Textbook of Cardiology

Heart Failure: Difference between revisions

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Heart Failure (view source)

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!Table 1 Definition of heart failure
!Table 1. Definition of heart failure
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|'''''Heart failure is a clinical syndrome in which patients have the following features:'''''
|'''''Heart failure is a clinical syndrome in which patients have the following features:'''''
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|'''''And'''''
|'''''And'''''
*'''Signs typical of heart failure'''
*'''Signs typical of heart failure'''
**Elevated jugular venous pressure **Hepatomegaly
**Elevated jugular venous pressure  
**Hepatomegaly
**Third heart sound
**Third heart sound
**Pulmonary rales
**Pulmonary rales
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{| class="wikitable" border="0" cellspacing="0" cellpadding="0"  width="600px"
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!colspan="2"|Table 2 NYHA functional classification
!colspan="2"|Table 2. NYHA functional classification
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|colspan="2"|'''''Severity based on symptoms and physical activity'''''
|colspan="2"|'''''Severity based on symptoms and physical activity'''''
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|width="20%"|'''Class I'''
|width="20%"|'''Class I'''
|No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea.
|No limitation of physical activity.  
 
Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea.
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|'''Class II'''
|'''Class II'''
|Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea.
|Slight limitation of physical activity.  
 
Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea.
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|'''Class III'''
|'''Class III'''
|Marked limitation of physical activity. Comfortable at rest,  but less than ordinary activity results in fatigue, palpitation, or dyspnoea.
|Marked limitation of physical activity.  
 
Comfortable at rest,  but less than ordinary activity results in fatigue, palpitation, or dyspnoea.
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|'''Class IV'''
|'''Class IV'''
|Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased.  
|Unable to carry on any physical activity without discomfort.  
 
Symptoms at rest.  
 
If any physical activity is undertaken, discomfort is increased.  
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===Laboratory tests===
===Laboratory tests===
[[Image:suspected_heart_failure.svg|thumb|400px|'''Figure 4.''' Flowchart suspected heart failure <cite>3</cite>]]
A standard blood assessment includes a complete blood count, electrolytes, renal function, glucose and liver function. Furthermore, urinalysis and other tests, depending on the clinical condition of the patient, complete the laboratory assessment.  For example, cardiac troponins must be sampled if an ACS is in the differential diagnosis. In patients suspected of HF, values of natriuretic peptides (such as B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP)) can provide important information regarding the diagnosis, management and prognosis of HF. Natriuretic peptides are enzymes, secreted by the atria or ventricles in response to myocardial wall stress. The most commonly used tests are BNP and NT-proBNP measurements, which despite their different half-lives in the plasma, do not differ substantially in terms of diagnostic ability. Cut-off values are different in acute settings with acute dyspnea compared to chronic settings. Normal values are almost 100% specific, and exclude heart failure in patients >18 year old. Abnormal values do not have a 100% predictive value, and objective evidence for heart failure is still needed. The values for BNP and NTproBNP are also used to evaluate the prognosis in patients with known HF, in whom higher values carry a worse prognosis.  
A standard blood assessment includes a complete blood count, electrolytes, renal function, glucose and liver function. Furthermore, urinalysis and other tests, depending on the clinical condition of the patient, complete the laboratory assessment.  For example, cardiac troponins must be sampled if an ACS is in the differential diagnosis. In patients suspected of HF, values of natriuretic peptides (such as B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP)) can provide important information regarding the diagnosis, management and prognosis of HF. Natriuretic peptides are enzymes, secreted by the atria or ventricles in response to myocardial wall stress. The most commonly used tests are BNP and NT-proBNP measurements, which despite their different half-lives in the plasma, do not differ substantially in terms of diagnostic ability. Cut-off values are different in acute settings with acute dyspnea compared to chronic settings. Normal values are almost 100% specific, and exclude heart failure in patients >18 year old. Abnormal values do not have a 100% predictive value, and objective evidence for heart failure is still needed. The values for BNP and NTproBNP are also used to evaluate the prognosis in patients with known HF, in whom higher values carry a worse prognosis.  
[[Image:suspected_heart_failure.svg|thumb|400px|'''Figure 4.''' Flowchart suspected heart failure <cite>3</cite>]]


===Exercise test===
===Exercise test===
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!colspan="3"|Table 3 Common echocardiographic abnormalities in heart failure
!colspan="3"|Table 3. Common echocardiographic abnormalities in heart failure
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!Measurement
!Measurement
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|Myocardial infarction/ischaemia,  
|Myocardial infarction/ischaemia,  


cardiomyopathy,  
Cardiomyopathy,  


myocarditis
Myocarditis
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|Left ventricular end-diastolic diameter
|Left ventricular end-diastolic diameter
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|Increased filling pressures,  
|Increased filling pressures,  


mitral valve dysfunction
Mitral valve dysfunction
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|Left ventricular thickness
|Left ventricular thickness
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|Hypertention,  
|Hypertention,  


aortic stenosis,  
Aortic stenosis,  


hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy
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|-
|Valvular structure and function
|Valvular structure and function
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|Effusion,  
|Effusion,  


haemopericardium,  
Haemopericardium,  


calcification
Calcification
|Consider tamponade,  
|Consider tamponade,  


malignancy,  
Malignancy,  


systemic disease,  
Systemic disease,  


acute or chronic pericarditis,  
Acute or chronic pericarditis,  


constrictive pericarditis
Constrictive pericarditis
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|Aortic outflow velocity time integral
|Aortic outflow velocity time integral
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|Increased right atrial pressures,  
|Increased right atrial pressures,  


right ventricular dysfunction,  
Right ventricular dysfunction,  


volume overload Pulmonary hypertention possible
Volume overload Pulmonary hypertention possible
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{| class="wikitable" border="0" cellpadding="0" cellspacing="0" width="600px"
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!colspan="5"|Table 4 Size of treatment effect
!colspan="5"|Table 4. Size of treatment effect
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|
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|'''Class I'''
|valign="top"|'''Class I'''


Benefit >>> Risk
Benefit >>> Risk
|'''Class IIa'''
|valign="top"|'''Class IIa'''


Benefit >> Risk
Benefit >> Risk


Additional studies with focused objectives needed
Additional studies with focused objectives needed
|'''Class IIb'''
|valign="top"|'''Class IIb'''


Benefit ≥ Risk
Benefit ≥ Risk


Additional studies with broad objectives needed; additional registry data would be helpful
Additional studies with broad objectives needed; additional registry data would be helpful
|'''Class III'''
|valign="top"|'''Class III'''


Benefit ≥ Risk
Benefit ≥ Risk
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|bgcolor="9ACD32"|
|bgcolor="9ACD32"|
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|colspan="5"|Table 5 Medication with a class I indication in patients with systolic heart failure. Note that AT-II antagonists are alternative medicine for ACE inhibitors in case of intolerance (coughing, allergy). Nitrates and Hydralazine are added therapy for patients of Afro-American descent, and alternative therapy for patients that cannot tolerate ACE-inhibitors and AT-II antagonists). Digoxin can also be seen as symptomatic (instead of added preventive) treatment, not always necessary in NYHA III or even IV.
|colspan="5"|'''Table 5.''' Medication with a class I indication in patients with systolic heart failure. Note that AT-II antagonists are alternative medicine for ACE inhibitors in case of intolerance (coughing, allergy). Nitrates and Hydralazine are added therapy for patients of Afro-American descent, and alternative therapy for patients that cannot tolerate ACE-inhibitors and AT-II antagonists). Digoxin can also be seen as symptomatic (instead of added preventive) treatment, not always necessary in NYHA III or even IV.
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{| class="wikitable" border="0" cellpadding="0" cellspacing="0" width="600px"
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!colspan="3"|Table 6 Medication in acute heart failure
!colspan="3"|Table 6. Medication in acute heart failure
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!Medication
!Medication
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*Furosemide i.v.
*Furosemide i.v.
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|valign="bottom"|
|40 mg
Renal failure
|-
|40 mg
|
80 mg – max 200 mg  
|Renal failure
|80 mg – max 200 mg  
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|
*Bumetanide i.v.
*Bumetanide i.v.
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|valign="bottom"|
Renal failure
|1 mg
|1 mg
|-
2 mg – max 5 mg  
|
|Renal failure
|2 mg – max 5 mg  
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|'''Vasodilators'''
|'''Vasodilators'''
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|If beta-blockade is thought to be contributing to hypoperfusion
|If beta-blockade is thought to be contributing to hypoperfusion
|0.1 µg/kg/min,
|0.1 µg/kg/min,
can be decreased to
can be decreased to 0.05 or increased to 0.2 µg/kg/min
0.05 or increased to
0.2 µg/kg/min
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|colspan="3"|'''Vasopressors'''
|colspan="3"|'''Vasopressors'''
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2 mg – max 25 mg  
2 mg – max 25 mg  
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|'''ACE inhibitors'''
|bgcolor="#F0F0F0" colspan="3"|'''ACE inhibitors'''
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|valign="top"|
|valign="top"|
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>7 weeks:::10-20mg twice daily.
>7 weeks:::10-20mg twice daily.
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|colspan="3"|'''Beta blockers'''
|bgcolor="#F0F0F0 " colspan="3"|'''Beta blockers'''
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|valign="top"|
|valign="top"|
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>7 weeks:::10mg once daily.
>7 weeks:::10mg once daily.
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|colspan="3"|'''Aldosterone antagonist'''
|bgcolor="#F0F0F0 " colspan="3"|'''Aldosterone antagonist'''
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Half dose with age above 70 or creatinin above 110 or with amiodarone use
Half dose with age above 70 or creatinin above 110 or with amiodarone use
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|colspan="3"|'''AT II blockers'''
|bgcolor="#F0F0F0 " colspan="3"|'''AT II blockers'''
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>7 weeks:::320mg once daily.
>7 weeks:::320mg once daily.
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|colspan="3"|'''Hydralazine and isosorbide dinitrate (H-ISDN)'''
|colspan="3" bgcolor="#F0F0F0 "|'''Hydralazine and isosorbide dinitrate (H-ISDN)'''
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