Falla Cardiaca Cronica

543

CHAPTER

28 Management of Heart Failure Patients with Reduced Ejection Fraction
Douglas L. Mann
MANAGEMENT OF PATIENTS WITH SYMPTOMATIC AND ASYMPTOMATIC HEART FAILURE, 549 Transient Left Ventricular Dysfunction, 549 Defining the Appropriate Strategy, 549 General Measures, 550 Management of Fluid Status, 551 Preventing Disease Progression, 558 Management of Patients Who RemainSymptomatic, 564 Management of Atherosclerotic Disease, 565 Special Populations, 565 Anticoagulation and Antiplatelet Therapy, 566 Management of Cardiac Arrhythmias, 566 Device Therapy, 566 Sleep-Disordered Breathing, 566 Disease Management, 567 Patients with Refractory End-Stage Heart Failure (Stage D), 568 FUTURE PERSPECTIVES, 568 REFERENCES, 568 GUIDELINES, 569

EPIDEMIOLOGY, 543 CAUSATIVE FACTORS,543 PROGNOSIS, 544 APPROACH TO THE PATIENT, 547 Stages of Heart Failure, 547

Epidemiology
The worldwide prevalence and incidence rates of heart failure (HF) are approaching epidemic proportions, as evidenced by the relentless increase in the number of HF hospitalizations, the growing number of HF-attributable deaths, and the spiraling costs associated with the care of HF patients. Worldwide, HFaffects almost 23 million people. In the United States, HF affects approximately 4.7 million persons (1.5% to 2% of the total population), with approximately 550,000 incident cases of HF diagnosed annually. Estimates of the prevalence of symptomatic HF in the general European population is similar to that in the United States, and ranges from 0.4% to 2%.1 The prevalence of HF follows anexponential pattern, rising with age, and affects 6% to 10% of people older than 65 years (Fig. 28-1). Data from the Framingham Heart Study suggest that the overall incidence of HF has declined among women but not among men.2 However, although the relative incidence of HF is lower in women than in men, women constitute at least 50% of cases of HF because of their longer life expectancy. In North America andEurope, the lifetime risk of developing HF is approximately one in five for a 40-year-old. The overall prevalence of HF is thought to be increasing, in part because our current therapies of cardiac disorders, such as myocardial infarction, valvular heart disease, and arrhythmias, are allowing patients to survive longer. Very little is known with respect to the prevalence or risk of developing HFin emerging nations because of the lack of population-based studies in these countries.3 Although HF was once thought to arise primarily in the setting of a depressed left ventricular ejection fraction (LVEF), epidemiologic studies have shown that approximately 50% of patients who develop HF have a normal or preserved EF (EF > 40% to 50%). Accordingly, HF patients are now broadly categorized intoone of two groups: (1) HF with a reduced (depressed) EF commonly referred to , as systolic failure; or (2) HF with a preserved EF commonly referred , to as diastolic failure. The epidemiology of HF with a normal EF is discussed in Chap. 30. Based on population-attributable risks, hypertension has the greatest impact on the development of HF accounting for 39% of HF events , in men and 59% inwomen. Despite its much lower prevalence in the population (3% to 10%), myocardial infarction also has a high attributable risk in men (34%) and women (13%).Valvular heart disease only accounted for 7% to 8% of HF (Table 28-1). Dyslipidemia characterized by a high total high-density lipoprotein (HDL) cholesterol ratio, but not the total cholesterol alone, was also a risk factor for the development ofHF .

Studies from the Framingham Study have suggested that obesity is a potential risk factor for the development of HF in men and women (Fig. 28-2).4 However, although obesity is a risk factor for the development of HF obese patients with HF seem to have a more favorable , clinical prognosis. The association between obesity, a traditional cardiovascular risk factor, and improved clinical...