Textbook of Cardiology

Heart Failure: Difference between revisions

Page Discussion

Heart Failure (view source)

Revision as of 13:04, 6 June 2012

1 byte added ,  6 June 2012
no edit summary
No edit summary
No edit summary
Line 282: Line 282:
===== Heart catheterization =====
===== Heart catheterization =====
Heart catheterization is not part of the routine diagnosis and work-up of patients with HF.  But in patients suffering angina pectoris despite optimal medical therapy, it should be considered (Class of recommendation IIa, level of evidence C, see Table 4). Also, coronary angiography is recommended in patients at high risk of coronary artery disease  (Class of recommendation I, level of evidence C) and in HF patients with significant valvular disease (Class of recommendation IIa, level of evidence C).
Heart catheterization is not part of the routine diagnosis and work-up of patients with HF.  But in patients suffering angina pectoris despite optimal medical therapy, it should be considered (Class of recommendation IIa, level of evidence C, see Table 4). Also, coronary angiography is recommended in patients at high risk of coronary artery disease  (Class of recommendation I, level of evidence C) and in HF patients with significant valvular disease (Class of recommendation IIa, level of evidence C).
== Management ==
The management of HF involves both pharmacological and non-pharmacological treatment. The emphasis is on the reduction in mortality and morbidity, prevention of the progression of HF, and the treatment of (non-)cardiovascular co-morbidities. Myocardial infarction (MI) is the most important cause of HF. Management of coronary disease is crucial in these patients, as revascularization of the myocardium will increase exercise capacity and survival.
Research shows that good adherence to medication is associated with a decrease in risk of death. <cite>Granger</cite> Nevertheless, the percentage of HF patients adhering to prescribed pharmacological and non-pharmacological treatment is as low as 20-60 % according to the literature <cite>Evangelista</cite> <cite>VanDerWal</cite>.
Treatment of diastolic- and systolic HF does not differ (vd wall). Non-pharmalogical treatment can be applied in every patient.
==== Non-pharmacological treatment ====
Although pharmacological treatment is usually emphasized, non-pharmacological management is of great importance for HF patients. It can have a significant impact on symptoms, functional capacity, wellbeing, morbidity, and prognosis. The most important non-pharmacological opinions are described below.
===== Education =====
Education of both the patient and their family about HF and its symptoms is important. The patient and/or the caregiver should be able to undertake appropriate actions such as adjusting the diuretic dose or contact the physician. (Class I recommendation, level of evidence C; see Table 4) Education on the importance  and (side) effects of medication should be provided to the patient in order to increase compliance. (Class I recommendation, level of evidence C)
===== Fluid and sodium restriction =====
In patients with severe symptoms of HF, restriction of fluid intake may be considered. (Class IIa recommendation, level of evidence C) Also, patients should be educated on salt content of food and minimize intake in order to prevent fluid retention. (Class I recommendation, level of evidence C)
===== Body weight =====
CHF patients should carefully monitor their body weight. A sudden increase in weight is a potential consequence of fluid retention and deterioration of HF. When patients notice a weight gain of >2kg in 3 days they should consult a physician. (Class I recommendation, level of evidence C) In obese patients (body mass index of > 30 kg/m2), weight reduction should be promoted to prevent progression of HF, decrease symptoms and improve the overall wellbeing of the patient. (Class IIa recommendation, level of evidence C) Also, attention should be paid to weight loss due to malnutrition which is frequently observed in severe HF. An altered metabolism, inflammatory mechanisms or a decreased food intake may be important factors in the pathophysiology of cardiac cachexia in HF. (Class I recommendation, level of evidence C)
===== Alcohol and tobacco =====
Alcohol intake should be minimized, as it may increase blood pressure and/or have a negative inotropic effect. (Class II a recommendation, level of evidence C) Smoking cessation should be encouraged. It is recommended that patients with HF receive support and advice on this topic. (Class I recommendation, level of evidence C). A reduction in alcohol and tobacco intake might also improve co-morbidities including sleep disorders.
===== Exercise =====
Exercise training is recommended to all chronic stable HF patients. Twenty years ago, exercise was strongly discouraged in patients with HF as the general conception was that it was harmful. Nowadays, numerous studies have shown the opposite. Rehabilitation programmes have shown to increase exercise capacity and health related quality of life and decrease hospitalization rates and symptoms. (Class I recommendation, level of evidence A)
===== Other =====
Other non-pharmacological treatment recommendations include immunization of HF patients (pneumococcal- and influenza vaccination should be considered), the consulting of a physician around pregnancy, the screening for depression and sleep disorders which require additional medical attention.
In conlusion, advices on lifestyle in general are very important. Yet, an extensive survey among HF patients showed that recall and adherence of lifestyle advice was disappointing <cite>Lainscak</cite>. Health professionals should make sure the patient is able the understand and recall the advice given. With the intention to support this, the European Society of Cardiology (ESC) initiated a website (2007) containing practical heart failure information for patients, families, and caregivers: www.heartfailurematters.org
=== Pharmacological treatment ===
[[File:Treatment_algorithm_as_proposed_in_the_ESC_guidelines_2008.png|thumb|right|Treatment algorithm as proposed in the ESC guidelines 2008]]
The treatment algorithm as proposed in the ESC guidelines 2008 are depicted in Figure 2. Patients for whom the medication is indicated,  mode of action, contraindications of the medication, and possible side effects included in this algorithm are discussed below.
Angiotensin-converting enzyme (ACE) inhibitors
ACE inhibitors are indicated for every HF patient with an EF ≤ 40 %, irrespective of symptoms. (Class I recommendation, level of evidence A) Contraindications for the use of ACE inhibitors are:
* History of angioedema
* Bilateral renal artery stenosis
* Serum potassium concentration > 5.0 mmol/L
* Serum creatine > 220 µmol/L
* Severe aortic stenosis
ACE inhibitors relieve the heart by decreasing the preload and afterload. This is achieved through two mechanisms. Firstly, conversion of angiotensin-I to angiotensin– II is inhibited, which reduces vasoconstriction and lowers BP. Secondly, production of aldosterone is decreased, as angiotensin II induces this production. Aldosterone increases blood volume and thus BP by stimulating sodium- and water retention.
Possible side effects are symptomatic hypotension (dizziness), hyperkalaemia, worsening renal function and cough. 
==== β-Blockers ====
β-Blockade is recommended for every symptomatic (NYHA class II-IV) HF patient with a LVEF ≤40% or asymptomatic patients with a LVEF ≤40% after a MI . (Class I recommendation, level of evidence A) Contraindications are:
* Asthma
* Second- or third degree heart block, sick sinus syndrome, sinus bradycardia
β-Blockers mainly exert their effect by lowering the cardiac output, perpherial vascular resistance and by influencing the renin-angiotensinsysteem. In addition, β-Blockers presumably compass the positive effect on mortality by lowering the chronic sympathic overstimulation.
Possible side effects include (symptomatic) hypotension, worsening of HF or bradycardia.
Diuretics (Aldosterone antagonists and angiotensin receptor blockers)
Diuretics reduce preload by venous vasodilatation and fluid secretion. As a result, filling pressures of the heart and the lung vasculature decreases and symptoms and signs decrease. (Class I recommendation, level of evidence B)
Aldosterone antagonists
Adding this drug to therapy is suggested for patients with severe symptomatic (NYHA class III or IV, refer to Table 2) HF and an LVEF < 35%. (Class I recommendation, level of evidence B) Contraindications:
* Serum potassium concentration > 5.0 mmol/L
* Serum creatine > 220 µmol/L
* Concomitant potassium sparing diuretic or potassium supplements
* Combination of an ACEI and ARB
By competing with aldosterone, the antagonists lower the blood pressure through reducing water and sodium retention.
Possible side effects include hyperkalaemia, worsening renal function, and breast tenderness and/or enlargement.
==== Angiotensin receptor blockers (ARBs) ====
In HF patients with a LVEF≤40% who remain symptomatic despite optimal ACEI en β-blocker treatment, use of ARBs is recommended. (Class I recommendation, level of evidence A). Contraindications are:
* Combination of an ACE inhibitor and an aldosterone antagonist
* Bilateral renal artery stenosis
* Serum potassium concentration > 5.0 mmol/L
* Serum creatine > 220 µmol/L
* Severe aortic stenosis
Possible side effects include symptomatic hypotension (dizziness), hyperkalaemia, and a worsening renal function.
==== Digoxine ====
For a long time digoxine, together with β-blockers, has been standard treatment in HF. Presumably, digoxine ameliorates contractility of the heart by increasing intracellular calcium and sodium concentrations. Nevertheless, in contradiction to other drugs (β-blockers , ACE inhibititors, ARBs) it has never proven to decrease mortality rates. Because of that reason, digoxine had to render its place in the treatment algorithm.
In patients with symptomatic HF and atrial fibrillation (AF) with a ventricular rate at rest of >80 beats per minute, use of digoxine may be considered to slow the ventricular rate. (Class I recommendation, level of evidence C)
In mild to severe symptomatic HF patients in sinus rhythm and with an LVEF ≤40% , digoxin (in addition to an ACEI) improves ventricular function and patient well-being, reduces hospital admission, but does not affect survival rates. (Class IIa recommendation, level of evidence B)
Contraindications for the use of digoxin are:
* Second- or third degree heart block without a permanent pacemaker, sick sinus syndrome
* Pre-exitation syndromes
Possible side effects include sinoatrial or atrioventricular block, arrhythmias or signs of toxicity.
==== Hydralazine and isosorbide dinitrate (H-ISDN) ====
H-ISDN can be used as an alternative treatment when both ACI and ARBs are not tolerated in symptomatic HF patients with a LVEF ≤40%. When patients continue to have symptoms despite optimal treatment with β-blockers, ACEI, ARBs or aldosterone antagonists, adding H-ISDN should be considered as this may decrease the risk of death in these patients. (Class IIa recommendation, level of evidence B) Treatment with H-ISDN has proven to reduce hospital admission for worsening HF (Class IIa recommendation, level of evidence B) and improves ventricular function and exercise tolerance (Class IIa recommendation, level of evidence A). Contraindications for the use of H-ISDN are:
* Symptomatic hypotention
* Lupus syndrome
* Severe renal failure
The H-ISDN work by decreasing peripheral vascular resistance.
Possible side effects include symptomatic hypotension or drug-induced lupus-like syndrome.
==== Other ====
*Anticoagulants
*Anti platelet agents
*Statins
*Anti arrhythmic medication
*Calcium antagonists
=== Management of HF patients with preserved LVEF (HFPEF) ===
To date, no evidence exists of any treatment reducing morbidity or mortality in this patient group. With the aim to control water and sodium retention and decrease breathlessness and edema, diuretics are prescribed to HFPEF patients.


<div align="center">
<div align="center">
Line 473: Line 379:
|}
|}
</div>
</div>
== Management ==
The management of HF involves both pharmacological and non-pharmacological treatment. The emphasis is on the reduction in mortality and morbidity, prevention of the progression of HF, and the treatment of (non-)cardiovascular co-morbidities. Myocardial infarction (MI) is the most important cause of HF. Management of coronary disease is crucial in these patients, as revascularization of the myocardium will increase exercise capacity and survival.
Research shows that good adherence to medication is associated with a decrease in risk of death. <cite>Granger</cite> Nevertheless, the percentage of HF patients adhering to prescribed pharmacological and non-pharmacological treatment is as low as 20-60 % according to the literature <cite>Evangelista</cite> <cite>VanDerWal</cite>.
Treatment of diastolic- and systolic HF does not differ (vd wall). Non-pharmalogical treatment can be applied in every patient.
==== Non-pharmacological treatment ====
Although pharmacological treatment is usually emphasized, non-pharmacological management is of great importance for HF patients. It can have a significant impact on symptoms, functional capacity, wellbeing, morbidity, and prognosis. The most important non-pharmacological opinions are described below.
===== Education =====
Education of both the patient and their family about HF and its symptoms is important. The patient and/or the caregiver should be able to undertake appropriate actions such as adjusting the diuretic dose or contact the physician. (Class I recommendation, level of evidence C; see Table 4) Education on the importance  and (side) effects of medication should be provided to the patient in order to increase compliance. (Class I recommendation, level of evidence C)
===== Fluid and sodium restriction =====
In patients with severe symptoms of HF, restriction of fluid intake may be considered. (Class IIa recommendation, level of evidence C) Also, patients should be educated on salt content of food and minimize intake in order to prevent fluid retention. (Class I recommendation, level of evidence C)
===== Body weight =====
CHF patients should carefully monitor their body weight. A sudden increase in weight is a potential consequence of fluid retention and deterioration of HF. When patients notice a weight gain of >2kg in 3 days they should consult a physician. (Class I recommendation, level of evidence C) In obese patients (body mass index of > 30 kg/m2), weight reduction should be promoted to prevent progression of HF, decrease symptoms and improve the overall wellbeing of the patient. (Class IIa recommendation, level of evidence C) Also, attention should be paid to weight loss due to malnutrition which is frequently observed in severe HF. An altered metabolism, inflammatory mechanisms or a decreased food intake may be important factors in the pathophysiology of cardiac cachexia in HF. (Class I recommendation, level of evidence C)
===== Alcohol and tobacco =====
Alcohol intake should be minimized, as it may increase blood pressure and/or have a negative inotropic effect. (Class II a recommendation, level of evidence C) Smoking cessation should be encouraged. It is recommended that patients with HF receive support and advice on this topic. (Class I recommendation, level of evidence C). A reduction in alcohol and tobacco intake might also improve co-morbidities including sleep disorders.
===== Exercise =====
Exercise training is recommended to all chronic stable HF patients. Twenty years ago, exercise was strongly discouraged in patients with HF as the general conception was that it was harmful. Nowadays, numerous studies have shown the opposite. Rehabilitation programmes have shown to increase exercise capacity and health related quality of life and decrease hospitalization rates and symptoms. (Class I recommendation, level of evidence A)
===== Other =====
Other non-pharmacological treatment recommendations include immunization of HF patients (pneumococcal- and influenza vaccination should be considered), the consulting of a physician around pregnancy, the screening for depression and sleep disorders which require additional medical attention.
In conlusion, advices on lifestyle in general are very important. Yet, an extensive survey among HF patients showed that recall and adherence of lifestyle advice was disappointing <cite>Lainscak</cite>. Health professionals should make sure the patient is able the understand and recall the advice given. With the intention to support this, the European Society of Cardiology (ESC) initiated a website (2007) containing practical heart failure information for patients, families, and caregivers: www.heartfailurematters.org
=== Pharmacological treatment ===
[[File:Treatment_algorithm_as_proposed_in_the_ESC_guidelines_2008.png|thumb|right|Treatment algorithm as proposed in the ESC guidelines 2008]]
The treatment algorithm as proposed in the ESC guidelines 2008 are depicted in Figure 2. Patients for whom the medication is indicated,  mode of action, contraindications of the medication, and possible side effects included in this algorithm are discussed below.
Angiotensin-converting enzyme (ACE) inhibitors
ACE inhibitors are indicated for every HF patient with an EF ≤ 40 %, irrespective of symptoms. (Class I recommendation, level of evidence A) Contraindications for the use of ACE inhibitors are:
* History of angioedema
* Bilateral renal artery stenosis
* Serum potassium concentration > 5.0 mmol/L
* Serum creatine > 220 µmol/L
* Severe aortic stenosis
ACE inhibitors relieve the heart by decreasing the preload and afterload. This is achieved through two mechanisms. Firstly, conversion of angiotensin-I to angiotensin– II is inhibited, which reduces vasoconstriction and lowers BP. Secondly, production of aldosterone is decreased, as angiotensin II induces this production. Aldosterone increases blood volume and thus BP by stimulating sodium- and water retention.
Possible side effects are symptomatic hypotension (dizziness), hyperkalaemia, worsening renal function and cough. 
==== β-Blockers ====
β-Blockade is recommended for every symptomatic (NYHA class II-IV) HF patient with a LVEF ≤40% or asymptomatic patients with a LVEF ≤40% after a MI . (Class I recommendation, level of evidence A) Contraindications are:
* Asthma
* Second- or third degree heart block, sick sinus syndrome, sinus bradycardia
β-Blockers mainly exert their effect by lowering the cardiac output, perpherial vascular resistance and by influencing the renin-angiotensinsysteem. In addition, β-Blockers presumably compass the positive effect on mortality by lowering the chronic sympathic overstimulation.
Possible side effects include (symptomatic) hypotension, worsening of HF or bradycardia.
Diuretics (Aldosterone antagonists and angiotensin receptor blockers)
Diuretics reduce preload by venous vasodilatation and fluid secretion. As a result, filling pressures of the heart and the lung vasculature decreases and symptoms and signs decrease. (Class I recommendation, level of evidence B)
Aldosterone antagonists
Adding this drug to therapy is suggested for patients with severe symptomatic (NYHA class III or IV, refer to Table 2) HF and an LVEF < 35%. (Class I recommendation, level of evidence B) Contraindications:
* Serum potassium concentration > 5.0 mmol/L
* Serum creatine > 220 µmol/L
* Concomitant potassium sparing diuretic or potassium supplements
* Combination of an ACEI and ARB
By competing with aldosterone, the antagonists lower the blood pressure through reducing water and sodium retention.
Possible side effects include hyperkalaemia, worsening renal function, and breast tenderness and/or enlargement.
==== Angiotensin receptor blockers (ARBs) ====
In HF patients with a LVEF≤40% who remain symptomatic despite optimal ACEI en β-blocker treatment, use of ARBs is recommended. (Class I recommendation, level of evidence A). Contraindications are:
* Combination of an ACE inhibitor and an aldosterone antagonist
* Bilateral renal artery stenosis
* Serum potassium concentration > 5.0 mmol/L
* Serum creatine > 220 µmol/L
* Severe aortic stenosis
Possible side effects include symptomatic hypotension (dizziness), hyperkalaemia, and a worsening renal function.
==== Digoxine ====
For a long time digoxine, together with β-blockers, has been standard treatment in HF. Presumably, digoxine ameliorates contractility of the heart by increasing intracellular calcium and sodium concentrations. Nevertheless, in contradiction to other drugs (β-blockers , ACE inhibititors, ARBs) it has never proven to decrease mortality rates. Because of that reason, digoxine had to render its place in the treatment algorithm.
In patients with symptomatic HF and atrial fibrillation (AF) with a ventricular rate at rest of >80 beats per minute, use of digoxine may be considered to slow the ventricular rate. (Class I recommendation, level of evidence C)
In mild to severe symptomatic HF patients in sinus rhythm and with an LVEF ≤40% , digoxin (in addition to an ACEI) improves ventricular function and patient well-being, reduces hospital admission, but does not affect survival rates. (Class IIa recommendation, level of evidence B)
Contraindications for the use of digoxin are:
* Second- or third degree heart block without a permanent pacemaker, sick sinus syndrome
* Pre-exitation syndromes
Possible side effects include sinoatrial or atrioventricular block, arrhythmias or signs of toxicity.
==== Hydralazine and isosorbide dinitrate (H-ISDN) ====
H-ISDN can be used as an alternative treatment when both ACI and ARBs are not tolerated in symptomatic HF patients with a LVEF ≤40%. When patients continue to have symptoms despite optimal treatment with β-blockers, ACEI, ARBs or aldosterone antagonists, adding H-ISDN should be considered as this may decrease the risk of death in these patients. (Class IIa recommendation, level of evidence B) Treatment with H-ISDN has proven to reduce hospital admission for worsening HF (Class IIa recommendation, level of evidence B) and improves ventricular function and exercise tolerance (Class IIa recommendation, level of evidence A). Contraindications for the use of H-ISDN are:
* Symptomatic hypotention
* Lupus syndrome
* Severe renal failure
The H-ISDN work by decreasing peripheral vascular resistance.
Possible side effects include symptomatic hypotension or drug-induced lupus-like syndrome.
==== Other ====
*Anticoagulants
*Anti platelet agents
*Statins
*Anti arrhythmic medication
*Calcium antagonists
=== Management of HF patients with preserved LVEF (HFPEF) ===
To date, no evidence exists of any treatment reducing morbidity or mortality in this patient group. With the aim to control water and sodium retention and decrease breathlessness and edema, diuretics are prescribed to HFPEF patients.
{{clr}}
{{clr}}


NiloferT
467

edits

Retrieved from "https://www.textbookofcardiology.org/wiki/Special:MobileDiff/1153"