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Heart Failure: Difference between revisions
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→Management of HF beyond medication
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==Management of HF beyond medication== | ==Management of HF beyond medication== | ||
[[Image:HF_prognosis_trials.svg|thumb|right|400px|Figure 9 Two-year mortality in landmark contemporary clinical heart failure trials (from Cleland et al)]] | |||
[[Image:CRT_flowchart.svg|thumb|400px|Figure 8 flowchart CRT]] | |||
===Device treatment=== | ===Device treatment=== | ||
Prevention of sudden death is an important goal in HF as approximately half of the deaths occur suddenly and many of these are related to ventricular arrhythmias. Implantable cardioverter-defibrillator (ICD) therapy is recommended in survivors of cardiac arrest , irrespective of EF, when life expectancy is >1 year. (Class I recommendation, level of evidence A). | Prevention of sudden death is an important goal in HF as approximately half of the deaths occur suddenly and many of these are related to ventricular arrhythmias. Implantable cardioverter-defibrillator (ICD) therapy is recommended in survivors of cardiac arrest , irrespective of EF, when life expectancy is >1 year. (Class I recommendation, level of evidence A). | ||
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===Timing of ICD implantation=== | ===Timing of ICD implantation=== | ||
Figure 5 offers recommendations to which patients should receive ICD treatment. In this flowchart, the timing of the placement has not been defined completely. In most patients, it should be safe to wait for their ICD whilst receiving (pharmalogical) treatment as events typically occur after 6-12 months. <cite>12</cite> In exception to this rule, in high risk patients (i.e. patients with major myocardial infarction (MI), extensive fibrosis on the MRI or NSVT despite optimal pharmalogical treatment), an ICD implantation should not be postponed too long. Early (within 40 days after event) ICD placement after an acute myocardial infarction has not been shown to reduce mortality, because the patients most at risk of sudden death are also the patients most at risk of death due to heart failure. <cite>13</cite><cite>14</cite><cite>15</cite> For this reason, prophylactic ICD treatment is recommended only after 40 days in post-infarct patients who have an EF < 35%. For non-ischemic heart failure patients, three months is considered a safe waiting time for an ICD. There are however also higher risk patients among them, and this should be a decision made for every patient individually.<cite>16</cite> | Figure 5 offers recommendations to which patients should receive ICD treatment. In this flowchart, the timing of the placement has not been defined completely. In most patients, it should be safe to wait for their ICD whilst receiving (pharmalogical) treatment as events typically occur after 6-12 months. <cite>12</cite> In exception to this rule, in high risk patients (i.e. patients with major myocardial infarction (MI), extensive fibrosis on the MRI or NSVT despite optimal pharmalogical treatment), an ICD implantation should not be postponed too long. Early (within 40 days after event) ICD placement after an acute myocardial infarction has not been shown to reduce mortality, because the patients most at risk of sudden death are also the patients most at risk of death due to heart failure. <cite>13</cite><cite>14</cite><cite>15</cite> For this reason, prophylactic ICD treatment is recommended only after 40 days in post-infarct patients who have an EF < 35%. For non-ischemic heart failure patients, three months is considered a safe waiting time for an ICD. There are however also higher risk patients among them, and this should be a decision made for every patient individually.<cite>16</cite> | ||
===Heart transplantation and Left Ventricular Assist Devices=== | ===Heart transplantation and Left Ventricular Assist Devices=== | ||
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===Prognosis=== | ===Prognosis=== | ||
The life expectancy of a patient with heart failure is determined by age, NYHA class, LVEF, normal level of sodium, systolic blood pressure, use of medication and use of ICD or CRT-D (Seattle Heart failure score). The mean yearly annual mortality is about 10%, varying from <6% per year when a normal LVEF is found, to > 14% per year with an EF of < 15%. | The life expectancy of a patient with heart failure is determined by age, NYHA class, LVEF, normal level of sodium, systolic blood pressure, use of medication and use of ICD or CRT-D (Seattle Heart failure score). The mean yearly annual mortality is about 10%, varying from <6% per year when a normal LVEF is found, to > 14% per year with an EF of < 15%. | ||
Trials with medication illustrate that the (short term) benefit of medication is highest when the NYHA class is higher (Figure 9).<cite>11</cite> | Trials with medication illustrate that the (short term) benefit of medication is highest when the NYHA class is higher (Figure 9).<cite>11</cite> | ||