease.
| | === [[Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)|Stage A: Patients at High Risk for Developing Heart Failure]] === |
| * Awaiting for heart transplantation
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| * Requiring continuous inotropic or mechanical support
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| * Hospital management of heart failure
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| ==Risk Factors for the Development of Heart Failure==
| | [[Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)#Treatment of Hypertension|Treatment of Hypertension]] | [[Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)#Treatment of Diabetes Mellitus|Treatment of Diabetes Mellitus]] | [[Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)#Management of Metabolic Syndrome|Management of Metabolic Syndrome]] | [[Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)#Management of Atherosclerotic Disease|Management of Atherosclerotic Disease]] | [[Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)#Control of Conditions That May Cause Heart Failure|Control of Conditions That May Cause Heart Failure]] | [[Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)#ACC/AHA Guidelines- Treatment of Patients at High Risk for Developing Heart Failure (Stage A)|ACC/AHA Guideline Recommendations]] |
| #Demographic factors
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| #*Age
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| #*Gender
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| #*Low socioeconomic status
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| #Lifestyle-related factors
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| #*Tobacco and coffee consumption
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| #*Alcohol consumption
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| #*Dietary sodium intake
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| #*Recreational drug use: [[Cocaine]], [[methamphetamine]]s.
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| #Comorbidities | |
| #*[[Hypertension]]
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| #*[[Left ventricular hypertrophy]]
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| #*[[Acute myocardial infarction|Myocardial infarction]] | |
| #*[[Obesity]]
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| #*[[Diabetes mellitus]]
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| #*[[Valvular heart disease]]
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| #*[[Renal insufficiency]]
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| #*[[Dyslipidemia]]
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| #*[[Sleep apnea]]
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| #*[[Tachycardia]]
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| #*Impaired lung function
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| #*[[Depression]]
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| #Echocardiographic factors
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| #*Ventricular dimension
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| #*Ventricular mass
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| #*Diastolic filling impairment
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| #Pharmacological factors
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| #*Chemotherapeutic agents
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| #*[[Non-steroidal anti-inflammatory drug]]s
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| #*Thiazolidinediones?
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| #*[[Doxazosin]]
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| #Biochemical
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| #*[[Albuminuria]]
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| #*[[Homocysteine]]: Elevated plasma [[homocysteine]] levels are associated with almost a 75% increase in risk for heart failure development.
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| #*[[Tumor necrosis factor-alpha]] ([[TNF-alpha]]): After adjustment for other risk factors, every tertile increment in tumor necrosis factor-alpha (TNF-alpha) levels was associated with a 60% increase in risk of heart failure. [[TNF-alpha]] has several negative pleiotropic effects and also negative inotropic properties that may be responsible for excessive heart failure risk. [[TNF-alpha]] is also associated with progression of heart failure. | |
| #*[[Interleukin-6]]: IL-6 is a pro-inflammatory [[cytokine]] which associated with an excessive risk of development of heart failure. | |
| #*[[C-reactive protein]] | |
| #*[[Insulin-like growth factor-I]] ([[IGF-I]])
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| #*[[Natriuretic peptides]]
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| #Genetic risk factors
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| #*[[Genetic polymorphism]]
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| ===Risk Factors Associated with Heart Failure Progression and Outcomes=== | | === [[Congestive heart failure treatment of patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)|Stage B: Patients with Cardiac Structural Abnormalities]] === |
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| #Clinical
| | === [[Congestive heart failure treatment of patients with current or prior symptoms of heart failure (Stage C)|Stage C: Patients with Current or Prior Heart Failure Symptoms]] === |
| #*Etiology
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| #*Age
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| #*Gender
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| #*Symptom duration
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| #*[[NYHA class]]
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| #*Weight
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| #*Heart rate
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| #*[[Mean arterial pressure]]
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| #*[[S3|S3 gallop]]
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| #*[[Jugular venous pressure]]
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| #*Cardiothoracic ratio
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| #*Renal function
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| #*Serum [[sodium]]
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| #*[[Troponin T]]
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| #*History of diabetes
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| #*[[Anemia]]
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| #Echocardiographic
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| #*Ejection fraction
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| #*Exercise ejection fraction
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| #*Ventricular dimensions
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| #*Sphericity index
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| #*Prolonged isovolumic relaxation
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| #*Restrictive mitral filling
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| #*Changes in E/A ratio
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| #*[[Mitral regurgitation]]
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| #*Contractile reserve
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| #*Left ventricular mass
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| #Exercise Tolerance
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| #*Exercise duration
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| #*Peak O2 consumption
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| #*VE/VCO2
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| #*Anaerobic threshold 6-minute walk test
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| #Hemodynamics
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| #*[[Cardiac index]]
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| #*Pulmonary artery pressure
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| #*Pulmonary artery wedge pressure
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| #*[[Pulmonary vascular resistance]]
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| #*Stroke work index
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| #*Right atrial pressure
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| #*A-V oxygen difference
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| #*Coronary sinus O<sub>2</sub> content
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| #Electrophysiological
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| #*Conduction delay
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| #*Atrial arrhythmia
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| #*Family history of sudden death
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| #*Presence of late potentials
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| #*QT dispersion
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| #*[[T wave alternans]]
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| #Neurohormonal
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| #*Renin-angiotensin system
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| #*[[Angiotensin II]]
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| #*[[Aldosterone]]
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| #*Plasma renin activity
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| #*Sympathetic nervous system
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| #*:*[[Norepinephrine]]
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| #*:*[[Epinephrine]]
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| #*:*Heart rate variability
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| #*:*Norepinephrine spillover
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| #Natriuretic factors
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| #*[[Atrial natriuretic peptide]]
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| #*B-type natriuretic peptide
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| #*N-terminal-pro-ANP
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| #[[Cytokines]] and others
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| #*[[TNF-alpha]]
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| #*[[Interleukin-6]]
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| #*[[Endothelin]]
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| #*[[ICAM-1]] and [[Neuropeptide Y]] (NPY)
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| #*[[Arginine vasopressin]]
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| ===Heart Failure in [[Cardiac Tamponade]], [[Pericarditis|Constrictive Pericarditis]], and [[Cardiomyopathy|Restrictive Cardiomyopathy]]=== | | === [[Congestive heart failure treatment of patients with refractory end-stage heart failure (Stage D)|Stage D: Patients with Refractory End-stage Heart Failure]] === |
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| | == [[Congestive heart failure implementation of practice guidelines|Implementation of Practice Guidelines]] == |
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| | == [[Congestive heart failure end-of-life considerations|End-Of-Life Considerations]] == |
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| | == Specific Groups == |
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| ===Electrocardiography ===
| | [[Congestive heart failure treatment of special populations|Special Populations]] | [[Congestive heart failure treatment of patients who have concomitant disorders|Patients who have concomitant disorders]] | [[Congestive heart failure and obstructive sleep apnea|Obstructive Sleep Apnea in the Patient with CHF]] |
| *Electrocardiograms have no definitive but only suggestive findings.
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| *[[Left ventricular hypertrophy]], [[left bundle branch block]], intraventricular conduction delay, chamber enlargement, non-specific [[ST segment]] and [[T wave]] changes.
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| ===Chest X-ray ===
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| *Cardiac enlargement
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| *Pulmonary congestion ([[Kerley B lines]], and [[pleural effusion]])
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| ===Echocardiography ===
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| *Evaluation of left ventricular function and ejection fraction
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| *Wall motion abnormalities
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| *Detection of mitral regurgitation
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| *Detection of aortic stenosis
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| *Measurement of pulmonary artery pressure
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| *Detection and evaluation of aneurysms
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| ===Exercise Stress Tests===
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| Exercise Stress Tests is useful in measuring the "functional capacity" of patients. It is also helpful in follow up period for evaluation of congestive heart failure treatment.
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| ===Myocardial Viability Studies ===
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| *Dobutamine echocardiography
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| *Nuclear tests (SPECT or PET)
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| *Cardiac MRI
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| ===Cardiac Catheterization===
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| [[Coronary angiography]] for evaluation of coronary arteries and right heart catheterization for assessment of pulmonary artery resistance.
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| ==Management of Heart Failure==
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| ===Pharmacotherapy===
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| ===A. Acute Pharmacotherapy===
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| #[[Diuretics]]
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| #[[Nitroprusside]]
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| #[[Nesiritide]]
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| #[[Milrinone]]
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| #[[Dobutamine]]
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| #[[Dopamine]]
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| #[[Nitroglycerine]]
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| ===B. Chronic Pharmacotherapy===
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| ====Antiarrhythmic Drugs====
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| Antiarrhythmic therapy should be considered as a therapy to prevent sudden death. There are multiple causes of the for sudden death including [[ventricular tachycardia]], [[ventricular fibrillation]] as low as [[pulmonary emboli]], [[hyperkalemia]], and primary [[bradyarrhythmias]].
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| Over 50% of patients will have asymptomatic non-sustained [[ventricular tachycardia]] and there is no general indication for treatment of this arrhythmia.
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| Metabolisms of following anti-arrhythmic drugs are significantly affected in patients with [[congestive heart failure]];
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| #[[Quinidine]]
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| #[[Procainamide]]
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| #[[Disopyramide]]: Contraindicated in patients with [[heart failure]].
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| #[[Moricizine]]
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| #[[Lidocaine]]
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| #[[Mexiletine]]
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| #[[Tocainide]]
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| #[[Flecainide]]
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| #[[Propafenone]]
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| #[[Amiodarone]]
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| ====Renin-Angiotensin-Aldosteron System Related Drugs====
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| #[[Angiotensin converting enzyme inhibitor|ACE Inhibitors]]
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| #*[[ACE Inhibitor]]s ([[Angiotensin converting enzyme inhibitor|ACEI]]) should be considered as first-line therapy for the treatment of patients with clinical heart failure due to reduced LVSD, patients with asymptomatic LV dysfunction, and for patients who are at high risk for the development of heart failure due to the presence of coronary, cerebrovascular, or peripheral vascular disease.
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| #*Treatment should not be deferred in patients with few or no symptoms because of the significant mortality benefit derived from [[Angiotensin converting enzyme inhibitor|ACEI]] therapy.
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| #*Initial therapy usually consist of 12.5 mg tid of [[captopril]], 2.5 mg bid of [[enalapril]], or 2.5 mg daily lisinopril. The optimal dose is usually established by change 4 to 6 weeks. ACE inhibitors are rarely adequate for the treatment of congestion without the use of [[diuretics]].
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| #*5-10 % patients cannot tolerate [[ACE inhibitors]] because of [[cough]]. [[Cough]] can be a sign of elevated left-sided filling pressures. Sometimes [[cough]] will diminish with the treatment of heart failure. Angiotensin 2 receptor blockers are now being studied as a substitute for [[ACE inhibitors]]. Renal artery stenosis should be considered if there's a decline in renal function with the initiation of [[ACE inhibitors]].
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| #Angiotensin receptor blockers (ARB)
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| #Aldosterone Antagonists
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| ====Anticoagulants====
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| The annual incidence of systemic and [[pulmonary embolism]] in patients with [[heart failure]] is 2-5%. This is not that is similar from the risk of severe bleeding among patients to its anticoagulants which is 0.8-2.5% per year.
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| As a result anticoagulation is not routinely recommended in the current guidelines for the treatment of [[heart failure]]. However among those patients with a [[atrial fibrillation]], a history of emboli, or multiple intracardiac thrombi, or akinesis or dyskinesis detected on echo should be anticoagulated.
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| ====Beta Blockers====
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| *[[Metoprolol]], [[Carvedilol]] and [[Bisoprolol]] have FDA approval.
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| * Blockade of compensatory sympathetic stimulation creates an arrhythmic, ischemic, remodeling, and apoptotic benefit.
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| * Used as monotherapy or combined with conventional heart failure management, beta-blockers reduce the combined risk of morbidity and mortality.
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| * Initiate low starting dosing and titrate up to tolerated target doses.
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| #[[Bisoprolol]]
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| #Bucindolol
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| #[[Carvedilol]]
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| #[[Metoprolol]]
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| #Nevibolol
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| | |
| ====Ca Channel Blockers====
| |
| | |
| Although calcium channel blockers cause vasodilation their overall benefit is minimized by the fact that they have a negative inotropic effect and by the reflex activation of the sympathetic nervous system.
| |
| | |
| These agents are not recommended as vasodilators in patients with congestive heart failure, however they may be useful as antihypertensive agents in patients with diastolic dysfunction.
| |
| | |
| ====[[Diuretics]]====
| |
| *Provide symptomatic relief.
| |
| *Slows the progression of ventricular remodeling by reducing ventricular filling pressure and wall stress.
| |
| *No survival benefit and may cause azotemia, hypokalemia, metabolic alkalosis and elevation of neurohormones.
| |
| *Although [[thiazide]] [[diuretics]] are effective in mild [[heart failure]] they are usually inadequate for the treatment of severe [[heart failure]].
| |
| *[[Thiazide]] [[diuretics]] have also been associative with [[hyponatremia]].
| |
| *Fluid retention usually responds best to [[furosemide]] (Lasix) and at doses of 10 to 20 mg per day. The patient should be told to return to their position in the next three to seven days for further assessment including assessment of their [[potassium]] concentration. Weight loss should not exceed 1 to 2 pounds/day.
| |
| *If there is no response to the initial dose then it can be increased by at least 50%. The maintenance dose of the [[diuretics]] lower than that required to initiate diuresis.
| |
| *If the patient gains more than two pounds and they are instructed to double the dose of their loop diuretic.
| |
| *Once the baseline weight has been re-established than they can resume their previous status.
| |
| *Intermittent use of [[metolazone]] into dose of 2.5 or 5 mg can be given if the patient is refractory to [[furosemide]] Lasix. [[Metolazone]] should be given in the inpatient setting.
| |
| *The role of [[potassium]] sparing diuretics such as [[spironolactone]] (Aldactone), [[amiloride]], or [[triamterene]] remains the subject of controversy.
| |
| *Extreme caution is necessary when adding a [[potassium]] sparing agent to the regiment that includes [[ACE inhibitor]]s particularly when diabetes or renal disease is present because the patient can become hyperkalemic.
| |
| *'''Electrolyte replacement''':
| |
| [[ACE inhibitor]]s reduce [[potassium]] excretion, but most patients with good renal function require [[potassium]] supplementation during daily therapy with the diuretics such as [[furosemide]] (Lasix) despite of [[ACE inhibitor]]s therapy.
| |
| *Dietary supplementation is rarely adequate.
| |
| *[[Hypokalemia]] can aggravate arrhythmia is precipitate muscle cramps.
| |
| *[[Potassium]] levels >6 (particularly when occurs rapidly) can be associated with reduction in myocardial contractility.
| |
| *Patients are actually at higher risk of [[hyperkalemia]] and [[hypokalemia]]. The goal is to maintain a [[potassium]] between 3.8 and 4.5 mEq.
| |
| *Unless the [[hypokalemia]] is very severe and at life-threatening level, [[potassium]] should be replaced by oral administration.
| |
| *For IV route, It should not be administered more than 10 mEq per hour.
| |
| *Patients who use [[diuretics]] usually require approximately 20-60 mEq/day of oral [[potassium]].
| |
| *Extra [[potassium]] should be given after the patient has noted diuresis or weight change. If patient lost more than two pounds, the electrolyte's level should be checked every three days.
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| | |
| ===== Loop Diuretics =====
| |
| * Furosemide, bumetanide, ethacrynic acid and torsemide.
| |
| * Inhibit the Na+/K+/2Cl- symporter.
| |
| * Furosemide IV has direct vasodilatory effect.
| |
| * Providing additional blood pressure reduction.
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| * Relaxes pre-contracted pulmonary venules: beneficial for treatment of Pulmonary Edema.
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| | |
| ===== Thiazide Diuretics =====
| |
| * Inhibit the Na+/Cl- co transporter in the distal convoluted tube.
| |
| * Recommended for management of chronic heart failure.
| |
| | |
| ===== Potassium Sparing Diuretics =====
| |
| * [[Spironolactone]], [[amiloride]] and [[triamterene]].
| |
| * Inhibit principal cells in the distal convoluted tubule and cortical collecting duct.
| |
| * Inhibits Na reabsorbtion and [[Potassium]] secretion.
| |
| * Their significant side effect is [[hyperkalemia]].
| |
| | |
| ====[[Nitrate]]s====
| |
| | |
| *[[Nitrate]]s can be added to [[ACE inhibitor]]s to relieve symptoms of congestion.
| |
| *The addition of a [[nitrate]] and [[ACE inhibitor]] may improve exercised tolerance.
| |
| *The combination of [[hydralazine]] and nitrates is useful when [[ACE inhibitor]]s are not well tolerated.
| |
| *[[Hydralazine]] by itself is only an arterial vasodilator and does not reduced ventricular filling pressures to the same extent that nitrates and [[ACE inhibitor]]s do. In fact when used alone it can stimulate sympathetic tone reflexively. The combination of hydralazine and nitrates has been shown to decrease mortality as well as improve the left ventricular ejection fraction and exercise capacity in patients with [[heart failure]]. However the combination of [[hydralazine]] and [[nitrate]]s has been found to be less effective than [[ACE inhibitor]]s.
| |
| *The major uses this combination is in those patients who are intolerant of [[ACE inhibitor]]s.
| |
| | |
| ====Positive Inotropics====
| |
| | |
| #Agents that increase intracellular cAMP
| |
| #*Alpha-adrenergic agonists
| |
| #*[[Phosphodiesterase inhibitors]]
| |
| #Agents that affect sarcolemmal ion pumps/channels
| |
| #*[[Digoxin]]
| |
| #Agents that modulate intracellular calcium mechanisms by either:
| |
| #*Release of [[sarcoplasmic reticulum]] [[calcium]] (IP3)
| |
| #*Increased sensitization of the contractile proteins to [[calcium]]
| |
| #Drugs having multiple mechanisms of action
| |
| #*Pimobendan
| |
| #*Vesnarinone
| |
| | |
| ===== Digoxin =====
| |
| *Inhibits Na,K+-ATPase resulting in an increase in intracellular Na+, extracellular Ca2+ exchange increasing the velocity and extent of sarcomere shortening.
| |
| *ACC/AHA recommend [[digoxin]] for symptomatic patients with left ventricular systolic dysfunction.
| |
| *Commonly used in patients with [[heart failure]] and [[atrial fibrillation]] to reduce the ventricular response rate.
| |
| *Mortality has not been shown to be improved with use of [[digoxin]], but the use of [[digoxin]] has been associated with a reduction in hospitalization.
| |
| *There is no need to load a patient with [[digoxin]] for most patients with normal renal function 0.25 mg of [[digoxin]] daily is usually adequate. In the only patient or in those patients with renal impairment a dose of 0.125 mg per day may be adequate.
| |
| *Drugs increase the same concentration of [[digoxin]] include antibiotics and anticholinergic agents as well as [[amiodarone]], [[quinidine]] and [[verapamil]].
| |
| | |
| ===== Dobutamine =====
| |
| *Activates beta-1 receptors resulting in enhanced cardiac contractility.
| |
| *Long-term dobutamine infusions are arrhythmogenic and increase mortality.
| |
| | |
| =====Dopamine =====
| |
| *Unique dose dependent mechanism of action.
| |
| *At low doses: (≤2 µg/kg/min), selective dilation of splanchnic and renal arterial beds. assists in increasing renal perfusion.
| |
| *At intermediate doses: (2 to 10 µg/kg/min), increased norepinephrine secretion results in increased cardiac contractility, heart rate and peripheral vascular resistance.
| |
| *At higher doses: (5 to 20 µg/kg/min), direct alpha-adrenergic receptor stimulation increases systemic vascular resistance.
| |
| | |
| ===== Milrinone =====
| |
| *Phosphodiesterase-III inhibitor that enhances contractility by increasing intracellular cyclic adenosine monophosphate (cAMP).
| |
| *Potent pulmonary vasodilatation that benefits pts with pulmonary hypertension.
| |
| *Unlike dobutamine: milrinone is beneficial to decompensated heart failure patients on beta-blocker therapy.
| |
| *Long term milrinone infusions are arrhythmogenic, and increase mortality.
| |
| | |
| ===Biventricular Pacing===
| |
| | |
| Biventricular pacing or cardiac resynchronization therapy is;
| |
| | |
| * Indicated for symptomatic patients with NYHA III-IV heart failure and wide QRS complex (>120ms).
| |
| * 70% of patients receiving synchronous ventricular contraction report significant symptomatic improvements.
| |
| | |
| ===Implantation of Intracardiac Defibrillator===
| |
| | |
| *50% of heart failure patients die of [[sudden cardiac death]].
| |
| *ICDs are indicated for patients with previous myocardial infarction and LVEF <30%, sustained ventricular tachycardia, inducible ventricular tachycardia.
| |
| *Morbidity/mortality benefit of ICD placement vs. anti-arrhythmic drug therapy is controversial.
| |
| | |
| ===Ultrafiltration===
| |
| The process of ultrafiltration consists of the production of plasma water from whole blood across a semipermeable membrane (hemofilter) in response to a transmembrane pressure gradient. Possible benefits of ultrafiltration as follow;
| |
|
| |
| #Provides fluid regulation
| |
| #:*Relieve pulmonary edema
| |
| #:*Reduce ascites and/or peripheral edema
| |
| #:*Hemodynamic stabilization
| |
| #:*Improve oxygenation
| |
| #:*Facilitate blood product replacement without excess volume
| |
| #:*Enable parenteral nutritional support without excess volume
| |
| #Improves solute regulation
| |
| #:*Correct acid-base balance
| |
| #:*Correct serum sodium content
| |
| #:*Eliminate myocardial depressant factors or known toxins
| |
| #:*Correct uremia
| |
| #:*Correct hyperkalemia
| |
| #:*Correct other electrolyte disturbances
| |
| #Helps to establish homeostasis
| |
| #:*Reset water omostat
| |
| #:*Restore diuretic responsiveness
| |
| #:*Reduce neurohormonal activation
| |
| | |
| ===Cardiac Surgery===
| |
| *Resection of non-viable myocardium
| |
| *Revascularization without resection of non-viable myocardium
| |
| *Dor procedure: Surgical resection of infarcted myocardium and left ventricular reconstruction.
| |
| *Placement of a passive containment device to prevent progressive cardiac dilation ('''Under investigation''')
| |
| | |
| ===Left Ventricular Assist Devices===
| |
| | |
| *LVADs are temporary devices to bridge end stage patients to cardiac transplantation.
| |
| *Current clinical research in implementing permanent portable LVADs is underway, and first studies have promising results.
| |
| | |
| ===Cardiac Transplantation===
| |
| | |
| * For patients with end-stage congestive heart failure despite all interventions.
| |
| * 80% 1 year survival and 60% 5 year survival.
| |
| * Lifelong immunosuppressive therapy to prevent (or postpone) rejection, increased risk for opportunistic infections and malignancies.
| |
| | |
| '''AHA/ACC Guidelines: Indications for heart transplantation'''
| |
| *Any hemodynamic compromise due to heart failure.
| |
| *Requiring IV inotropic support to maintain adequate organ perfusion.
| |
| *Peak Vo2 <10 ml/kg/min.
| |
| *NYHA Class IV symptoms not amenable to any other intervention.
| |
| *Recurrence of symptomatic ventricular arrhythmias refractory to all therapeutic intervention.
| |
| | |
| ==Exercise and Daily Activities==
| |
| *Patient should have uninterrupted exercise at least four days a week including a walking program.
| |
| *Rowing machines usually are too vigorous of exercise.
| |
| *Patients with heart failure should avoid weightlifting.
| |
| *The patient should not routinely lift more than 20 pounds.
| |
| *Patients can continue their sexual activity. Some patients take 2.5 or 5.0 mg of sublingual nitroglycerin before sexual activity.
| |
| | |
| ==Prognosis==
| |
| | |
| ===Mortality Associated with Heart Failure===
| |
| | |
| Based on the 44-year follow-up of the NHLBI’s Framingham Heart Study:
| |
| *80% of men and 70% of women under age 65 who have [[heart failure]] will die within following 8 years.
| |
| *In people diagnosed with [[heart failure]], [[sudden cardiac death]] occurs at 6 to 9 times the rate of the general population.
| |
| *One in eight deaths has [[heart failure]] mentioned on the death certificate.
| |
| | |
| ===Hospital Discharges===
| |
| | |
| *Hospital discharges for [[heart failure]] rose from 400,000 in 1979 to 1,084,000 in 2005, an increase of 171%. (NHDS / NHLBI and AHA calculations).
| |
| | |
| ===Cost===
| |
| • The estimated direct and indirect cost of [[heart failure]] in the United States for 2008 is '''$34.8 billion'''.
| |
| | |
| ==Pathological Findings==
| |
| | |
| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
| |
| | |
| <div align="left">
| |
| <gallery heights="175" widths="175">
| |
| Image:HEART Congestive heart failure, hydropic change.jpg|HEART: Congestive heart failure, hydropic change
| |
| Image:HEART Congestive heart failure, hydropic change 2.jpg|HEART: Congestive heart failure, hydropic change
| |
| Image:HEART Congestive heart failure, hydropic change 3.jpg|HEART: Congestive heart failure, hydropic change
| |
| </gallery>
| |
| </div>
| |
| | |
| | |
| <div align="left">
| |
| <gallery heights="175" widths="175">
| |
| Image:HEART Congestive heart failure, hydropic change 4.jpg|HEART: Congestive heart failure, hydropic change
| |
| Image:HEART Congestive heart failure, hydropic change 5.jpg|HEART: Congestive heart failure, hydropic change
| |
| Image:HEART Congestive heart failure, hydropic change 6.jpg|HEART: Congestive heart failure, hydropic change
| |
| </gallery>
| |
| </div>
| |
| | |
| | |
| <div align="left">
| |
| <gallery heights="175" widths="175">
| |
| Image:Lung, congestion, heart failure cells (hemosiderin laden macrophages).jpg|Lung, congestion, heart failure cells (hemosiderin laden macrophages)
| |
| Image:Lung, Congestive Heart Failure, bone marrow embolus.jpg|Lung, Congestive Heart Failure, bone marrow embolus
| |
| Image:Lung, pulmonary edema in patient with congestive heart failure.jpg|Lung, pulmonary edema in patient with congestive heart failure due to heart transplant rejection
| |
| </gallery>
| |
| </div>
| |
| | |
| | |
| <div align="left">
| |
| <gallery heights="175" widths="175">
| |
| Image:HEART Congestive heart failure, hydropic change 7.jpg|HEART: Congestive heart failure, hydropic change
| |
| Image:HEART Congestive heart failure, hydropic change 8.jpg|HEART Congestive heart failure, hydropic change
| |
| Image:Spleen, congestion, congestive heart failure.jpg|Spleen, congestion, congestive heart failure
| |
| </gallery>
| |
| </div>
| |
|
| |
|
| ==References== | | ==References== |
| {{Reflist|2}} | | {{Reflist|2}} |
| | {{WikiDoc Help Menu}} |
| | {{WikiDoc Sources}} |
|
| |
|
| ==External links==
| |
| * [http://my.clevelandclinic.org/heart/webchat/heart_failure_taylor.aspx Cleveland Clinic Webchat - Medical Treatments for Heart Failure with Dr. Davide Taylor]
| |
| * [http://my.clevelandclinic.org/heart/webchat/smedira091807.aspx Cleveland Clinic Webchat - Surgical Treatments for Heart Failure with Dr. Nicholas Smedira]
| |
| * [http://my.clevelandclinic.org/heart/webchat/hobbs081407.aspx Cleveland Clinic Webchat - Medical Treatment of Heart Failure with Dr. Roberts Hobbs]
| |
|
| |
| {{SIB}}
| |
|
| |
| [[Category:DiseaseState]]
| |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| | [[Category:Disease]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| | | [[Category:Intensive care medicine]] |
| {{WikiDoc Help Menu}}
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| {{WikiDoc Sources}}
| | [[Category:Up-To-Date]] |
| | [[Category:Up-To-Date cardiology]] |
