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Heart failure
Classification and external resources
ICD-10 I50.0
ICD-9 428.0
DiseasesDB 16209
MedlinePlus 000158
eMedicine med/3552 
MeSH D006333

Congestive heart failure (CHF), congestive cardiac failure (CCF) or just heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with blood or pump a sufficient amount of blood through the body. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings I00-I99 - Diseases of the Circulatory system (I00-I02 Acute rheumatic fever ( Rheumatic fever without mention of Heart The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books The heart is a muscular organ in all Vertebrates responsible for pumping Blood through the Blood vessels by repeated rhythmic The heart is a muscular organ in all Vertebrates responsible for pumping Blood through the Blood vessels by repeated rhythmic Blood is a specialized Bodily fluid that delivers necessary substances to the body's cells €”such as nutrients and oxygen—and transports Waste products It is not to be confused with "cessation of heartbeat", which is known as asystole, or with cardiac arrest, which is the cessation of normal cardiac function with subsequent hemodynamic collapse leading to death. In medicine asystole is a state of no cardiac electrical activity hence no contractions of the Myocardium and no cardiac output or blood flow A cardiac arrest, also known as cardiorespiratory arrest, cardiopulmonary arrest or circulatory arrest, is the abrupt cessation of normal circulation of Death is the termination of the biological functions that define living Organisms It refers both to a specific Because not all patients have volume overload at the time of initial or subsequent evaluation, the term "heart failure" (ICD-9 428. Hypervolemia, or fluid overload, is the medical condition where there is too much fluid in the blood 9) is preferred over the older term "congestive heart failure".

Other related terms include ischemic cardiomyopathy (implying that the cause of heart failure is coronary artery disease) and dilated cardiomyopathy (which is a description of echocardiographic findings characteristic of heart failure but which does not suggest any specific etiology. Coronary artery disease (CAD (or atherosclerotic Heart disease) is the end result of the accumulation of atheromatous plaques within the walls )

Congestive heart failure exacerbation or decompensated heart failure (DHF) refer to episodes in which a patient with known chronic heart failure acutely develops symptoms.

Congestive heart failure also contrasts with high output heart failure. CHF denotes a pathological process intrinsic to the myocardium, whereas in high output failure, cardiac function is actually normal or even supra-normal, but the demand of end-organs and other tissues outstrips what the heart can provide, occurring in the context of severe anemia, beriberi (vitamin B1/thiamine deficiency), thyrotoxicosis, Paget disease, arteriovenous fistulas or malformations, and inappropriate tachycardia. Anemia ( AmE) or anæmia/anaemia ( BrE) (from the Ancient Greek grc-Latn anaîmia, meaning “without blood†is defined as a qualitative Beriberi (pronounced Berry-berry) is a Nervous system ailment caused by Thiamine (vitamin B1 deficiency Hyperthyroidism is the term for overactive tissue within the Thyroid gland resulting in overproduction and thus an excess of circulating free thyroid hormones Thyroxine

Congestive heart failure is often undiagnosed due to a lack of a universally agreed definition and difficulties in diagnosis, particularly when the condition is considered "mild". Even with the best therapy, heart failure is associated with an annual mortality of 10%. [1] It is the leading cause of hospitalization in people older than 65. [2]

Contents

Signs and symptoms

Symptoms

Symptoms are dependent on two factors. The first is based on the side of the heart, right or left, that is involved. The second factor is based on the type of failure, either diastolic or systolic. Symptoms and presentation may be indistinguishable making diagnosis impossible based on symptoms.

Left sided failure

The most common symptoms are respiratory in nature. Failure of the left ventricle causes congestion of the pulmonary capillaries. The patient will have dyspnea (shortness of breath) on exertion (dyspnée d'effort) and in severe cases, dyspnea at rest. Dyspnea or dyspnoea (pronounced disp-nee-ah, IPA /dɪsp'niə/ from Latin dyspnoea, from Greek dyspnoia from Easy fatigueability and exercise intolerance are also common complaints. Increasing breathlessness on reclining, called orthopnea occurs. Orthopnea ( Greek from ortho, straight + pnoia, breath is Dyspnea which occurs when lying flat causing the person to have to sleep propped It is often measured in the number of pillows required to lie comfortably, and in severe cases, the patient may resort to sleeping while sitting up. Another symptoms of heart failure is paroxysmal nocturnal dyspnea, a sudden nighttime attack of severe breathlessness, usually several hours after going to sleep. If left ventricular function is extremely compromised, symptoms of poor systemic circulation become manifest, leading to dizziness, confusion and diaphoresis and cool extremities at rest. Many different terms are often used to describe what is collectively known as dizziness. Confusion, of a Pathological degree usually refers to loss of orientation (ability to place oneself correctly in the world by time location and personal identity and Diaphoresis is excessive sweating commonly associated with shock and other Medical emergency conditions

Right sided failure

The right side of the heart pumps blood returned from the tissues to the lungs, where CO2 is exchanged for O2. Carbon dioxide ( Chemical formula:) is a Chemical compound composed of two Oxygen Atoms covalently bonded to a single Oxygen (from the Greek roots ὀξÏÏ‚ (oxys (acid literally "sharp" from the taste of acids and -γενής (-genÄ“s (producer literally begetteris the Right ventricular failure leads to congestion of systemic capillaries. This leads to peripheral edema or anasarca and nocturia (frequent nighttime urination when the fluid from the legs is returned to the bloodstream). Peripheral Edema is the Swelling of tissues, usually in the lower limbs, due the accumulation of fluids Anasarca, also known as "extreme generalized Edema " is a Medical Condition characterised by widespread swelling of the Skin due to Nocturia (derived from Latin nox night, and Greek οÏÏα urine) also called nycturia (Greek νυκτουÏία) In more severe cases, ascites (fluid accumulation in the abdominal cavity) and hepatomegaly (painful enlargement of the liver) may develop. In Medicine ( Gastroenterology) ascites (also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more Hepatomegaly is the condition of having an enlarged Liver. It is a nonspecific medical sign having many causes which can broadly be broken down into Infection The liver is a vital organ in the human body and is present in Vertebrates and some other animals Hepatic congestion may actually impair liver function, and jaundice and even coagulopathy may occur. Coagulopathy is a medical term for a defect in the body's mechanism for Blood Clotting.

Heart failure (suboptimal left or right ventricular function) may decompensate easily. this most commonly results from an intercurrent illness (such as pneumonia), myocardial infarction (a heart attack), arrhythmias, uncontrolled hypertension, and patient non-compliance with diet or medication. Pneumonia is an inflammatory illness of the Lung. Frequently it is described as lung Parenchyma / alveolar inflammation and abnormal Myocardial infarction ( MI or AMI for acute myocardial infarction) also known as a heart attack, occurs when the blood supply Dysrhythmia redirects here For the American band see Dysrhythmia (band. Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the Blood pressure is chronically elevated [3] Other classic precipitating factors are anaemia and hyperthyroidism. Anemia ( AmE) or anæmia/anaemia ( BrE) (from the Ancient Greek grc-Latn anaîmia, meaning “without blood†is defined as a qualitative Hyperthyroidism is the term for overactive tissue within the Thyroid gland resulting in overproduction and thus an excess of circulating free thyroid hormones Thyroxine These place additional strain on the heart muscle, which may cause symptoms to rapidly worsen. Excessive fluid or salt intake (including intravenous fluids for unrelated indications, but more commonly from dietary indiscretion), and medication that causes fluid retention (such as NSAIDs and thiazolidinediones), may also precipitate decompensation. Intravenous therapy or IV therapy is the giving of Liquid substances directly into a Vein. Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAID s or NAID s, are drugs with Analgesic, Antipyretic and in higher The Medication class of thiazolidinedione (also called glitazones) was introduced in the late 1990s as an adjunctive therapy for Diabetes mellitus (type [4]

Signs

Left sided heart failure

Signs on physical exam indicating left ventricular failure are a laterally displaced apex beat (as the heart is enlarged) and a gallop rhythm (additional heart sounds) in case of decompensation. A gallop rhythm refers to a (usually abnormal rhythm of the heart on Auscultation. Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e. Murmurs are abnormal Heart sounds that are produced as a result of turbulent blood flow which is sufficient to produce audible noise g. aortic stenosis) or as a result (e. g. mitral regurgitation) of the heart failure. Mitral regurgitation ( MR) a Valvular heart disease also known as mitral insufficiency, is the abnormal leaking of blood through the Mitral valve

Common respiratory signs are tachypnea and increased work of breathing (non-specific signs of respiratory distress), rales or crackles, which suggests the development of pulmonary edema, dullness of the lung fields to percussion and diminished breath sounds at the bases of the lung, which suggests the development of a pleural effusion (fluid collection in the pleural cavity) that is transudative in nature, and cyanosis which suggests hypoxemia, caused by the decreased rate of diffusion of oxygen from fluid-filled alveoli to the pulmonary capillaries. Rales, crackles or crepitations, are the clicking rattling or crackling noises heard on auscultation of (listening to the Lung with a Stethoscope Pulmonary Edema (American English or oedema (British English is swelling and/or fluid accumulation in the Lungs It leads to impaired gas exchange and may cause Pleural effusion is excess fluid that accumulates in the Pleural cavity, the fluid-filled space that surrounds the Lungs Excessive amounts of such fluid can impair Cyanosis is a blue coloration of the Skin and mucous membranes due to the presence of deoxygenated Hemoglobin in Blood vessels near the skin surface

Right sided heart failure

The exam can reveal peripheral edema, ascites, and hepatomegaly. Oedema (or Edema in American English formerly known as dropsy or hydropsy, is the increase of Interstitial fluid in any organ &mdash swelling Jugular venous pressure is frequently assessed as a marker of fluid overload, which can be accentuated by the hepatojugular reflux. The jugular venous pressure (JVP sometimes referred to as jugular venous pulse) is the indirectly observed pressure over the venous system. The abdominojugular test (AJR also known as hepatojugular reflux, is used as an alternate test for measuring Jugular venous Pressure (JVP through the Systemic venous pressure in general is elevated, and this can be seen even in veins in the hand, which are distended when dependent, but which will flatten when the force of gravity overcomes right atrial pressure. In failure, the distention may not be relieved even when the hands are held completely overhead. A parasternal heave may be present, signifying the compensatory increase in contraction strength.

Note that the most common cause of right-sided heart failure is left-sided heart failure, so that patients commonly present with both sets of signs and symptoms.

Diagnosis

Imaging

Echocardiography is commonly used to support a clinical diagnosis of heart failure. An echocardiogram is a Sonography of the Heart. Also known as a cardiac ultrasound it uses standard ultrasound techniques to image two-dimensional slices of This modality uses ultrasound to determine the stroke volume (SV, the amount of blood in the heart that exits the ventricles with each beat), the end-diastolic volume (EDV, the total amount of blood at the end of diastole), and the SV in proportion to the EDV, a value known as the ejection fraction. Not to be confused with Supersonic. Ultrasound is cyclic Sound pressure with a Frequency greater than the upper Stroke volume (SV is the volume of Blood pumped by the right/ Left ventricle of the heart in one contraction. In Cardiovascular physiology, end-diastolic volume ( EDV) is the volume of Blood in a ventricle at the end of filling ( Diastole) In cardiovascular physiology, ejection fraction ( Ef) is the fraction of Blood pumped out of a ventricle with each heart beat In pediatrics, the shortening fraction is the preferred measure of systolic function. Normally, the EF should be between 50% and 70%; in systolic heart failure, it drops below 40%. Echocardiography can also identify valvular heart disease and assess the state of the pericardium (the connective tissue sac surrounding the heart). The pericardium is a double-walled sac that contains the Heart and the roots of the Great vessels. Echocardiography may also aid in deciding what treatments will help the patient, such as medication, insertion of an implantable cardioverter-defibrillator or cardiac resynchronization therapy. An implantable cardioverter-defibrillator ( ICD) is a small battery -powered electrical impulse generator which is implanted in patients who are at risk of Sudden For other uses see Pacemaker (disambiguation A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural pacemaker Echocardiography can also help determine if acute myocardial ischemia is the precipitating cause, and may manifest as regional wall motion abnormalities on echo.

Chest X-rays are frequently used to aid in the diagnosis of CHF. A chest X-ray, commonly abbreviated CXR, is a projection radiograph ( X-ray) taken by a Radiographer, of the Thorax which is used In the compensated patient, this may show cardiomegaly (visible enlargement of the heart), quantified as the cardiothoracic ratio (proportion of the heart size to the chest). Cardiomegaly is a medical condition wherein the Heart is enlarged In left ventricular failure, there may be evidence of vascular redistribution ("upper lobe blood diversion" or "cephalization"), Kerley lines, cuffing of the areas around the bronchi, and interstitial edema. Kerley lines are a sign seen on Chest x-rays with interstitial Pulmonary edema. A bronchus (plural bronchi, adjective bronchial) is a caliber of airway in the Respiratory tract that conducts air into the Lungs No Gas

Electrophysiology

An electrocardiogram (ECG/EKG) is used to identify arrhythmias, ischemic heart disease, right and left ventricular hypertrophy, and presence of conduction delay or abnormalities (e. Ischaemic or ischemic heart disease (IHD or myocardial ischaemia, is a Disease characterized by reduced blood supply to the heart muscle Right ventricular hypertrophy (RVH is a form of Ventricular hypertrophy affecting the Right ventricle. Left ventricular hypertrophy ( LVH) is the thickening of the Myocardium (muscle of the Left ventricle of the Heart. g. left bundle branch block). Left bundle branch block (LBBB is a cardiac conduction abnormality seen on the Electrocardiogram (ECG An ECG may also definitively diagnose acute myocardial ischemia (if ST elevation is present)

Blood tests

Blood tests routinely performed include electrolytes (sodium, potassium), measures of renal function, liver function tests, thyroid function tests, a complete blood count, and often C-reactive protein if infection is suspected. A blood test is a laboratory analysis performed on a Blood sample that is usually extracted from a Vein in the arm using a needle, or via An electrolyte is any substance containing free Ions that behaves as an electrically conductive medium Sodium (ˈsoʊdiəm is an element which has the symbol Na( Latin natrium, from Arabic natrun) atomic number 11 atomic mass 22 Potassium (pəˈtæsiəm is a Chemical element. It has the symbol K (kalium from qalīy Atomic number 19 and Atomic mass 39 Renal function, in Nephrology, is an indication of the state of the Kidney and its role in Renal physiology. Liver function tests (LFTs or LFs which include liver enzymes, are groups of Clinical biochemistry laboratory blood assays designed to give information about the Thyroid function tests ( TFTs) is a collective term for Blood tests used to check the function of the Thyroid. A complete blood count ( CBC) also known as full blood count ( FBC) or full blood exam ( FBE) or blood panel, is C-reactive protein ( CRP) is a Plasma protein, an Acute phase protein produced by the Liver and by Adipocytes. An elevated B-type natriuretic peptide (BNP) is a specific test indicative of heart failure. Brain natriuretic peptide (BNP also known as B-type natriuretic peptide (also BNP or GC-B, is a 32 amino acid polypeptide secreted by the ventricles Additionally, BNP can be used to differentiate between causes of dyspnea due to heart failure from other causes of dyspnea. If myocardial infarction is suspected, various cardiac markers may be used. Medical tests that are often referred to as cardiac markers include cardiac Troponin (the most sensitive and specific test for myocardial damage

According to a meta-analysis comparing BNP and N-terminal pro-BNP (NTproBNP) in the diagnosis of heart failure, BNP is a better indicator for heart failure and left ventricular systolic dysfunction. In Statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses In groups of symptomatic patients, a diagnostic odds ratio of 27 for BNP compares with a sensitivity of 85% and specificity of 84% in detecting heart failure. The odds ratio is a measure of Effect size particularly important in Bayesian statistics and Logistic regression. [5]

Angiography

Heart failure may be the result of coronary artery disease, and its prognosis depends in part on the ability of the coronary arteries to supply blood to the myocardium (heart muscle). Coronary circulation is the circulation of blood in the Blood vessels that supply Blood to and from the Heart muscle Myocardium is the muscular tissue of the Heart. Relationship to other layers The other tissues of the heart are the Endocardium As a result, coronary catheterization may be used to identify possibilities for revascularisation through percutaneous coronary intervention or bypass surgery. A coronary catheterization is a Minimally invasive procedure to access the Coronary circulation and blood filled chambers of the Heart using a Catheter Percutaneous coronary intervention ( PCI) commonly known as coronary angioplasty or simply Angioplasty, is a therapeutic procedure to treat Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgical procedure

Monitoring

Various measures are often used to assess the progress of patients being treated for heart failure. These include fluid balance (calculation of fluid intake and excretion), monitoring body weight (which in the shorter term reflects fluid shifts). Fluid balance is the concept of Human homeostasis that the amount of Fluid lost from the body is equal to the amount of fluid taken in Although many people prefer the less-ambiguous term body mass, the term body weight is overwhelmingly used in daily English speech and in biological and medical science contexts

Diagnostic criteria

No system of diagnostic criteria has been agreed as the gold standard for heart failure. In Medicine, a gold standard test or criterion standard test is a Diagnostic test or benchmark that is regarded as definitive Commonly used systems are the "Framingham criteria"[6] (derived from the Framingham Heart Study), the "Boston criteria",[7] the "Duke criteria",[8] and (in the setting of acute myocardial infarction) the "Killip class". The Framingham Heart Study is a cardiovascular study based in Framingham Massachusetts. The Killip classification is a system used in individuals with an Acute myocardial infarction (heart attack in order to risk stratify them [9]

Functional classification is generally done by the New York Heart Association Functional Classification. The New York Heart Association (NYHA Functional Classification provides a simple way of classifying the extent of heart failure. [10] This score documents severity of symptoms, and can be used to assess response to treatment. While its use is widespread, the NYHA score is not very reproducible and doesn't reliably predict the walking distance or exercise tolerance on formal testing. [11] The classes (I-IV) are:

In its 2001 guidelines, the American College of Cardiology/American Heart Association working group introduced four stages of heart failure:[12]

Classification

There are many different ways to categorize heart failure, including:

Causes

Causes and contributing factors to congestive heart failure include the following:[12]

Causes of heart failure
Left-sided: hypertension (high blood pressure), aortic and mitral valve disease, aortic coarctation Right-sided: pulmonary hypertension (primary pulmonary arterial hypertension versus hypoxic vasoconstriction and capillary destruction due to chronic lung disease), pulmonary or tricuspid valve disease. The miter valve (also known as the bicuspid valve or left atrioventricular valve) is a dual flap (bi = 2 valve in the Heart that lies between Valvular heart disease is any disease process involving one or more of the valves of the heart (the aortic and mitral valves on the left and the pulmonary In Medicine, pulmonary hypertension (PH is an increase in blood pressure in the Pulmonary artery, Pulmonary vein, or pulmonary capillaries together known The pulmonary valve, is the semilunar valve of the heart that lies between the Right ventricle and the Pulmonary artery and has three cusps The tricuspid valve (also known as the right atrioventricular valve) is on the right side of the heart between the Right atrium and the Right ventricle
May affect both sides: Ischemic heart disease (due to insufficient vascular supply, usually as a result of coronary artery disease); this may be chronic or due to acute myocardial infarction (a heart attack), chronic arrhythmias (e. Ischaemic or ischemic heart disease (IHD or myocardial ischaemia, is a Disease characterized by reduced blood supply to the heart muscle Dysrhythmia redirects here For the American band see Dysrhythmia (band. g. atrial fibrillation), cardiomyopathy of any cause, cardiac fibrosis, chronic severe anemia, thyroid disease (hyperthyroidism and hypothyroidism. Atrial fibrillation ( AF or afib) is a Cardiac arrhythmia (abnormal heart rhythm that involves the two upper chambers ( atria) of the Heart Cardiomyopathy, which literally means "heart muscle disease" is the deterioration of the function of the Myocardium (i Cardiac fibrosis refers to an abnormal thickening of the Heart valves due to inappropriate proliferation of cardiac fibroblasts Anemia ( AmE) or anæmia/anaemia ( BrE) (from the Ancient Greek grc-Latn anaîmia, meaning “without blood†is defined as a qualitative The thyroid is one of the largest Endocrine glands in the body Hypothyroidism is the disease state in humans and animals caused by insufficient production of Thyroid hormone by the Thyroid gland. Left sided failure commonly results in right sided failure. )

Pathophysiology

Heart failure is caused by any condition which reduces the efficiency of the myocardium, or heart muscle, through damage or overloading. As such, it can be caused by as diverse an array of conditions as myocardial infarction (in which the heart muscle is starved of oxygen and dies), hypertension (which increases the force of contraction needed to pump blood) and amyloidosis (in which protein is deposited in the heart muscle, causing it to stiffen). In Medicine, amyloidosis refers to a variety of conditions in which Amyloid Proteins are abnormally deposited in organs and/or tissues Over time these increases in workload will produce changes to the heart itself:

The general effect is one of reduced cardiac output and increased strain on the heart. This increases the risk of cardiac arrest (specifically due to ventricular dysrhythmias), and reduces blood supply to the rest of the body. In chronic disease the reduced cardiac output causes a number of changes in the rest of the body, some of which are physiological compensations, some of which are part of the disease process:

The increased peripheral resistance and greater blood volume place further strain on the heart and accelerates the process of damage to the myocardium. Vasoconstriction and fluid retention produce an increased hydrostatic pressure in the capillaries. This shifts of the balance of forces in favour of interstitial fluid formation as the increased pressure forces additional fluid out of the blood, into the tissue. Interstitial fluid (or tissue fluid) is a solution which bathes and surrounds the cells of multicellular animals This results in oedema (fluid build-up) in the tissues. Oedema (or Edema in American English formerly known as dropsy or hydropsy, is the increase of Interstitial fluid in any organ &mdash swelling In right-sided heart failure this commonly starts in the ankles where venous pressure is high due to the effects of gravity (although if the patient is bed-ridden, fluid accumulation may begin in the sacral region. ) It may also occur in the abdominal cavity, where the fluid build-up is called ascites. In left-sided heart failure oedema can occur in the lungs - this is called cardiogenic pulmonary oedema. Pulmonary Edema (American English or oedema (British English is swelling and/or fluid accumulation in the Lungs It leads to impaired gas exchange and may cause This reduces spare capacity for ventilation, causes stiffening of the lungs and reduces the efficiency of gas exchange by increasing the distance between the air and the blood. The consequences of this are shortness of breath, orthopnoea and paroxysmal nocturnal dyspnea. Orthopnea ( Greek from ortho, straight + pnoia, breath is Dyspnea which occurs when lying flat causing the person to have to sleep propped

The symptoms of heart failure are largely determined by which side of the heart fails. The left side pumps blood into the systemic circulation, whilst the right side pumps blood into the pulmonary circulation. Pulmonary circulation is the portion of the Cardiovascular system which carries Oxygen -depleted Blood away from the heart to the Lungs, and Whilst left-sided heart failure will reduce cardiac output to the systemic circultion, the initial symptoms often manifest due to effects on the pulmonary circulation. In systolic dysfunction, the ejection fraction is decreased, leaving an abnormally elevated volume of blood in the left ventricle. In diastolic dysfunction, end-diastolic ventricular pressure will be high. This increase in volume or pressure backs up to the left atrium and then to the pulmonary veins. Increased volume or pressure in the pulmonary veins impairs the normal drainage of the alveoli and favors the flow of fluid from the capillaries to the lung parenchyma, causing pulmonary edema. This impairs gas exchange. Thus, left-sided heart failure often presents with respiratory symptoms: shortness of breath, orthopnea and paroxysmal nocturnal dyspnea.

In severe cardiomyopathy, the effects of decreased cardiac output and poor perfusion become more apparent, and patients will manifest with cold and clammy extremities, cyanosis, claudication, generalized weakness, dizziness, and syncope

The resultant hypoxia caused by pulmonary edema causes vasoconstriction in the pulmonary circulation, which results in pulmonary hypertension. Since the right ventricle generates far lower pressures than the left ventricle (approximately 20 mmHg versus around 120 mmHg, respectively, in the healthy individual) but nonetheless generates cardiac output exactly equal to the left ventricle, this means that a small increase in pulmonary vascular resistance causes a large increase in amount of work the right ventricle must perform. However, the main mechanism by which left-sided heart failure causes right-sided heart failure is actually not well understood. Some theories invoke mechanisms that are mediated by neurohormonal activation. Mechanical effects may also contribute. As the left ventricle distends, the intraventricular septum bows into the right ventricle, decreasing the capacity of the right ventricle.

Systolic dysfunction

Heart failure caused by systolic dysfunction is more readily recognized. It can be simplistically described as failure of the pump function of the heart. It is characterized by a decreased ejection fraction (less than 45%). The strength of ventricular contraction is attenuated and inadequate for creating an adequate stroke volume, resulting in inadequate cardiac output. In general, this is caused by dysfunction or destruction of cardiac myocytes or their molecular components. In congenital diseases such as Duchenne muscular dystrophy, the molecular structure of individual myocytes is affected. Duchenne muscular dystrophy ( DMD) is a severe recessive x-linked form of Muscular dystrophy that is characterized by rapid progression of muscle degeneration eventually Myocytes and their components can be damaged by inflammation (such as in myocarditis) or by infiltration (such as in amyloidosis). In Medicine ( Cardiology) myocarditis is Inflammation of the Myocardium, the muscular part of the Heart. Toxins and pharmacological agents (such as ethanol, cocaine, and amphetamines) cause intracellular damage and oxidative stress. Cocaine ( benzoylmethyl ecgonine) is a Crystalline Tropane Alkaloid that is obtained from the leaves of the Coca plant Amphetamine, and related drugs such as Methamphetamine are a group of drugs that act by increasing levels of Norepinephrine, Serotonin, and Dopamine The most common mechanism of damage is ischemia causing infarction and scar formation. After myocardial infarction, dead myocytes are replaced by scar tissue, deleteriously affecting the function of the myocardium. On echocardiogram, this is manifest by abnormal or absent wall motion.

Because the ventricle is inadequately emptied, ventricular end-diastolic pressure and volumes increase. This is transmitted to the atrium. On the left side of the heart, the increased pressure is transmitted to the pulmonary vasculature, and the resultant hydrostatic pressure favors extravassation of fluid into the lung parenchyma, causing pulmonary edema. On the right side of the heart, the increased pressure is transmitted to the systemic venous circulation and systemic capillary beds, favoring extravassation of fluid into the tissues of target organs and extremities, resulting in dependent peripheral edema.

Diastolic dysfunction

Heart failure caused by diastolic dysfunction is generally described as the failure of the ventricle to adequately relax and typically denotes a stiffer ventricular wall. This causes inadequate filling of the ventricle, and therefore results in an inadequate stroke volume. The failure of ventricular relaxation also results in elevated end-diastolic pressures, and the end result is identical to the case of systolic dysfunction (pulmonary edema in left heart failure, peripheral edema in right heart failure. )

Diastolic dysfunction can be caused by processes similar to those that cause systolic dysfunction, particularly causes that affect cardiac remodeling.

Diastolic dysfunction may not manifest itself except in physiologic extremes if systolic function is preserved. The patient may be completely asymptomatic at rest. However, they are exquisitely sensitive to increases in heart rate, and sudden bouts of tachycardia (which can be caused simply by physiological responses to exertion, fever, or dehydration, or by pathological tachyarrhythmias such as atrial fibrillation with rapid ventricular response) may result in flash pulmonary edema. Atrial Fibrillation with Rapid Ventricular Response (afib with RVR is a type of abnormally fast heart rate ( Tachyarrhythmia) that may present as a medical emergency In Medicine, flash pulmonary edema (FPE is rapid onset Pulmonary edema. Adequate rate control (usually with a pharmacological agent that slows down AV conduction such as a calcium channel blocker or a beta-blocker) is therefore key to preventing decompensation.

Left ventricular diastolic function can be determined through echocardiography by measurement of various parameters such as the E/A ratio (early-to-atrial left ventricular filling ratio), the E (early left ventricular filling) deceleration time, and the isovolumic relaxation time.

Treatment

The treatment of CHF focuses on treating the symptoms and signs of CHF and preventing the progression of disease. If there is a reversible cause of the heart failure (e. g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, or hypertension), that should be addressed as well. An infection is the detrimental Colonization of a host Organism by a foreign Species. In Chemistry, an alcohol is any Organic compound in which a Hydroxyl group ( - O[[hydrogen H]]) is bound to a Carbon Hyperthyroidism is the term for overactive tissue within the Thyroid gland resulting in overproduction and thus an excess of circulating free thyroid hormones Thyroxine Dysrhythmia redirects here For the American band see Dysrhythmia (band. Treatments include exercise, eating healthy foods, reduction in salty foods, and abstinence from smoking and drinking alcohol.

Modalities

Diet and lifestyle measures

Patients with CHF are educated to undertake various non-pharmacological measures to improve symptoms and prognosis. Pharmacology (from Greek grc φάÏμακον pharmakon, "drug" and grc -λογία -logia) is the study of how Drugs Such measures include:[19]

Pharmacological management

There is a significant evidence–practice gap in the treatment of CHF; particularly the underuse of ACE inhibitors and β-blockers and aldosterone antagonists which have been shown to provide mortality benefit. ACE inhibitors, or inhibitors of '''A'''ngiotensin-'''C'''onverting '''E'''nzyme, are a group of Pharmaceuticals that are used primarily in treatment of Hypertension Beta blockers (sometimes written as β-blocker) are a class of drugs used for various indications but particularly for the management of Cardiac arrhythmias [21] Treatment of CHF aims to relieve symptoms, maintain a euvolemic state (normal fluid level in the circulatory system), and to improve prognosis by delaying progression of heart failure and reducing cardiovascular risk. Fluid balance is the concept of Human homeostasis that the amount of Fluid lost from the body is equal to the amount of fluid taken in Prognosis (older Greek Ï€Ïόγνωσις modern Greek Ï€Ïόγνωση - literally fore-knowing foreseeing) is a medical term denoting the Drugs used include: diuretic agents, vasodilator agents, positive inotropes, ACE inhibitors, beta blockers, and aldosterone antagonists (e. A diuretic is any Drug that elevates the rate of urination ( Diuresis) An inotrope (ˈaɪnÉ™troÊŠp is an agent that alters the force or energy of Muscular contractions Negatively inotropic agents weaken the force of muscular contractions ACE inhibitors, or inhibitors of '''A'''ngiotensin-'''C'''onverting '''E'''nzyme, are a group of Pharmaceuticals that are used primarily in treatment of Hypertension Beta blockers (sometimes written as β-blocker) are a class of drugs used for various indications but particularly for the management of Cardiac arrhythmias Aldosterone antagonist refers to drugs which antagonise the action of Aldosterone at Mineralocorticoid receptors This group of drugs is often used as adjunctive g. spironolactone). Spironolactone (marketed under the trade names Aldactone, Novo-Spiroton, Spiractin, Spirotone, Verospiron or Berlactone It should be noted that while intuitive, increasing heart function with some drugs, such as the positive inotrope Milrinone, leads to increased mortality. Milrinone (Primacor is a Phosphodiesterase III inhibitor It potentiates the effect of Cyclic adenosine monophosphate (cAMP [22][23]

Angiotensin-modulating agents

ACE inhibitor (ACE) therapy is recommended for all patients with systolic heart failure, irrespective of symptomatic severity or blood pressure. [24][12][25] ACE inhibitors improve symptoms, decrease mortality and reduce ventricular hypertrophy. Ventricular hypertrophy is the enlargement of ventricles (lower chambers in the heart Angiotensin II receptor antagonist therapy (also referred to as AT1-antagonists or angiotensin receptor blockers), particularly using candesartan, is an acceptable alternative if the patient is unable to tolerate ACEI therapy. Angiotensin II receptor antagonists, also known as angiotensin receptor blockers (ARBs AT1-receptor antagonists or sartans, are a group of Candesartan ( rINN) (ˌkændɨˈsɑrtən is an Angiotensin II receptor antagonist used mainly for the treatment of Hypertension. [26][27] ACEIs and ARBs decrease afterload by antagonizing the vasopressor effect of angiotensin, thereby decreasing the amount of work the heart must perform. It is also believed that angiotensin directly affects cardiac remodeling, and blocking its activity can thereby slow the deterioration of cardiac function.

Diuretics

Diuretic therapy is indicated for relief of congestive symptoms. A diuretic is any Drug that elevates the rate of urination ( Diuresis) Several classes are used, with combinations reserved for severe heart failure:[19]

If a heart failure patient exhibits a resistance to or poor response to diuretic therapy, ultrafiltration or aquapheresis may be needed to achieve adequate control of fluid retention and congestion. Aquapheresis is a Medical technology designed to remove excess salt and water from the body safely predictably and effectively from patients suffering from a condition called The use of such mechanical methods of fluid removal can produce meaningful clinical benefits in patients with diuretic-resistant heart failure and may restore responsiveness to conventional doses of diuretics. 9

Beta blockers

Until recently (within the last 20 years), β-blockers were contraindicated in CHF, owing to their negative inotropic effect and ability to produce bradycardia – effects which worsen heart failure. Bradycardia, as applied to adult medicine is defined as a resting Heart rate of under 60 beats per minute though it is seldom symptomatic until the rate drops below 50 beat/min However, current guidelines recommend β-blocker therapy for patients with systolic heart failure due to left ventricular systolic dysfunction after stabilization with diuretic and ACEI therapy, irrespective of symptomatic severity or blood pressure. [25] As with ACEI therapy, the addition of a β-blocker can decrease mortality and improve left ventricular function. Several β-blockers are specifically indicated for CHF including: bisoprolol, carvedilol, and extended-release metoprolol. Bisoprolol is a drug belonging to the group of Beta blockers a class of drugs used primarily in Cardiovascular diseases More specifically it is a selective type β1 Carvedilol is a non-selective beta blocker indicated in the treatment of mild to moderate Congestive heart failure (CHF Metoprolol is a selective β1 receptor blocker used in treatment of several diseases of thecardiovascular system especially Hypertension. The antagonism of β1 inotropic and chronotropic effects decreases the amount of work the heart must perform. It is also thought that catecholamines and other sympathomimetics have an effect on cardiac remodeling, and blocking their activity can slow the deterioration of cardiac function.

Positive inotropes

Digoxin (a mildly positive inotrope and negative chronotrope), once used as first-line therapy, is now reserved for control of ventricular rhythm in patients with atrial fibrillation; or where adequate control is not achieved with an ACEI, a beta blocker and a loop diuretic. Digoxin ( INN) (dɨˈdʒɒksɨn also known as Digitalis, is a purified Cardiac glycoside extracted from the Foxglove plant Digitalis [25] There is no evidence that digoxin reduces mortality in CHF, although some studies suggest a decreased rate in hospital admissions. [28] It is contraindicated in cardiac tamponade and restrictive cardiomyopathy.

The inotropic agent dobutamine is advised only in the short-term use of acutely decompensated heart failure, and has no other uses. Dobutamine is a Sympathomimetic Drug used in the treatment of Heart failure and Cardiogenic shock. [25]

Phosphodiesterase inhibitors such as milrinone are sometimes utilized in severe cardiomyopathy. Milrinone (Primacor is a Phosphodiesterase III inhibitor It potentiates the effect of Cyclic adenosine monophosphate (cAMP The mechanism of action is through the antagonism of adenosine receptors, resulting in inotropic effects and modest diuretic effects.

Alternative vasodilators

The combination of isosorbide dinitrate/hydralazine is the only vasodilator regimen, other than ACE inhibitors or angiotensin II receptor antagonists, with proven survival benefits. Isosorbide dinitrate/hydralazine is a fixed dose combination drug treatment specifically indicated for Black people with Congestive heart failure. This combination appears to be particularly beneficial in CHF patients with an African American background, who respond less effectively to ACEI therapy. [29][30]

Aldosterone receptor antagonists

The RALES trial[31] showed that the addition of spironolactone can improve mortality, particularly in severe cardiomyopathy (ejection fraction less than 25%. ) The related drug eplerenone was shown in the EPHESUS trial[32] to have a similar effect, and it is specifically labelled for use in decompesated heart failure complicating acute myocardial infarction. Eplerenone ( INN) (ɛpˈlɛrənoʊn is an Aldosterone antagonist used as an adjunct in the management of Chronic heart failure. While the antagonism of aldosterone will decrease the effects of sodium and water retention, it is thought that the main mechanism of action is by antagonizing the deleterious effects of aldosterone on cardiac remodeling.

Recombinant neuroendocrine hormones

Nesiritide, a recombinant form of B-natriuretic peptide, is indicated for use in patients with acute decompensated heart failure who have dyspnea at rest. Nesiritide (Natrecor is a Medication used to treat acutely decompensated Congestive heart failure with Dyspnea at rest or with minimal exertion (such as Nesiritide promotes diuresis and natriuresis, thereby ameliorating volume overload. It is thought that, while BNP is elevated in heart failure, the peptide that is produced is actually dysfunctional or non-functional and thereby ineffective.

Vasopressin receptor antagonists

Tolvaptan and conivaptan antagonize the effects of antidiuretic hormone (vasopressin), thereby promoting the specific excretion of free water, directly ameliorating the volume overloaded state, and counteracting the hyponatremia that occurs due to the release of neuroendocrine hormones in an attempt to counteract the effects of heart failure. Tolvaptan ( INN) also known as OPC-41061, is a selective competitive Arginine vasopressin receptor 2 antagonist under investigation Conivaptan (YM 087 brand name Vaprisol) is a non-peptide inhibitor of Antidiuretic hormone (vasopressin The EVEREST trial, which utilized tolvaptan, showed that when used in combination with conventional therapy, many symptoms of acute decompensated heart failure were significantly improved compared to conventional therapy alone[33] although they found no difference in mortality and morbidity when compared to conventional therapy. [34].

Devices

Patients with NYHA class III or IV, left ventricular ejection fraction (LVEF) of 35% or less and a QRS interval of 120 ms or more may benefit from cardiac resynchronization therapy (CRT; pacing both the left and right ventricles), through implantation of a bi-ventricular pacemaker, or surgical remodeling of the heart. A millisecond (from Milli- and Second; abbreviation ms is one thousandth of a Second. The left ventricle is one of four chambers (two atria and two ventricles in the Human Heart. The right ventricle is one of four chambers (two atria and two ventricles in the Human Heart. For other uses see Pacemaker (disambiguation A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural pacemaker These treatment modalities may make the patient symptomatically better, improving quality of life and in some trials have been proven to reduce mortality.

The COMPANION trial demonstrated that CRT improved survival in individuals with NYHA class III or IV heart failure with a widened QRS complex on an electrocardiogram. [35] The CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all cause mortality, and a reduction in cardiovascular-related hospitalization. [36]

Patients with NYHA class II, III or IV, and LVEF of 35% (without a QRS requirement) may also benefit from an implantable cardioverter-defibrillator (ICD), a device that is proven to reduce all cause mortality by 23% compared to placebo. This mortality benefit was observed in patients who were already optimally-managed on drug therapy. [37] Patients with severe cardiomyopathy are at high risk for sudden cardiac death due to ventricular dysrhythmias.

Another current treatment involves the use of left ventricular assist devices (LVADs). A Ventricular assist device, or VAD, is a mechanical device that is used to partially or completely replace the function of a failing Heart. LVADs are battery-operated mechanical pump-type devices that are surgically implanted on the upper part of the abdomen. They take blood from the left ventricle and pump it through the aorta. LVADs are becoming more common and are often used by patients who have to wait for heart transplants.

Surgery

The final option, if other measures have failed, is heart transplantation or (temporary or prolonged) implantation of an artificial heart. Heart transplantation or cardiac transplantation, is a surgical transplant procedure performed on patients with end-stage Heart failure or severe Coronary An artificial heart is a prosthetic device that is implanted into the body to replace the biological Heart. These remain the recommended surgical treatment options. However, the limited number of hearts available for transplantation in a growing group of candidates, has led to the development of alternative surgical approaches to heart failure. These commonly involve surgical left ventricular remodeling. The aim of the procedures is to reduce the ventricle diameter (targeting Laplace's law and the disease mechanism of heart failure), improve its shape and/or remove non-viable tissue. [38] These procedures can be performed together with coronary artery bypass surgery or mitral valve repair. Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgical procedure Mitral valve repair is a Cardiac surgery procedure performed by Cardiac surgeons to treat Stenosis (narrowing or Regurgitation (leakage of the

If heart failure ensues after a myocardial infarction due to scarring and aneurysm formation, reconstructive surgery may be an option. These aneurysms bulge with every contraction, making it inefficient. Cooley and coworkers reported the first surgical treatment of a left ventricular aneurysm in 1958. [39] The used a linear closure after their excision. In the 1980s, Vincent Dor developed a method using an circular patch stitched to the inside of the ventricle (the endoventricular circular patch plasty or Dor procedure) to close the defect after excision. In 1985 Vincent Dor MD introduced endoventricular circular patch plasty (EVCPP or the Dor procedure as a viable method for restoring a dilated left ventricle to its normal elliptical [40] His approach has been modified by others. Today, this is the preferred method for surgical treatment of incorrectly contracting (dyskinetic) left ventricle tissue, although a linear closure technique combined with septoplasty might be equally effective. [41][42] The multicenter RESTORE trial of 1198 participants demonstrated an increase in ejection fraction from about 30% to 40% with a concomitant shift in NYHA classes, with an early mortality of 5% and a 5-year survival of 70%. [43] As of yet, it remains unknown if surgery is superior to optimal medical therapy. The STICH trial (Surgical Treatment for IschemiC Heart Failure) will examine the role of medical treatment, coronary artery bypass surgery and left ventricle remodeling surgery in heart failure patients. Results are expected to be published in 2009 and 2011. [44]

The Batista procedure was invented by Brazilian doctor Randas Batista in 1994 for use in patients with non-ischemic dilated cardiomyopathy. The Batista procedure was an experimental open-heart surgical technique that aimed to reverse the effects of remodeling in cases of end-stage Dilated cardiomyopathy Year 1994 ( MCMXCIV) was a Common year starting on Saturday (link will display full 1994 Gregorian calendar) Dilated cardiomyopathy or DCM, also known as congestive cardiomyopathy, is a condition in which the Heart becomes weakened and enlarged and cannot pump It involves removal of a portion of viable tissue from the left ventricle to reduce its size (partial left ventriculectomy), with or without repair or replacement of the mitral valve. [45]. Although several studies showed benefits from this surgery, studies at the Cleveland Clinic concluded that this procedure was associated with a high early and late failure rate. The Cleveland Clinic (formally known as the Cleveland Clinic Foundation) is a multispecialty academic medical center located in Cleveland, Ohio, At 3 years only 26 percent were event-free and survival rate was only 60 percent. [46] Most hospitals have abandoned this operation and it is no longer included in heart failure guidelines. [38]

Newer procedures under examination are based on the observation that the spherical configuration of the dilated heart reduces ejection fraction compared to the elliptical form. Mesh-like constraint devices such as the Acorn CorCap aim to improve contraction efficacy and prevent further remodeling. Clinical trials are underway. [47] Another technique which aims to divide the spherical ventricle into two elliptical halves is used with the Myosplint device. [48]

Approach

Acute decompensation

In acute decompensated heart failure, the immediate goal is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that airway, breathing, and circulation are secure. Supplemental oxygen should be administered immediately to correct hypoxemia. Hypoxaemia (or hypoxemia is a deficiency in the concentration of dissolved oxygen in Arterial blood Acute decompensation may be complicated by respiratory failure, which will require treatment with endotracheal intubation and mechanical ventilation. Respiratory failure is a medical term for inadequate Gas exchange by the Respiratory system. In Medicine, intubation refers to the placement of a tube into an external or internal orifice of the body In Medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing when patients cannot do so on their own While heart failure is associated with a volume overloaded state, volume status should be adequately evaluated. Since heart failure patients are generally on chronic diuretics, overdiuresis can occur. In the case of diastolic dysfunction without systolic dysfunction, fluid resuscitation may in fact improve circulation by decreasing heart rate, which will allow the ventricles more time to fill. Even if the patient is edematous, fluid resuscitation may be the first line of treatment if the patient is hypotensive. The patient may in fact be intravascularly volume depleted, although if the hypotension is due to cardiogenic shock, additional fluid may make the situation worse. Cardiogenic shock is based upon an inadequate circulation of Blood due to primary failure of the ventricles of the Heart to function effectively If the patient's circulatory volume is adequate but there is persistent evidence of inadequate end-organ perfusion, inotropes may be administered. In certain circumstances, a left-ventricle assist device (LVAD) may be necessary.

Certain scenarios will require emergent consultation with cardiothoracic surgery. Cardiothoracic surgery is the field of Medicine involved in surgical treatment of Diseases affecting organs inside the Thorax (the chest Heart failure due to acute aortic regurgitation is a surgical emergency associated with high mortality. Heart failure may occur after rupture of ventricular aneurysm. These can form after myocardial infarction. If it ruptures on the free wall, it will cause cardiac tamponade. Cardiac tamponade, also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the Pericardium (the sac in which the If it ruptures on the intraventricular septum, it can create a ventricular septal defect. A ventricular septal defect ( VSD) is a defect in the Ventricular septum, the wall dividing the left and right ventricles of the Heart. Other causes of cardiac tamponade may also require surgical intervention, although emergent treatment at bedside may be adequate. It should also be determined whether the patient had a history of a repaired congenital heart disease as they often have complex cardiac anatomy with artificial grafts and shunts that may sustain damage, leading to acute decompensated heart failure. A congenital heart defect (CHD is a defect in the structure of the Heart and Great vessels of a Newborn.

Acute myocardial infarction can precipitate acute decompensated heart failure and will necessitate emergent revascularization with thrombolytics, percutaneous coronary intervention, or coronary artery bypass graft. Myocardial infarction ( MI or AMI for acute myocardial infarction) also known as a heart attack, occurs when the blood supply Thrombolytic drugs are used in Medicine to dissolve blood clots in a procedure termed Thrombolysis. Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgical procedure

Once the patient is stabilized, attention can be turned to treating pulmonary edema to improve oxygenation. Intravenous furosemide is generally the first line. However, patients on long-standing diuretic regimens can become tolerant, and dosages must be progressively increased. If high doses of furosemide are inadequate, boluses or continuous infusions of bumetanide may be preferred. These loop diuretics may be combined with thiazide diuretics such as oral metolazone or intravenous chlorthiazide for a synergistic effect. Loop diuretics are Diuretics that act on the ascending Loop of Henle in the Kidney. Thiazide is a term used to describe a type of molecule and a class of Diuretic. Not to be confused with Metaxalone, a muscle relaxant Metolazone is a Thiazide diuretic marketed under the brand names Zaroxolyn Intravenous preparations are preferred because of more predictable absorption. When a patient is extremely fluid overloaded, they can develop intestinal edema as well, which can affect enteral absorption of medications.

Another option is nesiritide, although it should only be considered if conventional therapy has been ineffective and the patient is extremely symptomatic. Nesiritide (Natrecor is a Medication used to treat acutely decompensated Congestive heart failure with Dyspnea at rest or with minimal exertion (such as

Provided that the patient has an adequate blood pressure and is not bradycardia, a β1 selective beta-blocker such as metoprolol should be started. Bradycardia, as applied to adult medicine is defined as a resting Heart rate of under 60 beats per minute though it is seldom symptomatic until the rate drops below 50 beat/min In cases of more severe cardiomyopathy, a beta blocker with alpha antagonist effects such as carvedilol or labetalol may be preferred. Labetalol ( Normodyne, Trandate, fixed combination with Hydrochlorothiazide: Normozyde) is a Drug that is a Racemic mixture An ACE inhibitor or angiotensin receptor blockers should be started as well. If the ejection fraction is poor, an aldosterone receptor antagonist should be started as well.

The criteria for successful treatment of acute decompensated heart failure is the re-establishment of adequate oxygenation off of supplemental oxygen, adequate perfusion of end-organs, and return to baseline symptomatology. A parameter frequently used is return to "dry" weight. As the test is becoming more easily available, return to baseline BNP can also serve as a measure of adequate treatment.

Chronic management

The goal is to prevent the development of acute decompensated heart failure, to counteract the deleterious effects of cardiac remodeling, and to minimize the symptoms that the patient suffers. In addition to pharmacologic agents (oral loop diuretics, beta-blockers, ACE inhibitors or angiotensin receptor blockers, vasodilators, and in severe cardiomyopathy aldosterone receptor antagonists), behavioral modification should be pursued, specifically with regards to dietary guidelines regarding salt and fluid intake. Beta blockers (sometimes written as β-blocker) are a class of drugs used for various indications but particularly for the management of Cardiac arrhythmias Exercise should be encouraged as tolerated, as sufficient conditioning can significantly improve quality-of-life.

In patients with severe cardiomyopathy, implantation of an automatic implantable cardioverter defibrillator(AICD) should be considered. A select population will also probably benefit from ventricular resynchronization.

In select cases, cardiac transplantation can be considered. Heart transplantation or cardiac transplantation, is a surgical transplant procedure performed on patients with end-stage Heart failure or severe Coronary While this may resolve the problems associated with heart failure, the patient generally must remain on an immunosuppressive regimen to prevent rejection, which has its own significant downsides.

Palliative care and hospice

Without transplantation, heart failure caused by ischemic heart disease is not reversible, and cardiac function typically deteriorates with time. (In particular, diastolic function worsens as a function of age even in individuals without ischemic heart disease. ) The growing number of patients with Stage D heart failure (intractable symptoms of fatigue, shortness of breath or chest pain at rest despite optimal medical therapy) should be considered for palliative care or hospice, according to American College of Cardiology/American Heart Association guidelines.

Prognosis

Prognosis in heart failure can be assessed in multiple ways including clinical prediction rules and cardiopulmonary exercise testing. Clinical prediction rules use a composite of clinical factors such as lab tests and blood pressure to estimate prognosis. Among several clinical prediction rules for prognosing acute heart failure, the 'EFFECT rule' slightly outperformed other rules in stratifying patients and identifying those at low risk of death during hospitalization or within 30 days. A clinical prediction rule is type of medical research study in which researchers try to identify the best combination of Medical sign, Symptoms, and other findings [49] Easy methods for identifying low risk patients are:

A very important method for assessing prognosis in advanced heart failure patients is cardiopulmonary exercise testing (CPX testing). CPX testing is usually required prior to heart transplantation as an indicator of prognosis. Cardiopulmonary exercise testing involves measurement of exhaled oxygen and carbon dioxide during exercise. The peak oxygen consumption (VO2 max) is used as an indicator of prognosis. As a general rule, a VO2 max less than 12-14 cc/kg/min indicates a poorer survival and suggests that the patient may be a candidate for a heart transplant. Patients with a VO2 max<10 cc/kg/min have clearly poorer prognosis. The most recent International Society for Heart and Lung Transplantation (ISHLT) guidelines (http://www.jhltonline.org/article/PIIS1053249806004608/fulltext#sec1) also suggest two other parameters that can be used for evaluation of prognosis in advanced heart failure, the heart failure survival score and the use of a criteria of VE/VCO2 slope>35 from the CPX test. The heart failure survival score is a score calculated using a combination of clinical predictors and the VO2 max from the cardiopulmonary exercise test.

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See also

External links

Dictionary

heart failure

-noun

  1. (cardiology, pathology) The chronic inability of the heart to pump a sufficient amount of blood throughout the body, leading to a pooling of blood and shortness of breath.
  2. (cardiology, pathology) The cessation of the heartbeat; cardiac arrest.
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