Contents

Search

chronic heart failure; congestive heart failure (CHF)

A clinical syndrome characterized by either: 1) signs & symptoms of intravascular & interstitial volume overload, including shortness of breath, rales, & edema 2) manifestations of inadequate tissue perfusion, such as fatigue or poor exercise tolerance Etiology: 1) myocardial infarction 2) cardiomyopathy 3) pharmacologic agents: a) beta blockers b) calcium channel antagonists c) estrogens d) non-steroidal anti-inflammatory agents 1] indomethacin 2] phenylbutazone 3] naproxen 4] piroxicam 5] especially long-acting NSAIDs e) steroids f) mannitol g) minoxidil Clinical manifestations: 1) paroxysmal nocturnal dyspnea (systolic heart failure) 2) jugular venous distension 3) rales (pulmonary crackles) 4) cardiomegaly (systolic heart failure) 5) acute pulmonary edema 6) S3 gallop (systolic heart failure) 7) S4 heart sound (diastolic heart failure) 8) increased venous pressure (> 16 cm H2O) 9) positive hepatojugular reflex 10) edema of extremities 11) cough at night (systolic heart failure) 12) dyspnea on exertion 13) hepatomegaly &/or hepatojuglular reflez 14) pleural effusion Laboratory: 1) chemistry 7 panel or basic metabolic panel a) every 6 months in stable patients [3] b) hyponatremia is a marker of advanced disease 2) elevated norepinephrine, atrial natriuretic factor & renin (rarely measured) 3) elevated serum BNP (ventricular pressure overload) - useful for distinguishing cardiac vs non-cardiac causes of dyspnea - B-type natriuretic peptide prohormone in serum alternatively useful [21] - serial meausurements to guide care not useful [3] 4) low or high serum estradiol is associated with increased mortality in men [] Special laboratory: 1) electrocardiogram a) asymptomatic, non-sustained ventricular tachycardia (> 3 onsecutive beats) reflects severity of disease & portends poor prognosis b) conduction system abnormalities c) non-specific ST segment & T wave changes d) left ventricular hypertrophy suggests diastolic rather than systolic dysfunction e) Q waves suggest prior myocardial infarction 2) echocardiogram: a) most useful diagnostic procedure b) global hypokinesis versus segmental wall motion anormalities c) chamber dimensions d) ventricular wall thickness e) evidence of valvular heart disease f) not useful for routine assessment of chronic heart failure unless there is a change in clinical status or a planned intervention [3] 3) assessment of coronary artery disease: a) exercise tolerance testing, myocardial perfusion study, cardiac catherization b) indications: 1] history of myocardial infarction 2] cardiac angina 3] atherosclerosis or peripheral vascular disease 4] high-risk for myocardial infarction Radiology: - chest X-ray a) cardiomegaly b) pulmonary venous redistribution c) interstitial or alveolar edema is uncommon Complications: 1) sudden cardiac death in 20-40% due to: a) ventricular tachycardia or fibrillation b) bradycardia c) electromechanical dissociation 2) depression or antidepressant therapy associated with increased mortality & risk of hospitalization [9] 3) increased risk of venous thromboembolism (RR=1.5) - DVT, pulmonary embolism [19] - prophylaxis for venous thromboembolism in hospitalized patients with heart failure decreases risk for 3.7% to 1.5% [19] Management: 1) also see heart failure 2) pharmacological agents a) ACE inhibitors - symptomatic congestive heart failure (NYHA class II-IV) - doses of ACE inhibitors shown to provide survival benefit - captopril 50 mg TID - enalapril 20 mg BID - lisinopril 10 mg QD - optimal doses (Kaiser) - lisinopril 40 mg QD - enalapril 20 mg QD - asymptomatic left ventricular (LV) dysfunction - LV ejection fraction <40% - post myocardial infarction b) angiotensin II receptor inhibitors - symptomatic CHF in elderly - patients intolerant of ACE inhibitors [3,18] c) diuretics - loop diuretic (Lasix) for volume overload - spironolactone 25 mg PO QD reduces mortality - may be used in conjunction with ACE inhibitor [4] d) digoxin - persistent symptoms of CHF despite therapy with ACE inhibitors in patients in sinus rhythm - rate control in atrial fibrillation e) nitrates - angina pectoris - preload reduction for peristent congestive symptoms f) hydralazine with isordil or other nitrate (BiDil) - patients intolerant of ACE inhibitors with symptomatic CHF - hydralazine 75 mg QID shown to be of benefit - AHA guideline for African Americans with symptoms that persist despite optimal medical therapy [11] g) beta-blockers (symptomatic improvement) - carvedilol (Coreg): start 3.125 mg (survival benefit) - metoprolol (Toprol XL): start 12.5 mg QD - bisoprolol (Zebeta) h) ivabradine may be of benefit in patients with LVEF < 35% for use in conjunction with ACE inhibitor, beta-blocker & aldosterone antagonist (see NGD {NICE}) i) SGLT2 inhibitors (flozins) may be of benefit in patients with or without diabetes mellitus & systolic heart failure [24] j) oral anticoagulation - previous embolic event - chronic or paroxysmal atrial fibrillation - left ventricular thrombus k) antiplatelet agents - treat comorbid cardiovascular disease - aspirin better than warfarin for patients in sinus rhythm [15] - avoid NSAIDs, especially those with long 1/2 life - increased systemic vascular resistance - reduced renal perfusion l) statin may be of benefit, even in non-ischemic heart failure [8] - little benefit in elderly [10] m) severe refractory congestive heart failure - dobutamine - milrinone 3) implantable cardioverter-defibrillator (ICD) - symptomatic ventricular tachycardia - unresponsive to pharmacologic agents, or - left ventricular ejection fraction < 35% - antiarrhythmic therapy is often required to prevent frequent ICD misfirings - does NOT prevent bradyarrhythmias 4) cardiac resynchronization therapy (CRT) for NYHA class III or IV - His bundle pacing may be non inferior to CRT [22] 5) nutritional counseling a) limit Na+ intake (< 2 g/day) - reducing sodium intake does not improve outcomes [23] b) limit fluid intake (< 1.5 L/day may be appropriate) c) vitamin D supplementation? - may improve LV ejection fraction & LV end diastolic volume - no benefit for 6 minute walk [20] 6) lifestyle modification - regular aerobic exercise [7] - exercise modestly reduces depressive symptoms [16] 7) daily weights - measure weight in AM, after awakening & voiding - if weight increases by > 2 pounds, double dose of diuretic & K+ [5] 8) cardiac transplantation

Related

cardiomyopathy left ventricular systolic dysfunction; heart failure with reduced ejection fraction (HFrEF) myocardial infarction (MI); heart attack New York Heart Association classification of heart failure

Specific

chronic diastolic heart failure chronic right ventricular failure; cor pumonale compensated chronic heart failure end-stage heart failure

General

heart failure (HF) chronic heart disease

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1291
  3. Medical Knowledge Self Assessment Program (MKSAP) 11,16,17,19. American College of Physicians, Philadelphia 1998,2012,2015,2022
  4. Journal Watch, Mass Med Soc 20(1):7 (Jan 1) 2000 Pitt B et al The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 341:709, 1999 PMID: 10471456
  5. Watson K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  6. Prescriber's Letter 10(8):44 2003
  7. Journal Watch 24(6):50-51, 2004 ExTraMATCH Collaborative, BMJ 328:189, 2004 PMID: 14729656 - ExTraMATCH Collaborative http://bmj.bmjjournals.com/cgi/content/full/328/7433/189
  8. Sola S et al, Atorvastatin improves left ventricular systolic function and serum markers of inflammation in nonischemic heart failure. J Am Coll Cardiol 2006, 47:332 PMID: 16412856 - Ramasubbu K and Mann DL The emerging role of statins in the treatment of heart failure. J Am Coll Cardiol 2006, 47:342 PMID: 16412858
  9. Sherwood A et al, Relationship of depression to death or hospitalization in patients with heart failure. Arch Intern Med 2007, 167:367 PMID: 17325298
  10. Kjekshus J et al for the CORONA group Rosuvastatin in older patients with systolic heart failure. N Engl J Med 2007, Nov 5 http://dx.doi.org/10.1056/NEJMoa0706201
  11. Jessup M et al 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. PMID: 19324967
  12. Jankowska EA et al Circulating estradiol and mortality in men with systolic chronic heart failure. JAMA 2009 May 13; 301:1892. PMID: 19436016
  13. University of Michigan Health System (UMHS) Guidelines on heart failure - systolic dysfunction http://cme.med.umich.edu/pdf/guideline/HeartFailure06.pdf
  14. Prescriber's Letter 17(2): 2010 Target Doses of Heart Failure Medications Detail-Document#: 260210 (subscription needed) http://www.prescribersletter.com
  15. Homma S et al Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm N Engl J Med, May 2, 2012 PMID: 22551105 http://www.nejm.org/doi/full/10.1056/NEJMoa1202299 - Eikelboom JW and Connolly SJ Warfarin in Heart Failure N Engl J Med, May 2, 2012 PMID: 22551103 http://www.nejm.org/doi/full/10.1056/NEJMe1202504
  16. Blumenthal JA et al. Effects of exercise training on depressive symptoms in patients with chronic heart failure: The HF-ACTION randomized trial. JAMA 2012 Aug 1; 380:465. PMID: 22851113 http://jama.jamanetwork.com/article.aspx?articleid=1273016
  17. O'Connor CM, Whellan DJ, Lee KL et al Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009 Apr 8;301(14):1439-50. PMID: 19351941
  18. Heran BS, Musini VM, Bassett K, Taylor RS, Wright JM Angiotensin receptor blockers for heart failure. Cochrane Database Syst Rev. 2012 Apr 18;4:CD003040 PMID: 22513909
  19. Tang L, Wu YY, Lip GY, Yin P, Hu Y Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis. The Lancet Haematology. Dec 3, 2015 PMID: 26765646 http://thelancet.com/journals/lanhae/article/PIIS2352-3026%2815%2900228-8/abstract
  20. Witte KK et al. Effects of vitamin D on cardiac function in patients with chronic HF: The VINDICATE study. J Am Coll Cardiol 2016 Apr 4; PMID: 27058906 Free Article
  21. Yancy CW et al 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017. copublished in J Am Coll of Cardiol http://circ.ahajournals.org/content/circulationaha/early/2017/04/26/CIR.0000000000000509.full.pdf
  22. Vinther M et al. A randomized trial of His pacing versus biventricular pacing in symptomatic heart failure patients with left bundle branch block (His-Alternative). JACC Clin Electrophysiol 2021 Apr 25; [e-pub]. PMID: 34167929 https://www.sciencedirect.com/science/article/abs/pii/S2405500X21003285
  23. Ezekowitz JA et al. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): An international, open-label, randomised, controlled trial. Lancet 2022 Apr 2; [e-pub]. PMID: 35381194 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00369-5/fulltext
  24. McMurray JJV, Solomon SF, Inzucchi SE et al Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med Sept 19, 2019 PMID: 31535829 https://www.nejm.org/doi/full/10.1056/NEJMoa1911303 - Fang JC Heart-Failure Therapy - New Drugs but Old Habits? N Engl J Med Sept 19, 2019 PMID: 31535828 https://www.nejm.org/doi/full/10.1056/NEJMe1912180