chronic heart failure; congestive heart failure (CHF)
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Introduction
A clinical syndrome characterized by either:
- signs & symptoms of intravascular & interstitial volume overload, including shortness of breath, rales, & edema
- manifestations of inadequate tissue perfusion, such as fatigue or poor exercise tolerance
Etiology
Clinical manifestations
- paroxysmal nocturnal dyspnea (systolic heart failure)
- jugular venous distension
- rales (pulmonary crackles)
- cardiomegaly (systolic heart failure)
- acute pulmonary edema
- S3 gallop (systolic heart failure)
- S4 heart sound (diastolic heart failure)
- increased venous pressure (> 16 cm H2O)
- positive hepatojugular reflex
- edema of extremities
- cough at night (systolic heart failure)
- dyspnea on exertion
- hepatomegaly &/or hepatojuglular reflez
- pleural effusion
Laboratory
- chemistry 7 panel or basic metabolic panel
- every 6 months in stable patients[3]
- hyponatremia is a marker of advanced disease
- elevated norepinephrine, atrial natriuretic factor & renin (rarely measured)
- elevated serum BNP (ventricular pressure overload)
- useful for distinguishing cardiac vs non-cardiac causes of dyspnea
- B-type natriuretic peptide prohormone in serum alternatively useful[21]
- serial meausurements to guide care not useful[3]
- low or high serum estradiol is associated with increased mortality in men []
Diagnostic procedures
- electrocardiogram
- asymptomatic, non-sustained ventricular tachycardia (> 3 onsecutive beats) reflects severity of disease & portends poor prognosis
- conduction system abnormalities
- non-specific ST segment & T wave changes
- left ventricular hypertrophy suggests diastolic rather than systolic dysfunction
- Q waves suggest prior myocardial infarction
- echocardiogram:
- most useful diagnostic procedure
- global hypokinesis versus segmental wall motion anormalities
- chamber dimensions
- ventricular wall thickness
- evidence of valvular heart disease
- not useful for routine assessment of chronic heart failure unless there is a change in clinical status or a planned intervention[3]
- assessment of coronary artery disease:
Radiology
- chest X-ray
- cardiomegaly
- pulmonary venous redistribution
- interstitial or alveolar edema is uncommon
Complications
- sudden cardiac death in 20-40% due to:
- depression or antidepressant therapy associated with increased mortality & risk of hospitalization[9]
- increased risk of venous thromboembolism (RR=1.5)
- DVT, pulmonary embolism[19]
- prophylaxis for venous thromboembolism in hospitalized patients with heart failure decreases risk for 3.7% to 1.5%[19]
Management
- also see heart failure
- pharmacological agents
- ACE inhibitors
- symptomatic congestive heart failure (NYHA class II-IV)
- doses of ACE inhibitors shown to provide survival benefit
- optimal doses (Kaiser)
- lisinopril 40 mg QD
- enalapril 20 mg QD
- asymptomatic left ventricular (LV) dysfunction
- LV ejection fraction <40%
- post myocardial infarction
- symptomatic congestive heart failure (NYHA class II-IV)
- angiotensin II receptor inhibitors
- symptomatic CHF in elderly
- patients intolerant of ACE inhibitors[3][18]
- diuretics
- loop diuretic (Lasix) for volume overload
- spironolactone 25 mg PO QD reduces mortality
- may be used in conjunction with ACE inhibitor[4]
- digoxin
- persistent symptoms of CHF despite therapy with ACE inhibitors in patients in sinus rhythm
- rate control in atrial fibrillation
- nitrates
- angina pectoris
- preload reduction for peristent congestive symptoms
- hydralazine with isordil or other nitrate (BiDil)
- patients intolerant of ACE inhibitors with symptomatic CHF
- hydralazine 75 mg QID shown to be of benefit
- AHA guideline for African Americans with symptoms that persist despite optimal medical therapy[11]
- beta-blockers (symptomatic improvement)
- carvedilol (Coreg): start 3.125 mg (survival benefit)
- metoprolol (Toprol XL): start 12.5 mg QD
- bisoprolol (Zebeta)
- ivabradine may be of benefit in patients with LVEF < 35% for use in conjunction with ACE inhibitor, beta-blocker & aldosterone antagonist (see NGD {NICE})
- SGLT2 inhibitors (flozins) may be of benefit in patients with or without diabetes mellitus & systolic heart failure[24]
- oral anticoagulation
- previous embolic event
- chronic or paroxysmal atrial fibrillation
- left ventricular thrombus
- antiplatelet agents
- treat comorbid cardiovascular disease
- aspirin better than warfarin for patients in sinus rhythm[15]
- avoid NSAIDs, especially those with long 1/2 life
- increased systemic vascular resistance
- reduced renal perfusion
- statin may be of benefit, even in non-ischemic heart failure[8]
- little benefit in elderly[10]
- severe refractory congestive heart failure
- ACE inhibitors
- implantable cardioverter-defibrillator (ICD)
- symptomatic ventricular tachycardia
- unresponsive to pharmacologic agents, or
- left ventricular ejection fraction < 35%
- antiarrhythmic therapy is often required to prevent frequent ICD misfirings
- does NOT prevent bradyarrhythmias
- symptomatic ventricular tachycardia
- cardiac resynchronization therapy (CRT) for NYHA class III or IV
- His bundle pacing may be non inferior to CRT[22]
- nutritional counseling
- limit Na+ intake (< 2 g/day)
- reducing sodium intake does not improve outcomes[23]
- limit fluid intake (< 1.5 L/day may be appropriate)
- vitamin D supplementation?
- may improve LV ejection fraction & LV end diastolic volume
- no benefit for 6 minute walk[20]
- limit Na+ intake (< 2 g/day)
- lifestyle modification
- regular aerobic exercise[7]
- exercise modestly reduces depressive symptoms[16]
- regular aerobic exercise[7]
- daily weights
- measure weight in AM, after awakening & voiding
- if weight increases by > 2 pounds, double dose of diuretic & K+[5]
- cardiac transplantation
More general terms
More specific terms
- chronic diastolic heart failure
- chronic right ventricular failure; cor pumonale
- compensated chronic heart failure
- end-stage heart failure
Additional terms
- cardiomyopathy
- left ventricular systolic dysfunction; heart failure with reduced ejection fraction (HFrEF)
- myocardial infarction (MI); heart attack
- New York Heart Association classification of heart failure
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1291
- ↑ 3.0 3.1 3.2 3.3 3.4 Medical Knowledge Self Assessment Program (MKSAP) 11,16,17,19. American College of Physicians, Philadelphia 1998,2012,2015,2022
- ↑ 4.0 4.1 Journal Watch, Mass Med Soc 20(1):7 (Jan 1) 2000 Pitt B et al The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 341:709, 1999 PMID: https://www.ncbi.nlm.nih.gov/pubmed/10471456
- ↑ 5.0 5.1 Watson K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ Prescriber's Letter 10(8):44 2003
- ↑ 7.0 7.1 Journal Watch 24(6):50-51, 2004 ExTraMATCH Collaborative, BMJ 328:189, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14729656
ExTraMATCH Collaborative http://bmj.bmjjournals.com/cgi/content/full/328/7433/189 - ↑ 8.0 8.1 Sola S et al, Atorvastatin improves left ventricular systolic function and serum markers of inflammation in nonischemic heart failure. J Am Coll Cardiol 2006, 47:332 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16412856
Ramasubbu K and Mann DL The emerging role of statins in the treatment of heart failure. J Am Coll Cardiol 2006, 47:342 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16412858 - ↑ 9.0 9.1 Sherwood A et al, Relationship of depression to death or hospitalization in patients with heart failure. Arch Intern Med 2007, 167:367 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17325298
- ↑ 10.0 10.1 Kjekshus J et al for the CORONA group Rosuvastatin in older patients with systolic heart failure. N Engl J Med 2007, Nov 5 http://dx.doi.org/10.1056/NEJMoa0706201
- ↑ 11.0 11.1 Jessup M et al 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. 2009 Apr 14;119(14):1977-2016. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19324967
- ↑ Jankowska EA et al Circulating estradiol and mortality in men with systolic chronic heart failure. JAMA 2009 May 13; 301:1892. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19436016
- ↑ University of Michigan Health System (UMHS) Guidelines on heart failure - systolic dysfunction http://cme.med.umich.edu/pdf/guideline/HeartFailure06.pdf
- ↑ Prescriber's Letter 17(2): 2010 Target Doses of Heart Failure Medications Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=260210&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 15.0 15.1 Homma S et al Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm N Engl J Med, May 2, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22551105 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1202299
Eikelboom JW and Connolly SJ Warfarin in Heart Failure N Engl J Med, May 2, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22551103 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1202504 - ↑ 16.0 16.1 Blumenthal JA et al. Effects of exercise training on depressive symptoms in patients with chronic heart failure: The HF-ACTION randomized trial. JAMA 2012 Aug 1; 380:465. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22851113 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1273016
- ↑ O'Connor CM, Whellan DJ, Lee KL et al Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009 Apr 8;301(14):1439-50. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19351941
- ↑ 18.0 18.1 Heran BS, Musini VM, Bassett K, Taylor RS, Wright JM Angiotensin receptor blockers for heart failure. Cochrane Database Syst Rev. 2012 Apr 18;4:CD003040 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22513909
- ↑ 19.0 19.1 19.2 Tang L, Wu YY, Lip GY, Yin P, Hu Y Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis. The Lancet Haematology. Dec 3, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26765646 <Internet> http://thelancet.com/journals/lanhae/article/PIIS2352-3026%2815%2900228-8/abstract
- ↑ 20.0 20.1 Witte KK et al. Effects of vitamin D on cardiac function in patients with chronic HF: The VINDICATE study. J Am Coll Cardiol 2016 Apr 4; PMID: https://www.ncbi.nlm.nih.gov/pubmed/27058906 Free Article
- ↑ 21.0 21.1 Yancy CW et al 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017. copublished in J Am Coll of Cardiol http://circ.ahajournals.org/content/circulationaha/early/2017/04/26/CIR.0000000000000509.full.pdf
- ↑ 22.0 22.1 Vinther M et al. A randomized trial of His pacing versus biventricular pacing in symptomatic heart failure patients with left bundle branch block (His-Alternative). JACC Clin Electrophysiol 2021 Apr 25; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34167929 https://www.sciencedirect.com/science/article/abs/pii/S2405500X21003285
- ↑ 23.0 23.1 Ezekowitz JA et al. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): An international, open-label, randomised, controlled trial. Lancet 2022 Apr 2; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35381194 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00369-5/fulltext
- ↑ 24.0 24.1 McMurray JJV, Solomon SF, Inzucchi SE et al Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med Sept 19, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31535829 https://www.nejm.org/doi/full/10.1056/NEJMoa1911303
Fang JC Heart-Failure Therapy - New Drugs but Old Habits? N Engl J Med Sept 19, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31535828 https://www.nejm.org/doi/full/10.1056/NEJMe1912180