Heart failure

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An anciently-recognised disease now regarded as more complicated and less certain. Not a certifiable cause of death as a mode of dying rather than a cause

The purpose of the heart is to pump blood to the tissues, which is equivalent to delivering oxygen. If it is not capable of meeting the demand, then it is probably failing.

Contents

Epidemiology

Over a third of acutely hospitalised patients with heart failure have atrial fibrillation or flutter, over another third have valvular disease and a quarter have dilated cardiomyopathy. Over a third have new onset heart failure, with about 40% of these new onset cases due to acute coronary syndrome. In-hospital mortality is 6.7%. On echocardiography it is possible to demonstrate some degree of mitral regurgitation in 80% [1]! There is a marked mortality gradient in terms of simply asking if a patient is poorly perfused or congested at presentation with good perfusion being the key good prognostic factor[2].

Diagnosis

Historically heart failure was a diagnosis, or group of diagnoses, made clinically. After some centuries technical aids, starting with the chest xray were introduced.

Paroxysmal nocturnal dyspnoea and orthopnoea suggest left sided heart failure with pulmonary oedema. Peripheral oedema suggests right-sided failure, congestive heart failure. Other causes of these and of reduced work capacity or effort tolerance exist.


Clinical diagnosis of heart failure in the community or ambulant patient does not correspond excellently well with the results of advanced investigations such as echocardiography or measurement of B-type natriuretic peptide (BNP). The later is increasingly going to be used in the community and acute diagnosis of this condition.

Pathogenesis

Treatment

Understand the cause. Its a bit embarrassing to miss beriberi or thyrotoxicosis. Even heart failure with iron deficiency has been shown to respond to ferric carboxymaltose iv[3] but for all we know any iron replacemant will do. The great advance in modern treatment of clinical acute heart failure was the introduction of potent diuretics. Later more subtle means of altering the circulation are actually more effective, but not so convincingly rapidly life-saving. Interestingly in chronic heart failure the only diuretics shown to be beneficial with respect to survival are spironolactone and its analogue eplerenone but evidence-based medicine will always attract such gems.


We may modify the homeostasis of the CVS; the preload and afterload and to some extent the pumping ability of the heart in various ways. As these multiplied more specialist involvement has occurred, in due course migration back to primary care may be expected with increased understanding of the conditions.

For patients with end stage heart failure refractory to medical treatment, surgical options include heart transplantation, mechanical circulatory support, and ventricular reconstruction . Other treatments such as cell therapy are being tried[4].

The optimal management of common heart failure presentations is well understood and will not be reproduced here as free high quality guidelines such as those from NICE should be familiar to all doctors in relevant clinical practice. ACE inhibitors have a major role where left ventricular dysfunction is present. Diuretics are important to relieve symptoms in many presentations. Only points not clear from such guidelines due to subsequent research will be mentioned here.

  • Benefit from betablockers in terms of mortality from heart failure is confined to patients in sinus rhythm[5]. Patients in atrial fibrillation and heart failure might benefit from other rate control options such as digoxin.

More reading

On Ganfyd see also

Guidelines are freely accessible and cover acute and chronic heart failure much better than Ganfyd can presently manage. See:


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References

  1. Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Follath F, Harjola VP, Hochadel M, Komajda M, Lassus J, Lopez-Sendon JL, Ponikowski P, Tavazzi L. EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population. European heart journal. 2006 Nov; 27(22):2725-36.(Link to article – subscription may be required.)
  2. Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH, Stevenson LW. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. Journal of the American College of Cardiology. 2003 May 21; 41(10):1797-804.
  3. Anker SD, Comin Colet J, Filippatos G, Willenheimer R, Dickstein K, Drexler H, Lüscher TF, Bart B, Banasiak W, Niegowska J, Kirwan BA, Mori C, von Eisenhart Rothe B, Pocock SJ, Poole-Wilson PA, Ponikowski P. Ferric carboxymaltose in patients with heart failure and iron deficiency. The New England journal of medicine. 2009 Dec 17; 361(25):2436-48.(Link to article – subscription may be required.)
  4. Patel AN, Henry TD, Quyyumi AA, Schaer GL, Anderson RD, Toma C, East C, Remmers AE, Goodrich J, Desai AS, Recker D, DeMaria A. Ixmyelocel-T for patients with ischaemic heart failure: a prospective randomised double-blind trial. Lancet (London, England). 2016 Jun 11; 387(10036):2412-21.(Link to article – subscription may be required.)
  5. Kotecha D, Holmes J, Krum H, Altman DG, Manzano L, Cleland JG, Lip GY, Coats AJ, Andersson B, Kirchhof P, von Lueder TG, Wedel H, Rosano G, Shibata MC, Rigby A, Flather MD. Efficacy of β blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis. Lancet. 2014 Dec 20; 384(9961):2235-43.(Link to article – subscription may be required.)
  6. Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, Strömberg A, van Veldhuisen DJ, Atar D, Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG, Swedberg K, Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL, Tendera M, Auricchio A, Bax J, Böhm M, Corrà U, Della Bella P, Elliott PM, Follath F, Gheorghiade M, Hasin Y, Hernborg A, Jaarsma T, Komajda M, Kornowski R, Piepoli M, Prendergast B, Tavazzi L, Vachiery JL, Verheugt FW, Zamorano JL, Zannad F. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). European heart journal. 2008 Oct; 29(19):2388-442.(Link to article

This article is a work in progress. Please feel free to contribute to it.