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Heart Failure

Updated : June 27, 2024





Background

Heart failure characterized by the heart muscle’s inability to pump blood effectively that causes pulmonary dyspnea and delay. It can be brought by excessive blood pressure and narrowing of artery which could also improve by lifestyle modifications including stress management, exercise, weight loss, and reduced salt intake can improve quality of life which can improve symptoms and life expectancy. The use of equipment’s helps to pump blood is necessary in cases of severe symptoms such as heart transplants. 

Epidemiology

The prevalence and Incidence rate of heart failure is a widespread illness that affects millions of people worldwide. It becomes worse with age and is more prevalent in older persons. Heart failure can affect both men and women although the disparity in incidence diminishes as people age particularly in the elderly population. 

Anatomy

Pathophysiology

Deficiency in Pumping includes systolic dysfunction where left ventricle is unable to contract firmly which lowers the ejection fraction where diastolic dysfunction impairs ventricular filling as left ventricle’s inability to relax. Vasoconstriction increases in preload and afterload which result from the activation of neurohormonal systems by reduced cardiac output. Structural alterations in heart caused by prolonged stress and are referred to cardiac remodelling. When workload increases then left ventricular hypertrophy is a frequent reaction and myocardial Ischemia and Infarction compromises contractile performance and damages the heart muscle. Prolonged inflammation impairs heart function by causing myocardial damage and fibrosis. When heart failure exists its metabolism changes depending more on glycolysis and less on the metabolism of fatty acids. 

Etiology

Coronary Artery Disease (CAD): 

  • Atherosclerosis and narrowing of the coronary arteries can lead to reduced blood flow to the heart muscle. 
  • Myocardial infarction (heart attack) resulting from CAD can cause damage to the heart muscle and contribute to heart failure. 

Hypertension (High Blood Pressure): 

  • Chronic high blood pressure places increased stress on the heart, leading to hypertrophy (thickening) of the heart muscle. 
  • Persistent hypertension can cause structural changes in the heart and impair its ability to pump effectively. 

Cardiomyopathies: 

  • Cardiomyopathies are diseases of the heart muscle that can result in heart failure. They may be classified as dilated, hypertrophic, or restrictive cardiomyopathies. 
  • Dilated cardiomyopathy is characterized by enlargement of the heart chambers, leading to decreased contractility. 

Valvular Heart Disease: 

  • Malfunctioning heart valves, such as aortic stenosis or mitral regurgitation, can affect blood flow within the heart, leading to volume overload and heart failure. 
  • Valve replacement or repair may be necessary to alleviate the strain on the heart. 

Myocarditis: 

  • Inflammation of the heart muscle (myocarditis) can result from viral or bacterial infections. 
  • Myocarditis can lead to myocardial damage and impair the heart’s pumping ability. 

Ischemic Heart Disease: 

  • Conditions that reduce blood supply to the heart, such as chronic ischemic heart disease, can contribute to heart failure. 
  • Ischemia and infarction can damage the myocardium and impair its contractile function. 

Congenital Heart Defects: 

  • Some individuals may develop heart failure due to congenital heart defects that affect the heart’s structure and function. 
  • Surgical correction or intervention may be required in certain cases. 

Arrhythmias: 

  • Abnormal heart rhythms, especially chronic tachyarrhythmias (fast heart rates), can lead to heart failure. 
  • Irregular heart rhythms can disrupt the coordination of atrial and ventricular contractions, reducing cardiac output. 

Genetics

Prognostic Factors

Ejection Fraction: 

  • Ejection fraction (EF) is a measure of the heart’s pumping ability, expressed as the percentage of blood pumped out with each contraction. 
  • Reduced ejection fraction (typically below 40%) is associated with a poorer prognosis, especially in systolic heart failure. 

New York Heart Association (NYHA) Functional Class: 

  • The NYHA classification system categorizes heart failure into four classes based on the degree of limitation of physical activity. 
  • A higher NYHA class indicates more severe symptoms and is associated with a worse prognosis. 

Symptoms and Quality of Life: 

  • Persistent and severe symptoms such as dyspnea (shortness of breath), fatigue, and exercise intolerance are indicative of a higher risk. 
  • Impaired quality of life, as assessed through patient-reported outcomes, can also be a prognostic factor. 

<b>B-type Natriuretic Peptide (BNP) and N-terminal pro-B-type Natriuretic Peptide (NT-proBNP): 

  • Elevated levels of BNP or NT-proBNP are associated with increased ventricular filling pressures and are used as biomarkers in heart failure. 
  • Higher levels are generally indicative of more severe heart failure and a poorer prognosis. 

Renal Function: 

  • Impaired renal function, as indicated by elevated serum creatinine or reduced glomerular filtration rate (GFR), is a strong prognostic factor. 
  • Worsening renal function during heart failure exacerbations is particularly concerning. 

Co-morbidities: 

  • The presence of comorbid conditions, such as diabetes, chronic kidney disease, or chronic obstructive pulmonary disease (COPD), can impact prognosis. 
  • Comorbidities contribute to the complexity of heart failure management and may worsen outcomes. 

Left Bundle Branch Block (LBBB) and QRS Duration: 

  • Presence of LBBB and prolonged QRS duration on electrocardiogram (ECG) may be associated with a higher risk of adverse events. 

Medication Adherence: 

  • Adherence to prescribed medications, including beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs), is crucial for improving outcomes. 

Clinical History

Age group 

The clinical presentation in adults who are under 65 years of age may experience the risk of CVD symptoms. Elderly people could have cardiomyopathies or congenital heart disease as underlying cardiac problems. 

Physical Examination

General appearance examination Vital Signs Evaluate Jugular Venous Distension Inspection of the Neck Chest Inspection Auscultation of the Lungs and Heart Palpation of the Apical Pulse Peripheral Edema Examination Abdominal Examination 

Age group

Associated comorbidity

Comorbidities of HF includes coronary artery disease, hypertension and diabetes mellitus and also manifestations of CKD include lung congestion and edema which increases risk may be due to respiratory problems and exhaustion made worse by being overweight. 

Associated activity

Acuity of presentation

  • Chronic Stable Heart Failure: Patients with chronic stable heart failure may have gradually worsening symptoms over time. They may experience dyspnea on exertion, fatigue, peripheral edema, and reduced exercise tolerance. 
  • Acute Decompensated Heart Failure: Acute decompensation can occur due to factors such as infection, uncontrolled hypertension, medication non-compliance, or acute myocardial infarction. Patients may present with sudden onset or worsening of symptoms, including severe dyspnea at rest, orthopnea (difficulty breathing while lying flat), paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath), and pulmonary edema. 

Differential Diagnoses

COPD 

Pneumonia 

Asthma 

Pulmonary Embolism 

Valvular Heart Disease 

Renal Failure 

Liver Cirrhosis 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Modifications to Lifestyle: Limit Sodium Intake, control retention of fluids, and manage your weight for heart health in general. Regularly partake in moderate activity that is adapted to your own ability. Pharmacological Interventions: Diuretics can help with symptoms of congestion and decrease fluid retention. Use of beta-blockers, ACE inhibitors, and isosorbide dinitrate is recommended.  

Device Therapy: For patients who run the risk of sudden cardiac death, use an implanted cardioverter-defibrillator (ICD). 

 Surgical Procedures: Coronary artery bypass grafting involves in improvement of valvular heart disease with valve repair or replacement. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Use of a non-pharmacological approach for treating Heart Failure

Limit sodium to manage fluid retention and eat fruits, veggies, lean proteins, and healthy fats for heart health. 

Reduce fluid intake to control fluid retention and regularly check weight to catch fluid retention. 

Quitting smoke and limiting alcohol intake can avoid the risk of cardiovascular disease manifestations. 

Applying the techniques for stress management will improve the quality of life and sleep induction. 

 

Use of diuretics in the treatment of heart failure

Furosemide 

Furosemide is a common diuretic that inhibits Na/K/Cl co-transporter and improve the risk of this disease. 

Bumetanide 

It is an alternative analog to furosemide which acts similarly on the loop of Henle and is used when furosemide is not tolerated. 

Torsemide 

It has a longer half-life than furosemide and work on distal tubule and is less potent than loop diuretics which is preferred for milder cases. In severe cases fluid overload, loop diuretics are preferred for effective effects. 

Use of Angiotensin-Converting Enzyme (ACE) Inhibitors in the treatment of heart failure

They are a class of medications commonly used in the treatment of heart failure. They play a crucial role in managing heart failure by targeting the renin-angiotensin-aldosterone system (RAAS). ACE inhibitors work by inhibiting the activity of angiotensin-converting enzyme, which converts angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor and stimulates the release of aldosterone, leading to sodium and water retention. ACE inhibitors have been shown to prevent or slow down adverse cardiac remodeling, a process in which the heart undergoes structural changes in response to injury or stress. Inhibitors are typically initiated at low doses and gradually titrated upwards based on individual patient response and tolerability. 

  • Enalapril: It inhibits the angiotensin-converting enzyme (ACE), which is responsible for converting angiotensin I to angiotensin II. This inhibition leads to vasodilation, reduced aldosterone release, and decreased sodium and water retention. It is indicated for the treatment of heart failure with reduced ejection fraction (HFrEF). It helps improve symptoms, reduce hospitalizations, and enhance survival in heart failure patients. 
  • Lisinopril: Like enalapril, lisinopril is an ACE inhibitor that blocks the conversion of angiotensin I to angiotensin II. This results in vasodilation, reduced afterload, and improved cardiac function. It is commonly used in the management of heart failure with reduced ejection fraction. It is part of standard pharmacological therapy to optimize outcomes in these patients. 
  • Ramipril: Ramipril, as an ACE inhibitor, inhibits the conversion of angiotensin I to angiotensin II. This action reduces vasoconstriction, aldosterone release, and sodium/water retention. It is indicated for the treatment of heart failure, particularly in patients with reduced ejection fraction. It is part of the therapeutic approach to manage symptoms and improve overall prognosis.

Use of Angiotensin receptor-neprilysin inhibitors in the treatment of heart failure

Angiotensin Receptor-Neprilysin Inhibitors (ARNIs) represent a newer class of medications that have shown significant benefits in the treatment of heart failure, particularly heart failure with reduced ejection fraction (HFrEF).  

  • Valsartan (ARB): Valsartan blocks the angiotensin II type 1 (AT1) receptor, leading to vasodilation, reduced aldosterone release, and inhibition of the harmful effects of angiotensin II on the cardiovascular system. 
  • Sacubitril (Neprilysin Inhibitor): Sacubitril inhibits neprilysin, an enzyme responsible for breaking down natriuretic peptides such as atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). By inhibiting neprilysin, sacubitril increases the levels of these peptides, which promote vasodilation, natriuresis, and diuresis and inhibit the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system. 

Use of Hydralazine in the treatment of Heart Failure

  • Hydralazine is an antihypertensive medication that has been used in the treatment of heart failure, particularly in specific populations. Hydralazine is a direct-acting vasodilator that primarily dilates arterioles. It works by relaxing smooth muscle in the blood vessels, leading to reduced systemic vascular resistance. It is typically used in combination with isosorbide dinitrate (a nitrate) in the treatment of heart failure, particularly in patients who cannot tolerate ACE inhibitors or ARBs. 
  • The combination of hydralazine and isosorbide dinitrate has been shown to improve outcomes in African American patients with heart failure and reduce ejection fraction. 

Use of Intervention with a procedure in treating Heart Failure

  • Coronary Artery Revascularization (Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting): When heart failure is due to underlying coronary artery disease (CAD), revascularization procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting may be performed. These procedures restore blood flow to the heart muscle, relieving ischemia and potentially improving cardiac function. 
  • Implantable Cardioverter-Defibrillator (ICD): For patients at risk of life-threatening ventricular arrhythmias, particularly those with reduced left ventricular function, an ICD may be implanted. ICDs monitor the heart rhythm and deliver an electrical shock if a dangerous arrhythmia occurs, restoring normal rhythm and preventing sudden cardiac death. 
  • Cardiac Resynchronization Therapy (CRT): CRT, often in the form of a biventricular pacemaker, is used to improve synchronization of the heart’s chambers in patients with heart failure and electrical dyssynchrony. By coordinating the contractions of the ventricles, CRT can improve cardiac function, symptoms, and quality of life. 
  • Left Ventricular Assist Device (LVAD): In advanced heart failure with severe left ventricular dysfunction and symptoms refractory to medical therapy, an LVAD may be implanted. LVADs are mechanical pumps that assist the heart in pumping blood throughout the body, providing circulatory support. At the same time, patients await heart transplantation (bridge-to-transplant) or as destination therapy for those ineligible for transplant. 
  • Transcatheter Valve Repair or Replacement: Heart failure can result from valvular heart disease, such as mitral regurgitation or aortic stenosis. Transcatheter procedures, such as transcatheter aortic valve replacement (TAVR) or transcatheter mitral valve repair (e.g., MitraClip), offer less invasive alternatives to traditional surgical valve repair or replacement, particularly in high-risk or inoperable patients. 
  • Alcohol Septal Ablation or Surgical Myectomy: For patients with hypertrophic cardiomyopathy (HCM) and severe symptoms refractory to medical therapy, interventions such as alcohol septal ablation (percutaneous) or surgical myectomy (open-heart surgery) may be performed to alleviate left ventricular outflow tract obstruction and improve symptoms. 
  • Heart Transplantation: In end-stage heart failure, when other treatments are no longer effective, heart transplantation may be considered. This involves surgically replacing the failing heart with a healthy donor heart, offering the potential for long-term survival and improved quality of life. 

Use of phases in managing Heart Failure

Identification and Diagnosis: 

  • Recognition of symptoms suggestive of heart failure, such as shortness of breath, fatigue, swelling (edema), and exercise intolerance. 
  • Comprehensive medical history, physical examination, and diagnostic tests, including echocardiography, electrocardiography (ECG), and blood tests (e.g., BNP, NT-proBNP) to confirm the diagnosis and assess the severity of heart failure. 

Acute Stabilization: 

  • Initial management focuses on stabilizing acute symptoms and addressing any precipitating factors, such as myocardial infarction, arrhythmias, or volume overload. 
  • Hospitalization may be necessary for close monitoring, intravenous medications (e.g., diuretics), and interventions such as oxygen therapy or mechanical ventilation in severe cases. 

Chronic Management: 

  • Once stabilized, long-term management aims to optimize symptom control, improve functional capacity, and reduce the risk of disease progression. 
  • Pharmacological interventions form the cornerstone of chronic management, including medications such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers, diuretics, aldosterone antagonists, and, in select cases, sacubitril/valsartan (ARNI). 
  • Lifestyle modifications, including dietary changes (e.g., sodium restriction), regular exercise, smoking cessation, and alcohol moderation, are emphasized. 
  • Patient education regarding medication adherence, symptom recognition, self-monitoring (e.g., daily weight), and when to seek medical attention is essential. 

Risk Factor Modification: 

  • Identification and management of cardiovascular risk factors, such as hypertension, dyslipidemia, diabetes, and obesity, to reduce the risk of cardiovascular events and disease progression. 
  • Encouragement of adherence to evidence-based therapies for comorbid conditions, such as antiplatelet agents for coronary artery disease and anticoagulation for atrial fibrillation. 

Regular Monitoring and Adjustments: 

  • Ongoing assessment of symptoms, functional status, fluid balance, and medication adherence at regular intervals. 
  • Monitoring of serum electrolytes, renal function, and cardiac biomarkers to guide medication adjustments and detect worsening heart failure. 
  • Adjustment of medications based on changes in clinical status, tolerability, and emerging evidence to optimize therapy and minimize adverse effects. 

Advanced Therapies: 

  • Consideration of advanced therapies for patients with refractory symptoms despite optimal medical management, including device therapies (e.g., CRT, ICD), cardiac resynchronization therapy (CRT), left ventricular assist devices (LVADs), heart transplantation, or palliative care in select cases. 

End-of-Life Care: 

  • In cases of advanced heart failure with a limited prognosis, initiation of discussions regarding goals of care, advance directives, and palliative care to ensure appropriate end-of-life management and support for patients and their families. 

Medication

 
 
 

nebivolol 

<70 years: Not established
>70years: 1.25mg/day orally, increase up to 2.5mg/day every 1-2 weeks. Do not exceed 10mg/day.



Media Gallary

Heart Failure

Updated : June 27, 2024




Heart failure characterized by the heart muscle’s inability to pump blood effectively that causes pulmonary dyspnea and delay. It can be brought by excessive blood pressure and narrowing of artery which could also improve by lifestyle modifications including stress management, exercise, weight loss, and reduced salt intake can improve quality of life which can improve symptoms and life expectancy. The use of equipment’s helps to pump blood is necessary in cases of severe symptoms such as heart transplants. 

The prevalence and Incidence rate of heart failure is a widespread illness that affects millions of people worldwide. It becomes worse with age and is more prevalent in older persons. Heart failure can affect both men and women although the disparity in incidence diminishes as people age particularly in the elderly population. 

Deficiency in Pumping includes systolic dysfunction where left ventricle is unable to contract firmly which lowers the ejection fraction where diastolic dysfunction impairs ventricular filling as left ventricle’s inability to relax. Vasoconstriction increases in preload and afterload which result from the activation of neurohormonal systems by reduced cardiac output. Structural alterations in heart caused by prolonged stress and are referred to cardiac remodelling. When workload increases then left ventricular hypertrophy is a frequent reaction and myocardial Ischemia and Infarction compromises contractile performance and damages the heart muscle. Prolonged inflammation impairs heart function by causing myocardial damage and fibrosis. When heart failure exists its metabolism changes depending more on glycolysis and less on the metabolism of fatty acids. 

Coronary Artery Disease (CAD):