Heart Failure: Difference between revisions

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===== Physical examination =====

There are several key features in the clinical examination of a patient presenting with HF, and these include observation, palpitation and auscultation. The physical examination should focus on the general appearance of the patient, pulse and blood pressure, signs of fluid overload (increased jugular venous pressure, peripheral oedema, ascites and hepatomegaly), the lungs, and the heart (apex, Gallop rhythm, third heart sound, murmurs).

===== Additional diagnostic test =====

In order to assist in diagnosing HF and differentiate between causes, the following modalities are available.  

===== Electrocardiogram =====

In every patient suspected of HF, an electrocardiogram (ECG) should be performed. Several common abnormalities (including possible causes) indicative of HF on the ECG include but are not limited to; sinus tachy- or bradycardia, atrial tachycardia, -flutter, or –fibrillation, ventricular arrhythmias, ischemia (including myocardial infarction), abnormal Q waves, left ventricular hypertrophy, micro voltages, and QRS length >120 ms. Allthough an abnormal ECG (exluding arrhythmias) has a low positive predictive value for HF, a normal ECG is highly indicative of the absence of HF.

===== Chest X-ray =====

A chest X-ray is a part of the standard examination in potential HF patients. Importantly, the x-ray is a tool to detect cardiomegaly or other possible cues that indicate HF. Also, it is important to rule out other causes of dyspnoea.  

===== Echocardiography =====

Echocardiography is the cornerstone in diagnosing HF, and should routinely be performed, because ventricular function can be evaluated accurately with this technique. It can provide objective evidence of a structural or functional abnormality of the heart at rest besides signs and symptoms typical of heart failure. Important parameters that can be assessed include but are not limited to wall motion, valve function, and left ventricular ejection fraction and diastolic function. Diastolic dysfunction might be an important finding in symptomatic patients with a preserved ejection fraction. Please refer to Table 3 for common echocardiographic findings in HF. Transoesophageal echocardiography is indicated in patients with an inadequate thansthoracic echo window, suspected endocarditis, complicated valvular disease or to exclude a LV thrombus. If echocardiography provides inadequate information or in patients with suspected coronary artery disease, additional imaging includes CT scanning, cardiac magnetic resonance imaging or radionuclide imaging.

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===== Laboratory tests =====

A standard blood assessment covers a complete blood count. Electrolytes, renal function, glucose and liver function. Furthermore, an urinalysis complete and other tests depending on the clinical condition complete the laboratory assessment.  For example, cardiac troponins must be sampled if an ACS is in the differential diagnosis. In patients suspected of HF, values of natriuretic peptides  atrial natriuretic peptide (ANP), N-terminal  ANP (NT-ANP), B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) can provide important information regarding diagnosis, management and prognosis of HF. Natriuretic peptides are enzymes, secreted by the atria or ventricles in response to myocardial wall stress. ANP and NT-ANP are secreted primarily by the atria, BNP and NT-proBNP mainly by the ventricles. These values are used for evaluating prognosis in patients with known HF, for defining medication dose, and for making a diagnosis in patients suffering shortness of breath. Especially for the last mentioned group, peptide counts can help differentiate between pulmonary- or cardiac problems when they present in the emergency room.  

===== Exercise test =====

This test is usually performed on a treadmill or on an ergo meter. The patient is asked to give maximal effort while the work load gradually increases. During the test, ECG is constantly monitored for ischemia. When possible, oxygen consumption should be measured during the test. Not only is an oxygen consumption test a good tool to discriminate between lung- peripheral- or heart problems, the obtained maximal oxygen uptake (VO2-max) also has an important prognostic value.  

===== 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).

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.  

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

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

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)

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

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

=== 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.  

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