Congestive heart failure natural history

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Overview

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Risk calculators and risk factors for Congestive heart failure natural history

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Saleh El Dassouki, M.D. [3]; Atif Mohammad, M.D.

Overview

Heart failure is associated with significantly reduced physical and mental health, resulting in a markedly decreased quality of life.[1][2] Congestive heart failure is also associated with a poor prognosis. With the exception of heart failure caused by reversible conditions, the condition usually worsens with time. Although some people survive many years, progressive disease is associated with an overall annual mortality rate of 10%.[3] In the Framingham experience, 80% of men and 70% of women with heart failure who were under 65 years of age had died within 8 years of the diagnosis.

Complications

1. Cardiac Arrhythmias:

  • Ventricular tachycardia and ventricular fibrillation can occur as serious complications of heart failure when its pump function is severely impaired. This further worsens the cardiac output and even possible death.
  • Atrial fibrillation which is rapid beating of atrium without optimal forward pumping of blood is another complication of heart failure which occurs as a result of resistance to blood flow from atrium to ventricles. These patients are at increased risk of stroke.
  • Left bundle branch block is an abnormality in electrical conduction in the heart.

2. Pulmonary Congestion:

3. Angina and myocardial infarction: Cardiac ischemia and infarction can also occur when heart failure patients undergo exertion. With LV dilation, LV wall stress increases, and this increases the risk of angina. Autopsy studies demonstrate that plaque rupture and coronary thrombosis is a common mode of death in patients with congestive heart failure.

4. Renal failure: Renal impairment can occur secondary to decreased renal perfusion. This further worsens heart failure by fluid retention.

5. Cardiac cachexia: Unintentional rapid weight loss (a loss of at least 7.5% of normal weight within 6 months) can occur in chronic heart failure[5]. This is a bad prognostic factor.

Prognosis

Risk Stratification Tools

The prognosis in patients with heart failure can be assessed using a variety of risk stratification tools and cardiopulmonary exercise testing. Clinical prediction rules use a composite of clinical factors such as lab tests and blood pressure to estimate prognosis. Among several clinical prediction rules for assessing the prognosis in acute heart failure, the 'EFFECT rule' slightly outperformed other rules in stratifying patients and identifying those at low risk of death during hospitalization or within 30 days.[6] Other simpler methods for identifying low risk patients include the:

A very important method for assessing prognosis in advanced heart failure patients is cardiopulmonary exercise testing (CPX testing). CPX testing is usually required prior to heart transplantation as an indicator of prognosis. Cardiopulmonary exercise testing involves measurement of exhaled oxygen and carbon dioxide during exercise. The peak oxygen consumption (VO2 max) is used as an indicator of prognosis. As a general rule, a VO2 max less than 12-14 cc/kg/min indicates a poor survival and suggests that the patient may be a candidate for a heart transplant. Patients with a VO2 max<10 cc/kg/min have clearly poorer prognosis. The most recent International Society for Heart and Lung Transplantation (ISHLT) guidelines[7] also suggest two other parameters that can be used for evaluation of prognosis in advanced heart failure, the heart failure survival score and the use of a criterion of VE/VCO2 slope > 35 from the CPX test. The heart failure survival score is a score calculated using a combination of clinical predictors and the VO2 max from the cardiopulmonary exercise test.

Mortality Associated with Heart Failure

Based on the 44-year follow-up of the NHLBI’s Framingham Heart Study:

References

  1. Juenger J, Schellberg D, Kraemer S; et al. (2002). "Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables". Heart. 87 (3): 235–41. doi:10.1136/heart.87.3.235. PMC 1767036. PMID 11847161. Unknown parameter |month= ignored (help)
  2. Hobbs FD, Kenkre JE, Roalfe AK, Davis RC, Hare R, Davies MK (2002). "Impact of heart failure and left ventricular systolic dysfunction on quality of life: a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population". Eur. Heart J. 23 (23): 1867–76. doi:10.1053/euhj.2002.3255. PMID 12445536. Unknown parameter |month= ignored (help)
  3. Neubauer S (2007). "The failing heart — an engine out of fuel". N Engl J Med. 356 (11): 1140–51. doi:10.1056/NEJMra063052. PMID 17360992.
  4. Moussavian SN, Dincsoy HP, Goodman S, Helm RA, Bozian RC (1982). "Severe hyperbilirubinemia and coma in chronic congestive heart failure". Digestive Diseases and Sciences. 27 (2): 175–80. PMID 7075414. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  5. Freeman LM (2009). "The pathophysiology of cardiac cachexia". Current Opinion in Supportive and Palliative Care. 3 (4): 276–81. doi:10.1097/SPC.0b013e32833237f1. PMID 19797959. Retrieved 2011-04-30. Unknown parameter |month= ignored (help)
  6. Auble TE, Hsieh M, McCausland JB, Yealy DM (2007). "Comparison of four clinical prediction rules for estimating risk in heart failure". Annals of emergency medicine. 50 (2): 127–35, 135.e1–2. doi:10.1016/j.annemergmed.2007.02.017. PMID 17449141.
  7. Mandeep R. Mehra; et al. "Evaluation of listing criteria for cardiac transplantation". Journal of Heart and Lung Transplantation. Retrieved 8 April 2010.



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