Textbook of Cardiology

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''Peter Damman, MD; Ineke Nederend, MD''
<div align="right">'''Peter Damman, MD''', Ineke Nederend, MD</div>


== Introduction ==
== Introduction ==
[[File:Foxglove_(digitalis).png|thumb|right|Foxglove (digitalis), used as a medicine for heart failure]]
[[File:Foxglove_(digitalis).png|thumb|right|Foxglove (digitalis), used as a medicine for heart failure]]
=== History ===
=== History ===
In 1628, William Harvey first described circulation. Little understanding of the nature of heart failure could have existed before that time. Almost 200 years later, René Laennec invents the stethoscope. Röntgen's discovery of x-rays  in 1895 and Einthoven's development of electrocardiography (ECG) in the 1890s led to improvements in the understanding of heart failure. In former days, the foxglove was used as a medicine to treat heart failure. This was described by William Withering <cite>Withering</cite>. The flower improves contractility of the cardiac muscle and has important parasympathic effects, particularly on the atrioventricular node.
In 1628, William Harvey first described circulation. Little understanding of the nature of heart failure could have existed before that time. Almost 200 years later, René Laennec invents the stethoscope. Röntgen's discovery of x-rays  in 1895 and Einthoven's development of electrocardiography (ECG) in the 1890s led to improvements in the understanding of heart failure. In former days, the foxglove was used as a medicine to treat heart failure. This was described by William Withering <cite>Withering</cite>. The flower improves contractility of the cardiac muscle and has important parasympathic effects, particularly on the atrioventricular node.
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In 1984, the Framingham heart study launched. At start, 5209 residents of the town Framingham aged between 30 and 62 were included in the study which is still continued today. This study is considered the most important longitudinal source of data on the epidemiology of heart failure.  
In 1984, the Framingham heart study launched. At start, 5209 residents of the town Framingham aged between 30 and 62 were included in the study which is still continued today. This study is considered the most important longitudinal source of data on the epidemiology of heart failure.  


== Definition and diagnosis ==


Foxglove (digitalis), used as a medicine for heart failure
=== Definition of heart failure ===
The term heart failure (HF) (or decompensatio cordis) basically describes an acute or chronic situation in which the amount of blood pumped through the circulation by the heart, is insufficient to meet the body’s demands. It is a complex syndrome highlighted by several features including haemodynamics, oxygen consumption and exercise capacity. According to the guidelines of the European Society of Cardiology, HF is defined as a syndrome in which the patient should have the following threefold of features: symptoms of typical of HF; signs typical of HF; and objective evidence of a structural or functional abnormality of the heart at rest (Table 1).


== Definition and diagnosis ==
<div align="center">
=== Definition of heart failure ===
{| class="wikitable" border="1" width="80%" cellpading="2" cellspacing="2"
{| class="wikitable" border="1" width="600" align="left" style="float: right"
|-
|-
| style="border-top: 0; border-bottom: 0; background-color: white;" | '''Table 1. Definition of heart failure'''
|align="center" bgcolor="#E3E4FA"|'''Table 1. Definition of heart failure'''
|-
|-
| style="border-top: 0; border-bottom: 0; background-color: #CCCCFF;" | '''Heart failure is a clinical syndrome in which patients have the following features:'''
|'''Heart failure is a clinical syndrome in which patients have the following features:'''
|-
|-
| style="border-top: 0; border-bottom: 0; background-color: white;" |  
|
* Symptoms typical of heart failure
* Symptoms typical of heart failure
(breathlessness at rest or during exercise, fatigue, tiredness, ankle swelling)
**Breathlessness at rest or during exercise
**Fatigue
**Tiredness
**Ankle swelling
|-
|-
| style="border-top: 0; border-bottom: 0; background-color: #CCCCFF;" | '''and'''
|'''and'''
|-  
|-
| style="border-top: 0; border-bottom: 0; background-color: white;" |  
|
* Signs typical of heart failure
* Signs typical of heart failure
(tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral edema, hepatomegaly)
**Tachycardia
**Tachypnoea
**Pulmonary rales
**Pleural effusion
**Raised jugular venous pressure
**Peripheral edema  
**Hepatomegaly
|-
|-
| style="border-top: 0; border-bottom: 0; background-color: #CCCCFF;" | '''and'''
|'''and'''
|-
|-
| style="border-top: 0; background-color: white;" |
|
* Objective evidence of a structural or functional abnormality of the heart at rest
* Objective evidence of a structural or functional abnormality of the heart at rest
(cardiomegaly, third heart sound, cardiac murmurs, abnormality on the electrocardiogram, raised natriuretic peptide concentration)
**Cardiomegaly
**Third heart sound
**Cardiac murmurs
**Abnormality on the electrocardiogram
**Raised natriuretic peptide concentration
|}
|}
The term heart failure (HF) (or decompensatio cordis) basically describes an acute or chronic situation in which the amount of blood pumped through the circulation by the heart, is insufficient to meet the body’s demands. It is a complex syndrome highlighted by several features including haemodynamics, oxygen consumption and exercise capacity. According to the guidelines of the European Society of Cardiology, HF is defined as a syndrome in which the patient should have the following threefold of features: symptoms of typical of HF; signs typical of HF; and objective evidence of a structural or functional abnormality of the heart at rest (Table 1).
</div>


=== Acute and chronic heart failure ===
=== Acute and chronic heart failure ===
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===== Heart rhythm disorders =====
===== Heart rhythm disorders =====
Atrial fibrillation is a common rhythm disorder in the elderly. With this condition, the atria do not contract in the coordinated fashion unlike when in normal sinus rhythm, and therefore the atria never optimally empty. Normally, this ‘atrial kick’ contributes to around 15% of the LVEF. The absence of the atrial kick during atrial fibrillation can contribute to a reduced LVEF. Less frequently, , blood can stagnate in the atria during fibrillation which is prone to thrombus formation and embolisation to the coronary arteries with myocardial infarction and HF as possible consequences.
Atrial fibrillation is a common rhythm disorder in the elderly. With this condition, the atria do not contract in the coordinated fashion unlike when in normal sinus rhythm, and therefore the atria is never optimally empty. Normally, this ‘atrial kick’ contributes to around 15% of the LVEF. The absence of the atrial kick during atrial fibrillation can contribute to a reduced LVEF. Less frequently, blood can stagnate in the atria during fibrillation which is prone to thrombus formation and embolisation to the coronary arteries with myocardial infarction and HF as possible consequences.


===== Valvular disease =====
===== Valvular disease =====
Valvular disease, especially mitral- or aortic, can cause volume overload of the heart. This overload causes dilation of the ventricle which makes the pump function less pristine.
Valvular disease, especially ''mitral'' or ''aortic'', can cause volume overload of the heart. This overload causes dilation of the ventricle which makes the pump function less pristine.


===== Cardiomyopathies =====
===== Cardiomyopathies =====
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===== Drugs =====
===== Drugs =====
β-blockers, calcium antagonist, antiarrhythmics, cytotoxic agents.
*β-blockers  
*Calcium antagonist
*Antiarrhythmics
*Cytotoxic agents
 
===== Toxins =====
===== Toxins =====
Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic).
*Alcohol
*Medication
*Cocaine
*Trace elements (mercury, cobalt, arsenic)


===== Endocrine disorders =====
===== Endocrine disorders =====
Diabetes mellitus, hypo- or hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytoma.
*Diabetes mellitus
*Hypo- or hyperthyroidism  
*Cushing syndrome
*Adrenal insufficiency
*Excessive growth hormone  
*Phaeochromocytoma


===== Nutrional status =====
===== Nutrional status =====
Deficiency of thiamine, selenium, or camitine, obesity, cachexia.
*Deficiency of thiamine
*Selenium or camitine
*Obesity
*Cachexia


===== Infiltrative disorders =====
===== Infiltrative disorders =====
Sacroidosis, amyloidosis, haemochromatosis, connective tissue disease.
*Sacroidosis  
*Amyloidosis
*Haemochromatosis
*Connective tissue disease


===== Others =====
===== Others =====
Chaga’s disease, HIV infection,  end-stage renal failure.
*Chaga’s disease
*HIV infection
*End-stage renal failure


=== Prevalence ===
=== Prevalence ===
The prevalence of HF in the western world is estimated as 1 to 2%, and the incidence is around 5 to 10 per 1000 persons per year REF MOSTERD, HEART 2007. Because at young age coronary heart disease is more prevalent in men, prevalence of HF is also higher in this group compared to age matched women. At older age, prevalence of HF is equal between sexes.
The prevalence of HF in the western world is estimated as 1 to 2%, and the incidence is around 5 to 10 per 1000 persons per year. (Ref Mosterd, Heart 2007) Because at young age coronary heart disease is more prevalent in men, prevalence of HF is also higher in this group compared to age matched women. At older age, prevalence of HF is equal between sexes.


== Clinical aspects ==
== Clinical aspects ==
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=== Symptoms ===
=== Symptoms ===
{| class="wikitable" border="1" style="float: right" align="left" width="450"
{| class="wikitable" border="1" width="80%" cellpading="2" cellspacing="2"
|-  
|-  
| colspan="2" style="border-bottom: 0; background-color: white;" | '''Table 2. NYHA functional classification'''
| colspan="2" | '''Table 2. NYHA functional classification'''
|-
|-
| colspan="2" style="border-top: 0; border-bottom: 0; background-color: white;" |  
| colspan="2"|  
|-
|-
| colspan="2" style="border-top: 0; background-color: white;" | '''Severity based on symptoms and physical activity'''
| colspan="2" style="border-top: 0; background-color: white;" | '''Severity based on symptoms and physical activity'''
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| width="350" style="width: 350; background-color: white; border-left: 0;  border-top: 0;" | Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased.  
| width="350" style="width: 350; background-color: white; border-left: 0;  border-top: 0;" | Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased.  
|}
|}
HF can manifest with a multitude of different symptoms, but shortness of breath and tiredness are the most characteristic. Other symptoms include:
HF can manifest with a multitude of different symptoms, but shortness of breath and tiredness are the most characteristic. Other symptoms include:
* Orthopnoea
* Orthopnoea
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{| class="wikitable" border="1" style="float: right" width="600"
{| class="wikitable" border="1" style="float: right" width="600"
|-
|-
| colspan="3" style="border-bottom: 0; background-color: white" | '''Table 3. Common echocardiographic abnormalities in heart failure'''
| colspan="3"| '''Table 3. Common echocardiographic abnormalities in heart failure'''
|-
|-
| colspan="3" style="border-bottom: 0; border-top: 0; background-color: white" |  
| colspan="3" style="border-bottom: 0; border-top: 0; background-color: white" |  
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{| class="wikitable" border="1" align="left" style="float: center"
{| class="wikitable" border="1" align="left" style="float: center"
|-
|-
| colspan="6" style="border-bottom: 0; background-color: white;" | '''Table 4'''
| colspan="6" | '''Table 4'''
|-
|-
| colspan="6" align="center" style="border-bottom: 0; border-top: 0; background-color: white;" | '''Size of treatment effect'''
| colspan="6" align="center" style="border-bottom: 0; border-top: 0; background-color: white;" | '''Size of treatment effect'''
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