Heart failure: Difference between revisions

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imported>Robert Badgett
imported>Robert Badgett
(Started prognosis section)
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! colspan="2" rowspan="2"| !! colspan="2" | Congestion†?<br>(jugular venous distention and <br>radiographic redistribution)<ref name="pmid9169900">{{cite journal |author=Badgett RG, Lucey CR, Mulrow CD |title=Can the clinical examination diagnose left-sided heart failure in adults? |journal=JAMA |volume=277 |issue=21 |pages=1712-9 |year=1997 |pmid=9169900 |doi=}}</ref>
! colspan="2" rowspan="2"| !! colspan="2" | Congestion†?<br>(jugular venous distention and <br>radiographic redistribution)<ref name="pmid9169900">{{cite journal |author=Badgett RG, Lucey CR, Mulrow CD |title=Can the clinical examination diagnose left-sided heart failure in adults? |journal=JAMA |volume=277 |issue=21 |pages=1712-9 |year=1997 |pmid=9169900 |doi=}}</ref>
|-
|-
|  No || Yes
'''No''' || '''Yes'''
|-
|-
| rowspan="2" | '''Hypoperfusion‡?'''<br>(proportional pulse pressure < 25%<ref name="pmid2913385">{{cite journal |author=Stevenson LW, Perloff JK |title=The limited reliability of physical signs for estimating hemodynamics in chronic heart failure |journal=JAMA |volume=261 |issue=6 |pages=884–8 |year=1989 |pmid=2913385 |doi=}}</ref><ref name="pmid11420761">{{cite journal |author=Shah MR, Hasselblad V, Stinnett SS, ''et al'' |title=Hemodynamic profiles of advanced heart failure: association with clinical characteristics and long-term outcomes |journal=J. Card. Fail. |volume=7 |issue=2 |pages=105–13 |year=2001 |pmid=11420761 |doi=10.1054/jcaf.2001.24131}}</ref>, <br>cool extremities<ref name="pmid11303155">{{cite journal |author=Kaplan LJ, McPartland K, Santora TA, Trooskin SZ |title=Start with a subjective assessment of skin temperature to identify hypoperfusion in intensive care unit patients |journal=The Journal of trauma |volume=50 |issue=4 |pages=620–7; discussion 627–8 |year=2001 |pmid=11303155 |doi=}}</ref>) || No || Warm and dry<br>(46% mortality at one year) || Warm and wet
| rowspan="2" | '''Hypoperfusion‡?'''<br>(proportional pulse pressure < 25%<ref name="pmid2913385">{{cite journal |author=Stevenson LW, Perloff JK |title=The limited reliability of physical signs for estimating hemodynamics in chronic heart failure |journal=JAMA |volume=261 |issue=6 |pages=884–8 |year=1989 |pmid=2913385 |doi=}}</ref><ref name="pmid11420761">{{cite journal |author=Shah MR, Hasselblad V, Stinnett SS, ''et al'' |title=Hemodynamic profiles of advanced heart failure: association with clinical characteristics and long-term outcomes |journal=J. Card. Fail. |volume=7 |issue=2 |pages=105–13 |year=2001 |pmid=11420761 |doi=10.1054/jcaf.2001.24131}}</ref>, <br>cool extremities<ref name="pmid11303155">{{cite journal |author=Kaplan LJ, McPartland K, Santora TA, Trooskin SZ |title=Start with a subjective assessment of skin temperature to identify hypoperfusion in intensive care unit patients |journal=The Journal of trauma |volume=50 |issue=4 |pages=620–7; discussion 627–8 |year=2001 |pmid=11303155 |doi=}}</ref>) || '''No''' || Warm and dry<br>(46% mortality at one year) || Warm and wet
|-
|-
| Yes|| Cold and dry || Cold and wet<br>(33% mortality at one year<ref name="pmid11420761"/>)
| '''Yes'''|| Cold and dry || Cold and wet<br>(33% mortality at one year<ref name="pmid11420761"/>)
|-
|-
| colspan="4" | Notes:<br>
| colspan="4" | Notes:<br>
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====Left ventricular assist devices====
====Left ventricular assist devices====
Left ventricular assist devices (LVADs) may be an option for patients with end stage heart failure.<ref name="pmid17723934">{{cite journal |author=Delgado RM, Radovancevic B |title=Symptomatic relief: left ventricular assist devices versus resynchronization therapy |journal=Heart failure clinics |volume=3 |issue=3 |pages=259–65 |year=2007 |pmid=17723934 |doi=10.1016/j.hfc.2007.05.004}}</ref>
Left ventricular assist devices (LVADs) may be an option for patients with end stage heart failure.<ref name="pmid17723934">{{cite journal |author=Delgado RM, Radovancevic B |title=Symptomatic relief: left ventricular assist devices versus resynchronization therapy |journal=Heart failure clinics |volume=3 |issue=3 |pages=259–65 |year=2007 |pmid=17723934 |doi=10.1016/j.hfc.2007.05.004}}</ref>
==Prognosis==
Mortality can be predicted with the  The Seattle Heart Failure Model.<ref name="pmid16534009">{{cite journal |author=Levy WC, Mozaffarian D, Linker DT, ''et al'' |title=The Seattle Heart Failure Model: prediction of survival in heart failure |journal=Circulation |volume=113 |issue=11 |pages=1424–33 |year=2006 |pmid=16534009 |doi=10.1161/CIRCULATIONAHA.105.584102 |issn=}}</ref> The model can show the affect of interventions on prognosis. The model is available online at http://depts.washington.edu/shfm/.


==References==
==References==
<references/>
<references/>

Revision as of 13:21, 15 January 2008

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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

Angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme inhibitors (ACE inhibitors) should not be used if:[10]

  • 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

Angiotensin-converting enzyme inhibitors combined with angiotensin-receptor blockers

This combination should be avoided due to increased azotemia, hyperkalemia, and symptomatic hypotension.[11]

Aldosterone antagonists

Aldosterone antagonists, initial dose of spironolactone 12.5 mg or eplerenone 25 mg, may be used as long as:[10]

  • 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:[10]

  • 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:[10]

  • 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

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.[12][13] Among the different modes of NPPV, CPAP may be slightly better than BiPAP.[13] It is not clear that NPPV helps patients with normal partial pressures of carbon dioxide.[14]

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).[15]

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%.[16] 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.[17]

Implantable cardioverter-defibrillator

Implantable cardioverter-defibrillators (ICD) can reduce mortality in patients who have an ejection fraction of less than 35%.[18]

Left ventricular assist devices

Left ventricular assist devices (LVADs) may be an option for patients with end stage heart failure.[19]

Prognosis

Mortality can be predicted with the The Seattle Heart Failure Model.[20] 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 10.2 10.3 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
  11. 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.
  12. 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.
  13. 13.0 13.1 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.
  14. 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.
  15. 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.
  16. 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
  17. 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.
  18. 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.
  19. 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.
  20. 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.