Heart failure

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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

Hemodynamic Profiles
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]
† Congestion is defined as pulmonary capillary wedge pressure of 20 mm Hg or more[4]
‡ Hypoperfusion is defined as cardiac index of 1.8 L/min/m2.[4] This is associated with elevate lactate.[5]

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

Race-based therapeutics?
The controversial approval[10] by the U.S. Food and Drug Administration of NitroMed has led to the concept of race-based therapeutics.[11] Presumably, pharmacogenomics will lead to individualized drug treatment; until then the use of race may be a proxy of pharmacogenomic variations.
Angiotensin-converting enzyme inhibitors
There is conflicting evidence whether ACE inhibitors are as effective in African-American patients as in Anglo patients.[12][13]
Beta-blockers
There is conflicting evidence whether beta-blockers are as effective in African-American patients as in Anglo patients.[12]
Isosorbide dinitrate and hydralazine combination
Isosorbide dinitrate and hydralazine combination treatment reduces mortality in African-American patients with class III or IV heart failure.[14]

Whether this benefit is more than occurs for Anglo patients is unclear, but is suggested by two controversial post-hoc analyses of subgroups in earlier randomized controlled trials.[15]


Angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme inhibitors (ACE inhibitors) should not be used if:[16]

  • 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

There is conflicting evidence whether ACE inhibitors are as effective in African-American patients as in Anglo patients.[12][13]

Angiotensin-converting enzyme inhibitors combined with angiotensin-receptor blockers

This combination should be avoided due to increased azotemia, hyperkalemia, and symptomatic hypotension.[17]

Beta-blockers

There is conflicting evidence whether beta-blockers are as effective in African-American patients as in Anglo patients.[12]

Aldosterone antagonists

Aldosterone antagonists, initial dose of spironolactone 12.5 mg or eplerenone 25 mg, may be used as long as:[16]

  • 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:[16]

  • 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:[16]

  • 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

Isosorbide dinitrate and hydralazine combination treatment

Isosorbide dinitrate and hydralazine combination treatment reduces mortality in African-American patients with class III or IV heart failure.[14] The U.S. Food and Drug Administration has approved the drug BiDil for African Americans[18] which has created controversy[10] for reasons including the approval helped the manufacturer, NitroMed, add a second race-related patent that extended protection for BiDil for 13 years[19].

Noninvasive positive pressure ventilation

Noninvasive positive pressure ventilation (NPP) can help treat acute cardiac pulmonary edema according to a meta-analyses of randomized controlled trials.[20][21] Among the different modes of NPPV, CPAP may be slightly better than BiPAP.[21] It is not clear that NPPV helps patients with normal partial pressures of carbon dioxide.[22]

Implantable devices

Several implantable devices may help long term treatment; however, it is not clear that implantable cardioverter-defibrillators (ICD) add benefit over cardiac resynchronisation therapy (CRT).[23]

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%.[24] 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.[25]

Implantable cardioverter-defibrillator

Implantable cardioverter-defibrillators (ICD) can reduce mortality in patients who have an ejection fraction of less than 35%.[26]

Left ventricular assist devices

Left ventricular assist devices (LVADs) may be an option for patients with end stage heart failure.[27]

Prognosis

Mortality can be predicted with the The Seattle Heart Failure Model.[28] The model can show the affect of interventions on prognosis. The model is available online at http://depts.washington.edu/shfm/.

References

  1. ↑ National Library of Medicine. Heart Failure, Congestive. Retrieved on 2007-10-19.
  2. ↑ 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]
  3. ↑ 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. ↑ 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. ↑ 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. ↑ 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]
  7. ↑ 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]
  8. ↑ 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]
  9. ↑ 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. ↑ 10.0 10.1 Bibbins-Domingo K, Fernandez A (2007). "BiDil for heart failure in black patients: implications of the U.S. Food and Drug Administration approval". Ann. Intern. Med. 146 (1): 52–6. PMID 17200222. [e]
  11. ↑ Bloche MG (2004). "Race-based therapeutics". N. Engl. J. Med. 351 (20): 2035–7. DOI:10.1056/NEJMp048271. PMID 15533852. Research Blogging.
  12. ↑ 12.0 12.1 12.2 12.3 Shekelle PG, Rich MW, Morton SC, et al (2003). "Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials". J. Am. Coll. Cardiol. 41 (9): 1529–38. PMID 12742294. [e]
  13. ↑ 13.0 13.1 Exner DV, Dries DL, Domanski MJ, Cohn JN (2001). "Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction". N. Engl. J. Med. 344 (18): 1351–7. PMID 11333991. [e]
  14. ↑ 14.0 14.1 Taylor AL, Ziesche S, Yancy C, et al (2004). "Combination of isosorbide dinitrate and hydralazine in blacks with heart failure". N. Engl. J. Med. 351 (20): 2049–57. DOI:10.1056/NEJMoa042934. PMID 15533851. Research Blogging.
  15. ↑ Bibbins-Domingo K, Fernandez A (2007). "BiDil for heart failure in black patients". Ann. Intern. Med. 147 (3): 214–5; author reply 215–6. PMID 17679712. [e]
  16. ↑ 16.0 16.1 16.2 16.3 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
  17. ↑ 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.
  18. ↑ Temple R, Stockbridge NL (2007). "BiDil for heart failure in black patients: The U.S. Food and Drug Administration perspective". Ann. Intern. Med. 146 (1): 57–62. PMID 17200223. [e]
  19. ↑ Kahn JD (2007). "BiDil for heart failure in black patients". Ann. Intern. Med. 147 (3): 215; author reply 215–6. PMID 17679713. [e]
  20. ↑ Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD (2006). "Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis". Lancet 367 (9517): 1155–63. DOI:10.1016/S0140-6736(06)68506-1. PMID 16616558. Research Blogging.
  21. ↑ 21.0 21.1 Masip J, Roque M, Sánchez B, Fernández R, Subirana M, Expósito JA (2005). "Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis". JAMA 294 (24): 3124–30. DOI:10.1001/jama.294.24.3124. PMID 16380593. Research Blogging.
  22. ↑ Nava S, Carbone G, DiBattista N, et al (2003). "Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial". Am. J. Respir. Crit. Care Med. 168 (12): 1432–7. DOI:10.1164/rccm.200211-1270OC. PMID 12958051. Research Blogging.
  23. ↑ 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.
  24. ↑ 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
  25. ↑ 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.
  26. ↑ 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.
  27. ↑ 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.
  28. ↑ Levy WC, Mozaffarian D, Linker DT, et al (2006). "The Seattle Heart Failure Model: prediction of survival in heart failure". Circulation 113 (11): 1424–33. DOI:10.1161/CIRCULATIONAHA.105.584102. PMID 16534009. Research Blogging.
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