Download Heart Failure - Cat`s TCM Notes

Heart Failure: A Review
The most common cause of heart failure is left ventricular systolic dysfunction (about 60% of
patients). Currently, 5 million Americans are afflicted with heart failure, approximately 2% of the
population. 1 Patients with heart failure account for about 1 million hospital admissions annually,
with another 2 million patients having heart failure as a secondary diagnosis. One third of these
patients are readmitted within 90 days for recurrent decompensation
Patients at high risk for developing heart failure are those with hypertension, coronary artery
disease, diabetes mellitus, familial history of cardiomyopathy, use of cardiotoxins, and obesity.
Initially, as a direct result of inadequate cardiac output and systemic perfusion, the body activates
several neurohormonal pathways to increase circulating blood volume. The sympathetic nervous
system increases heart rate and contractility, both of which increase cardiac output. Circulating
catecholamines also cause arteriolar vasoconstriction in nonessential vascular beds and stimulate
secretion of renin from the juxtaglomerular apparatus of the kidney.
Table 1: American College of Cardiology–American Heart Association Classification of Chronic Heart Failure
Stage
Description
A—high risk for developing heart Hypertension, diabetes mellitus, CAD, family history of
failure
cardiomyopathy
B—asymptomatic heart failure
Previous MI, LV dysfunction, valvular heart disease
Structural heart disease, dyspnea and fatigue, impaired
C—symptomatic heart failure
exercise tolerance
D—refractory end-stage heart
Marked symptoms at rest despite maximal medical therapy
failure
Signs and symptomsThere is a wide spectrum of potential clinical manifestations of heart failure.
Most patients have signs and symptoms of fluid overload and pulmonary congestion, including
dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Patients with right ventricular failure have
jugular venous distention, peripheral edema, hepatosplenomegaly, and ascites. Others, however,
do not have congestive symptoms but have signs and symptoms of low cardiac output, including
fatigue, effort intolerance, cachexia, and renal hypoperfusion. The NYHA functional classification
scheme is used to assess the severity of functional limitations and correlates fairly well with
prognosis
Table 2: New York Heart Association (NYHA) Heart Failure Symptom Classification System
NYHA
Class
I
II
III
IV
Level of Impairment
No symptom limitation with ordinary physical activity
Ordinary physical activity somewhat limited by dyspnea (e.g., long-distance walking, climbing two flights of
stairs)
Exercise limited by dyspnea with moderate workload (e.g., short-distance walking, climbing one flight of
stairs)
Dyspnea at rest or with very little exertion
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On physical examination, patients with heart failure may be tachycardic and tachypneic, with
bilateral inspiratory rales, jugular venous distention, and edema. They often are pale and
diaphoretic. The first heart sound usually is relatively soft if the patient is not tachycardic. An S 3 will
be present.
Diagnosis
Electrocardiogram, chest radiograph, and B-type natriuretic peptide assay.
The single most useful diagnostic test is the echocardiogram, which can distinguish between
systolic and diastolic dysfunction.
A useful diagnostic test for the detection of heart failure is the B-type natriuretic peptide (BNP)
assayBNP levels correlate with severity of heart failure and decrease as a patient reaches a
compensated state. This blood test may be useful for distinguishing heart failure from pulmonary
disease. Because smokers often have both these clinical diagnoses, differentiating between them
may be challenging.
Summary
* Jugular venous distention is a useful physical sign of heart failure.
* The lungs usually are clear in chronic heart failure.
* The BNP assay improves the accuracy of diagnosing heart failure.
* Echocardiography is the single most useful diagnostic modality.
* Coronary angiography confirms or excludes coronary artery disease as the cause.
Treatment
Lifestyle Modifications
Dietary sodium and fluid restrictions should be implemented in all patients with congestive heart
failure. Limiting patients to 2 g/day of dietary sodium and 2 L/day of fluid will lessen congestion and
lower the need for diuretics. Patient education guidelines are listed below:
Patient Education Guidelines
 2-g sodium diet
 Monitoring weight daily
 2-L fluid restriction
 Monitoring blood pressure
 Medications
 Smoking cessation
 Light aerobic exercise
 Knowing who to call
 Achieving ideal weight
 Follow-up visits
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Drugs:
Angiotensin-Converting Enzyme Inhibitors
Angiotensin Receptor Blockers
Beta Blockers
Digoxin
Diuretics
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All heart failure patients should receive an ACE inhibitor and a beta blocker.
Diuretics are needed in most patients to manage fluid retention.
Digoxin is reserved for patients with signs and symptoms of heart failure.
Aldosterone antagonists are used in patients with Class III or IV heart failure.
ARBs or a hydralazine plus nitrate may be added to standard therapy for
additional benefit.
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