HEART FAILURE

INTRODUCTION: Heart failure (HF), sometimes referred to as congestive HF, is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. HF is a clinical syndrome characterized by signs and symptoms of fluid overload or inadequate tissue perfusion. The underlying mechanism of HF involves impaired contractile properties of the heart (systolic dysfunction) or filling of the heart (diastolic) that leads to a lower-than-normal cardiac output. The low cardiac output can lead to compensatory mechanisms that cause increased workload on the heart and eventual resistance to filling of the heart. HF is a progressive, life-long condition that is managed with lifestyle changes and medications to prevent episodes of acute decompensated HF, which are characterized by an increase in symptoms, decreased CO, and low perfusion.

RISK FACTORS: HF results from a variety of cardiovascular conditions, including chronic hypertension, coronary artery disease, and valvular disease. These conditions can result in systolic failure, diastolic failure, or both. Several systemic conditions (eg, progressive renal failure and uncontrolled hypertension) can contribute to the development and severity of cardiac failure. 

CLINICAL MANIFESTATIONS: The signs and symptoms of HF can be related to which ventricle is affected. Left-sided HF (left ventricular failure) causes different manifestations than right-sided HF (right ventricular failure). In chronic HF, patients may have signs and symptoms of both left and right ventricular failure.

Left-Sided HF:  Most often precedes right-sided cardiac failure; Pulmonary congestion: dyspnea, cough, pulmonary crackles, and low oxygen saturation levels; an extra heart sound, the S3, or “ventricular gallop,” may be detected on auscultation. Dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal dyspnea (PND). Cough initially dry and nonproductive; may become moist over time. Large quantities of frothy sputum, which is sometimes pink (blood-tinged). Bibasilar crackles advancing to crackles in all lung fields. Inadequate tissue perfusion. Oliguria and nocturia. With progression of HF: altered digestion; dizziness, lightheadedness, confusion, restlessness, and anxiety; pale or ashen and cool and clammy skin. Tachycardia, weak, thready pulse; fatigue.

Right-Sided HF: Congestion of the viscera and peripheral tissues. Edema of the lower extremities (dependent edema), hepatomegaly (enlargement of the liver), ascites (accumulation of fluid in the peritoneal cavity), anorexia and nausea, and weakness and weight gain due to retention of fluid.

ASSESSMENT AND DIAGNOSTIC METHODS: Assessment of ventricular function. Echocardiogram, chest x-ray, electrocardiogram (ECG). Laboratory studies: serum electrolytes, blood urea nitrogen (BUN), creatinine, thyroid-stimulating hormone (TSH), CBC count, brain natriuretic peptide (BNP), and routine urinalysis. Cardiac stress testing, cardiac catheterization.

MEDICAL MANAGEMENT: The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival. Treatment options vary according to the severity of the patient’s condition and may include oral and IV medications, major lifestyle changes, supplemental oxygen, implantation of assistive devices, and surgical approaches, including cardiac transplantation. Lifestyle recommendations include restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated; and regular exercise.

Pharmacologic Therapy: Alone or in combination: vasodilator therapy (angiotensinconverting enzyme [ACE] inhibitors), angiotensin II receptor blockers (ARBs), selective beta-blockers, calcium channel blockers, diuretic therapy, cardiac glycosides (digitalis), and others. IV infusions: nesiritide, milrinzne, dobutamine. Medications for diastolic dysfunction. Possibly anticoagulants, medications that manage hyperlipidemia (statins). 

SURGICAL MANAGEMENT: Coronary bypass surgery, percutaneous transluminal coronary angioplasty (PTCA), other innovative therapies as indicated (eg, mechanical assist devices, transplantation).

RELATED;

1.  CORONARY ARTERY DISEASE

2.  ARTERIOSCLEROSIS

3.  HYPERTENSION

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