Heart Failure: Difference between revisions

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Heart Failure (view source)

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===Heart catheterization===
===Heart catheterization===
Heart catheterization is not always part of the routine diagnosis and work-up of patients with HF.  It should be considered however to exclude coronary heart disease (Class of recommendation IIa, level of evidence C, see Table 4). Coronary angiography is recommended in patients at high risk of coronary artery disease  (Class of recommendation I, level of evidence C) and in HF patients with significant valvular disease (Class of recommendation IIa, level of evidence C).
Heart catheterization is not always part of the routine diagnosis and work-up of patients with HF.  It should be considered however to exclude coronary heart disease (Class of recommendation IIa, level of evidence C, see [[Heart_Failure_Table_4|Table 4]]). Coronary angiography is recommended in patients at high risk of coronary artery disease  (Class of recommendation I, level of evidence C) and in HF patients with significant valvular disease (Class of recommendation IIa, level of evidence C).


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!colspan="5"|Table 4. Size of treatment effect
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|valign="top"|'''Class I'''
Benefit >>> Risk
|valign="top"|'''Class IIa'''
Benefit >> Risk
Additional studies with focused objectives needed
|valign="top"|'''Class IIb'''
Benefit ≥ Risk
Additional studies with broad objectives needed; additional registry data would be helpful
|valign="top"|'''Class III'''
Benefit ≥ Risk
No additional studies needed
|-
|
|Procedure/treatment should be performed/administered
|It is reasonable to perform/administer treatment
|Procedure/treatment may be considered
|Procedure/treatment should not be performed/administered since it is not helpful and may be harmful
|-
|'''Level A'''
Multiple (3-5) population risk strata evaluated
|
*Recommendation that procedure or treatment is useful/effective
*Sufficient evidence from multiple randomized trials or non-randomized trials
|
*Recommendation in favor of treatment or procedure being useful/effective
*Some conflicting evidence from multiple randomized trials or meta-analyses
|
*Recommendation’s usefulness/efficacy less well established
*Greater conflicting evidence from multiple randomized trials or meta-analyses
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*Recommendation that procedure or treatment not useful/effective and may be harmful
*Sufficient evidence from multiple randomized trials or meta-analyses
|-
|'''Level B'''
Limited (2-3) population risk strata evaluated
|
*Recommendation that procedure or treatment is useful/effective
*Limited evidence from single randomized trial or non-randomized studies
|
*Recommendation in favor of treatment or procedure being useful/effective
*Some conflicting evidence from single randomized trial or non-randomized studies
|
*Recommendation’s usefulness/efficacy less well established
*Greater conflicting evidence from single randomized trial or non-randomized studies
|
*Recommendation that procedure or treatment not useful/effective and may be harmful
*Limited evidence from single randomized trial or non-randomized studies
|-
|'''Level C'''
Very limited (1-2) population risk strata evaluated
|
*Recommendation that procedure or treatment is useful/effective
*Only experts opinion, case studies, or standard-of-care
|
*Recommendation in favor of treatment or procedure being useful/effective
*Only diverging expert opinion case studies, or standard-of-care
|
*Recommendation’s usefulness/efficacy less well established
*Only diverging expert opinion case studies, or standard-of-care
|
*Recommendation that procedure or treatment not useful/effective and may be harmful
*Only expert opinion case studies, or standard-of-care
|}
==Etiology of heart failure==
==Etiology of heart failure==
===Coronary heart disease===  
===Coronary heart disease===  
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Deficiency of thiamine, selenium, or camitine, in states of severe cachexia.
Deficiency of thiamine, selenium, or camitine, in states of severe cachexia.


Infiltrative and storage disorders
===Infiltrative and storage disorders===
*Sarcoidosis
*[[Sarcoidosis]]
*Amyloidosis
*[[Amyloidosis]]
*Haemochromatosis  
*[[Haemochromatosis]]
*Connective tissue disease
*Connective tissue disease


===Infectious disease===
===Infectious disease===
*Chagas’ disease
*[[Chagas’ disease]]
*HIV infection
*[[HIV infection]]
*Viral, bacterial or protozoal diseases causing myocarditis.
*Viral, bacterial or protozoal diseases causing myocarditis.


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|bgcolor="99FFCC" align="center"|'''Aldosteron antagonist'''
|bgcolor="99FFCC" align="center"|'''Aldosteron antagonist'''
|bgcolor="99FFCC"|
|bgcolor="99FFCC"|
|bgcolor="9ACD32" align="center"|'''EF = 35%'''
|bgcolor="9ACD32" align="center"|'''EF < 35%'''
|bgcolor="9ACD32" align="center"|'''EF = 35%'''
|bgcolor="9ACD32" align="center"|'''EF < 35%'''
|bgcolor="9ACD32" align="center"|'''EF = 35%'''
|bgcolor="9ACD32" align="center"|'''EF < 35%'''
|-
|-
|bgcolor="99FFCC" align="center"|'''Nitrate / Hydralazine'''
|bgcolor="99FFCC" align="center"|'''Nitrate / Hydralazine'''
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|bgcolor="9ACD32" align="center"|'''Afro-American'''
|bgcolor="9ACD32" align="center"|'''Afro-American'''
|bgcolor="9ACD32" align="center"|'''Afro-American'''
|bgcolor="9ACD32" align="center"|'''Afro-American'''
|-
|bgcolor="99FFCC" align="center"|'''Ivabradine'''
|bgcolor="99FFCC"|
|bgcolor="9ACD32" align="center"|'''SR>75/min & EF<35%'''
|bgcolor="9ACD32" align="center"|'''SR>75/min & EF<35%'''
|bgcolor="9ACD32" align="center"|'''SR>75/min & EF<35%'''
|-
|-
|bgcolor="99FFCC" align="center"|'''Digoxin'''
|bgcolor="99FFCC" align="center"|'''Digoxin'''
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===Angiotensin-converting enzyme (ACE) inhibitors===  
===Angiotensin-converting enzyme (ACE) inhibitors===  
An ACE inhibitor (in addition to beta blocker) is indicated for every patient with symptomatic systolic HF and an EF ≤40 % (NYHA class II-IV). (Class I recommendation, level of evidence A) Contraindications for the use of ACE inhibitors are:
An ACE inhibitor is indicated for every patient with symptomatic systolic HF and an EF ≤40 % (NYHA class II-IV). (Class I recommendation, level of evidence A) Contraindications for the use of ACE inhibitors are:
*History of angioedema
*History of angioedema
*Bilateral renal artery stenosis
*Bilateral renal artery stenosis
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==Therapy of acute heart failure==
==Therapy of acute heart failure==
[[Image:acute_hf_flowchart.svg|400px|thumb|'''Figure 7.''' Flowchart acute HF.]]
When severe symptoms of heart failure quickly develop over time, it is termed acute heart failure. In Table 6, common acute HF medications and their recommended doses are summarized. In Figure 7, a flowchart for the treatment of acute HF is depicted. The mainstay of acute heart failure therapy includes diuretics, vasodilators, inotropics and vasopressors. Moreover, oxygen and morphine can be added.  
When severe symptoms of heart failure quickly develop over time, it is termed acute heart failure. In Table 6, common acute HF medications and their recommended doses are summarized. In Figure 7, a flowchart for the treatment of acute HF is depicted. The mainstay of acute heart failure therapy includes diuretics, vasodilators, inotropics and vasopressors. Moreover, oxygen and morphine can be added.  
[[Image:acute_hf_flowchart.svg|400px|thumb|'''Figure 7.''' Flowchart acute HF.]]


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|'''Diuretics'''
|'''Diuretics'''
|Adequate blood pressure and signs of overfilling
|colspan="2"|Adequate blood pressure and signs of overfilling
|
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Renal failure
Renal failure
|40 mg
|40 mg
80 mg – max 200 mg  
125 mg – max 1000 mg  
|-
|-
|
|
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Renal failure
Renal failure
|1 mg
|1 mg
2 mg – max 5 mg  
3 mg – max 25 mg  
|-
|-
|'''Vasodilators'''
|'''Vasodilators'''
|Adequate blood pressure and signs of severe overfilling
|colspan="2"|Adequate blood pressure and signs of severe overfilling
|-
|
|
*Nitroglycerine i.v.
*Nitroglycerine i.v.
|-
|
|
|20 µg/min – max 200 µg/min (guided by blood pressure)  
|20 µg/min – max 200 µg/min (guided by blood pressure)  
|-
|
|
*Nitroprusside i.v.
*Nitroprusside i.v.
|-
||Hypertensive crisis or in combination with inotropic in case of a cardiogenic shock
|
|Hypertensive crisis or in combination with inotropic in case of a cardiogenic shock
|0.3 µg/kg/min – max 5 µg/kg/min (guided by blood pressure)  
|0.3 µg/kg/min – max 5 µg/kg/min (guided by blood pressure)  
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|valign="top"|
|valign="top"|
*Lisinopril
*Lisinopril
|
|Start 2.5-5mg
 
1<sup>st</sup> week 5-10mg once daily.
 
5-7 weeks 25mg three times daily.
 
>7 weeks 50 mg three times daily.
|-
|valign="top"|
*Enalapril/quinalapril
|
|
|Start 2.5-5mg
|Start 2.5-5mg
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*Valsartan
*Valsartan
|
|
|Start 80mg
|Start 40mg twice daily


3-5 weeks 160mg once daily.
3-5 weeks 80mg twice daily.


>7 weeks 320mg once daily.
>7 weeks 160mg twice daily.
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|colspan="3" bgcolor="#F0F0F0 "|'''Hydralazine and isosorbide dinitrate (H-ISDN)'''
|colspan="3" bgcolor="#F0F0F0 "|'''Hydralazine and isosorbide dinitrate (H-ISDN)'''
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