Download DISEASEDEX™ General Medicine Summary Heart failure, chronic

DISEASEDEX™ General Medicine Summary
Heart failure, chronic; Congestive heart failure - Chronic
DISEASEDEX General Medicine Clinical Review
Heart failure, chronic; Congestive heart failure - Chronic (Clinical Checklist™)
Definition
A complex clinical syndrome resulting from any structural or functional cardiac abnormality that impairs the ability of
the ventricle to fill with or eject blood
Because not all patients with heart failure have volume overload at the time of the initial or subsequent evaluation,
the term heart failure is preferred over the older congestive heart failure term .
Medical History











Infectious disease
Renal failure
Drug or substance use factors
Coronary arteriosclerosis
Hypertension [Hypertension - Chronic]
Diabetes mellitus [Diabetes mellitus - Chronic]
Obesity [Obesity - Chronic]
Smoking
Alcohol Abuse
Anemia [Anemia - Chronic]
Family history of Cardiomyopathy
Findings





















Dyspnea
Fatigue
Peripheral edema
Respiratory crackles
Decreased breath sounds
Orthopnea
Paroxysmal nocturnal dyspnea
S3 gallop
Jugular venous distention
Hepatojugular reflux
Hepatomegaly
Ascites
Nocturnal cough
Nocturnal asthma
Second heart sound split
Tricuspid valve regurgitation
Tachycardia
Palpitations
Chest pain
Early satiety
Nausea and vomiting




Abdominal pain
Cold extremities
Confusion
Syncope
Differential Diagnosis
















Acute myocardial infarction - Acute
Pulmonary embolism
Community acquired pneumonia - Acute
Asthma - Acute
Chronic obstructive pulmonary disease - Chronic
Pulmonary hypertension - Chronic
Obstructive sleep apnea - Chronic
Renal failure
Liver failure - Chronic
Obesity - Chronic
Physical deconditioning
Anemia
Hypoalbuminemia
Deficiency of macronutrients
Anxiety
Depression - Chronic
Testing
Suspected or known heart failure
 Plain chest X-ray: Radiographic findings in heart failure may include evidence of cardiac chamber
enlargement, increased pulmonary venous pressure, interstitial or alveolar edema, pleural
effusions, valvular or pericardial calcification, or lung disease , but a chest x-ray should not be
used as a primary test for identifying the specific cardiac dysfunction associated with HF .
Suspected or known heart failure
 12 lead ECG: In patients with heart failure, a 12-lead ECG is frequently abnormal and may show
evidence of ischemia, myocardial infarction, left ventricular hypertrophy, cardiac conduction
abnormality, or cardiac arrhythmia .
Suspected or known heart failure
 Brain natriuretic peptide measurement: Acute heart failure is likely in the presence of acute
dyspnea if the B-type natriuretic peptide (BNP) level is greater than 500 picog/mL or NT-proBNP
is greater than 1000 picog/mL and is unlikely if BNP is less than 100 picog/mL or NT-proBNP is
less than 300 picog/mL . Although levels vary, these cut-off values may still be useful to assess
decompensation of chronic heart failure .
Suspected or known heart failure .
 Two dimensional echocardiography: All patients presenting with heart failure should receive
echocardiographic evaluation of left ventricular ejection fraction, left and right ventricular size
and function, ventricular wall thickness, valve function, and pericardial pathology .
Suspected or known heart failure
 Complete blood count
 Magnesium measurement, serum
 Serum calcium measurement
 Blood urea nitrogen measurement
 Fasting blood glucose measurement
 Liver function tests - general
 Thyroid stimulating hormone measurement
 Fasting lipid profile
Suspected or known heart failure
 Urinalysis: Urinalysis should be obtained in all patients presenting with acute heart failure to detect
infection and assess renal function, especially if hypotension may have occurred .
Suspected or known heart failure
 Serum potassium measurement: The target level of serum potassium in heart failure patients
ranges from 4.0 to 5.5 mmol/L; hypokalemia is independently associated with increased
mortality .
Suspected or known heart failure
 Sodium measurement, serum: In heart failure, serum sodium levels below 136 mEq/L are
associated with increased risk of mortality and prolonged hospitalization .
Suspected or known heart failure
 Creatinine measurement, serum: Serum creatinine should be measured and followed closely in all
patients with heart failure. Creatinine levels provide management guidance as well as
prognostic information .
Suspected or known heart failure
 Albumin measurement, serum
Suspected or known acute coronary syndrome
 Coronary angiography: Coronary angiography assesses risk and guides therapy in high-risk acute
coronary syndrome patients, especially when invasive treatment is planned .
Treatment
Drug Therapy
First-line therapy for fluid overload and maintenance of euvolemia
FUROSEMIDE
Adults: Initial dose 20 to 40 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give
determined dose daily or twice daily; maximum total daily dose 600 mg
BUMETANIDE
Adults: Initial dose 0.5 to 1 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give
determined dose daily or twice daily; maximum daily dose 10 mg
TORSEMIDE
Adults: Initial dose 10 to 20 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give
determined dose daily or twice daily; maximum daily dose 200 mg
Heart failure with hypertension or alternative diuretic therapy for mild volume overload, or combination
therapy with loop diuretics for decreased diuretic response
CHLOROTHIAZIDE
Adults: Initial dose 250 mg to 500 mg orally once or twice daily; maximum total daily dose 1000 mg
CHLORTHALIDONE
Adults: Initial dose 12.5 to 25 mg orally daily; maximum daily dose 100 mg
HYDROCHLOROTHIAZIDE
Adults: Initial dose 25 mg orally daily or twice daily; maximum total daily dose 200 mg
METOLAZONE
Adults: Initial dose 2.5 mg orally once daily; maximum daily dose 20 mg
INDAPAMIDE
Adults: Initial dose 2.5 mg orally once daily; maximum daily dose 5 mg
Heart failure with reduced left ventricular ejection fraction (LVEF) or with preserved LVEF and increased
cardiovascular risk
CAPTOPRIL
Adults: 6.25 mg orally 3 times daily; maximum 50 mg orally 3 times daily
ENALAPRIL MALEATE
Adults: 2.5 mg orally twice daily; maximum 10 to 20 mg twice daily
LISINOPRIL
Adults: 2.5 to 5 mg orally once daily; maximum 20 to 40 mg once daily
PERINDOPRIL ERBUMINE
Adults: Initial dose 2 mg orally once daily; maximum 8 to 16 mg once daily
RAMIPRIL
Adults: Initial dose 1.25 to 2.5 mg orally once daily; maximum 10 mg once daily
TRANDOLAPRIL
Adults: Initial dose 1 mg orally once daily; maximum 4 mg once daily
FOSINOPRIL SODIUM
Adults: Initial dose 5 to 10 mg orally once daily; maximum 40 mg once daily
QUINAPRIL HYDROCHLORIDE
Adults: Initial dose 5 mg orally twice daily; maximum 20 mg twice daily
Intolerance to ACE inhibitors or in combination with ACE inhibitors for persistent symptoms
CANDESARTAN CILEXETIL
Adults: 4 to 8 mg orally once daily; maximum 32 mg once daily
VALSARTAN
Adults: 20 to 40 mg orally twice daily; maximum 160 mg twice daily
LOSARTAN POTASSIUM
Adults: 25 to 50 mg orally once daily; maximum 50 to 100 mg once daily
Clinically stable heart failure due to reduced left ventricular systolic ejection fraction
BISOPROLOL FUMARATE
Adults: 1.25 mg orally once daily; maximum 10 mg once daily
CARVEDILOL (Related toxicological information in CARVEDILOL)
Adults: Initial dose 3.125 mg orally twice daily; maximum 25 mg twice daily (50 mg twice daily for patients over 85 kg)
METOPROLOL SUCCINATE
Adults (extended release tablets): Initial dose 12.5 to 25 mg orally once daily; maximum 200 mg once daily
Selective use for moderate to severe symptoms of HF and decreased left ventricular ejection fraction with
recent decompensation, or LV dysfunction after myocardial infarction
SPIRONOLACTONE
Adults: Initial dose 12.5 to 25 mg orally once daily; maximum 25 mg once or twice daily
EPLERENONE
Adults: Initial dose 25 mg orally once daily; maximum 50 mg once daily
Mild to moderate heart failure with decreased left ventricular ejection fraction and persistent symptoms
despite standard therapies or atrial fibrillation, or severe heart failure while awaiting response to standard
therapies
DIGOXIN (Related toxicological information in CARDIAC GLYCOSIDES)
Adults: 0.125 mg to 0.25 mg orally daily; target plasma concentration 0.5 to 1 nanogram/mL
Adults (over 70 years, lean body mass, or renal dysfunction): Initial dose 0.125 mg orally daily or every other day
Blacks with symptomatic heart failure with decreased left ventricular ejection fraction, and consideration for
non-blacks with persistent symptoms despite standard therapies
Isosorbide Dinitrate / Hydralazine
Adults: Initial dose 1 tablet orally three times daily; titrate upward as tolerated to maximum 2 tablets three times daily
Prevention of ischemic stroke in heart failure complicated by atrial fibrillation
WARFARIN SODIUM
Adults: Initial dose not to exceed 5 mg orally daily ; adjust subsequent doses to achieve a target INR of 2.5 (range, 2
to 3)
Procedural Therapy
Acute coronary syndrome

Percutaneous coronary intervention: Coronary revascularization with percutaneous
coronary intervention is suitable for most high-risk patients with ST-segment elevation MI,
non-ST-segment elevation MI, and unstable angina .
Dyssynchronous ventricular contraction

Implantation of biventricular cardiac pacemaker system
Coronary artery disease

Coronary artery bypass graft: CABG is the preferred revascularization strategy for most
patients with significant left main coronary artery stenosis, 3-vessel coronary artery
disease, and multivessel disease with treated diabetes or left ventricular dysfunction . It is
appropriate in high-risk acute coronary syndrome when fibrinolysis or catheter-based
treatment fails or is not indicated .
Severe refractory heart failure

Transplantation of heart: Although heart transplantation is the only established surgical
treatment for refractory heart failure, the procedure is available to only a limited number
of patients .
Non-Procedural Therapy
Chronic heart failure

Education and Counseling

Lifestyle Modification
Ongoing Assessment
Clinical Evaluation
Laboratory Assessment and Testing
Suspected or known coronary artery disease and evaluation of functional impairment

Cardiovascular stress test using treadmill

Coronary angiography
Coronary arteriosclerosis
Suspected or known coronary artery disease


Radionuclide study of heart
Stress echocardiography
Evaluation of nutritional status


Serum prealbumin level
Nitrogen balance test
Reassessment
Laboratory Reassessment
Suspected or known heart failure

Serum potassium measurement: The target level of serum potassium in heart
failure patients ranges from 4.0 to 5.5 mmol/L; hypokalemia is independently
associated with increased mortality .
Suspected or known heart failure

Creatinine measurement, serum: Serum creatinine should be measured and
followed closely in all patients with heart failure. Creatinine levels provide
management guidance as well as prognostic information .
Suspected or known heart failure .

Two dimensional echocardiography: All patients presenting with heart failure
should receive echocardiographic evaluation of left ventricular ejection fraction, left
and right ventricular size and function, ventricular wall thickness, valve function, and
pericardial pathology .
Last Modified: October 27, 2010