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Heart Failure: Difference between revisions
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===Management=== | ===Management=== | ||
[[Image:Image1.jpg|thumb|400px|Figure 3 management in heart failure.]] | |||
When a patient presents with symptoms of heart failure, it is worthwhile to have a dedicated diagnostic and therapeutic plan, in the order as indicated below (Figure 3). Clinical aspects are important for diagnosis, but the final diagnosis is only made after objective evidence of heart dysfunction. | When a patient presents with symptoms of heart failure, it is worthwhile to have a dedicated diagnostic and therapeutic plan, in the order as indicated below (Figure 3). Clinical aspects are important for diagnosis, but the final diagnosis is only made after objective evidence of heart dysfunction. | ||
==Clinical aspects== | ==Clinical aspects== | ||
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|colspan="2"|'''''Severity based on symptoms and physical activity''''' | |colspan="2"|'''''Severity based on symptoms and physical activity''''' | ||
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|'''Class I''' | |width="20%"|'''Class I''' | ||
|No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea. | |No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea. | ||
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|Pericardium | |Pericardium | ||
|Effusion, haemopericardium, calcification | |Effusion, | ||
haemopericardium, | |||
calcification | |||
|Consider tamponade, | |Consider tamponade, | ||
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#Assess ischemia: are there indications of ischemic etiology (ECG: Q’s or significant and changing ST segments, laboratory: troponins, and echocardiogram: segmental wall motion abnormality in coronary territory areas) ? If yes, then proceed with further coronary artery or myocardial perfusion imaging. | #Assess ischemia: are there indications of ischemic etiology (ECG: Q’s or significant and changing ST segments, laboratory: troponins, and echocardiogram: segmental wall motion abnormality in coronary territory areas) ? If yes, then proceed with further coronary artery or myocardial perfusion imaging. | ||
#Are there no indications for ischemic etiology? | #Are there no indications for ischemic etiology? | ||
*Classify phenotype of cardiomyopathy: dilated, hypertrophic, restrictive, arrhytmogenic right ventricular cardiomyopathy. | #*Classify phenotype of cardiomyopathy: dilated, hypertrophic, restrictive, arrhytmogenic right ventricular cardiomyopathy. | ||
*Then assess with additional laboratory tests, including creatinin kinase, autoimmune markers, eosinophilia, ferritin and iron saturation. In some suspected cases: calcium and albumin. | #*Then assess with additional laboratory tests, including creatinin kinase, autoimmune markers, eosinophilia, ferritin and iron saturation. In some suspected cases: calcium and albumin. | ||
*Look for clues of etiologies: history, family history (including maternal inheritage of diabetes in a family) | #*Look for clues of etiologies: history, family history (including maternal inheritage of diabetes in a family) | ||
*In case of fever look for infectious etiology, MRI confirmation for possible myocarditis, plasma serology. | #*In case of fever look for infectious etiology, MRI confirmation for possible myocarditis, plasma serology. | ||
*Look for clues on ECG: microvoltage on the ECG, AV block in combination with later atrial fibrillation. Additional lab may be warranted (monoclonal proteins in case of microvoltage in the presence of sufficient amounts of myocardium and the absence of pericardial fluid or pulmonary emphysema) | #*Look for clues on ECG: microvoltage on the ECG, AV block in combination with later atrial fibrillation. Additional lab may be warranted (monoclonal proteins in case of microvoltage in the presence of sufficient amounts of myocardium and the absence of pericardial fluid or pulmonary emphysema) | ||
*MRI for further classification of cardiomyopathy and assessment of presence and localization of delayed contrast enhancement | #*MRI for further classification of cardiomyopathy and assessment of presence and localization of delayed contrast enhancement | ||
*Coronary arteriography or coronary CT scan to exclude coronary artery disease | #*Coronary arteriography or coronary CT scan to exclude coronary artery disease | ||
*Myocardial biopsy in cases where the suspicion of severe underlying disease is high (e.g. fulminant myocarditis, sarcoidosis suspicion on MRI with no other organ involved). | #*Myocardial biopsy in cases where the suspicion of severe underlying disease is high (e.g. fulminant myocarditis, sarcoidosis suspicion on MRI with no other organ involved). | ||
*Genetic testing after counseling | #*Genetic testing after counseling | ||
==Therapy of heart failure== | ==Therapy of heart failure== | ||
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|Start:::2.5-5mg | |Start:::2.5-5mg | ||
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|1<sup>st</sup> week:::2.5-5mg b.i.d. | |1<sup>st</sup> week:::2.5-5mg b.i.d. | ||
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