Heart Failure

Diagnosis and Management of Heart Failure: IntroductionIn the classic text Diseases of the Heart published in 1933,1 Sir Thomas Lewis identified the diagnosis and management of chronic heart failure as the cardinal problem in clinical cardiology. This observation is relevant today, because heart failure represents one of the most rapidly growing and costly forms of cardiovascular disease. Asdiscussed in Chap. 25, both the incidence and prevalence of heart failure are substantial and rising, because heart failure remains a principal complication of virtually every form of heart disease. Moreover, heart failure is associated with high rates of morbidity, mortality, and economic cost. For example, it is estimated that at any time 30 to 40 percent of heart failure patients are judged to bein New York Heart Association (NYHA) functional class III or IV, indicating an advanced degree of disability.2 Readmission rates for heart failure remain high, and 5-year mortality ranges from 15 percent for those with asymptomatic disease to more than 50 percent in patients with advanced heart failure.3–6 A sound understanding of the pathophysiology of the disease (as reviewed in Chap. 24) alongwith a systematic approach to the evaluation and management of heart failure (presented in this chapter) results in improved patient outcomes.The current evaluation and management of patients with chronic systolic heart failure has a large evidence base. Recommendations for its treatment are supported by numerous randomized controlled trials or by substantial clinical and observational experience.Several national and international guidelines directing the evaluation and management of chronic systolic heart failure in adults have been published.7–10 In contrast, the treatment of diastolic heart failure remains largely empirical and is directed toward controlling symptoms by reducing ventricular filling pressures without reducing cardiac output. The treatment of acute, worsening, or rapidlydecompensated heart failure has been inadequately studied. Although published guidelines address the management of decompensated heart failure, recommendations are generally based on consensus expert opinion rather than randomized controlled trials.7–11 |

General Principles of ManagementHeart failure should be prevented through the early treatment of risk factors and, when present,asymptomatic left ventricular (LV) dysfunction. The first revision to the 1995 American College of Cardiology/American Heart Association Guideline for the Evaluation and Management of Heart Failure developed a framework for heart failure prevention.12 This guideline, published in November 200112 and updated in September 2005,7 views heart failure as a continuum beginning with risk factors and culminating inend-stage or refractory disease. According to these guidelines, there are known risk factors and structural prerequisites leading to the development of LV systolic and/or diastolic dysfunction and the clinical syndrome of heart failure.The guideline proposes four stages describing the progression of heart failure (Table 26–1).7 Stage A describes patients who exhibit one or more risk factors forthe development of heart failure. If inadequately treated, these risk factors, such as hypertension, diabetes, and coronary artery disease, frequently lead to the development of a structural abnormality of the heart. Stage B is defined by the development of such a structural abnormality of the heart but no symptoms of heart failure. This is the true asymptomatic or never been symptomatic stage ofcardiovascular disease progression to heart failure. Examples of progression from stage A to stage B include the development of LV hypertrophy in the hypertensive subject or the onset of a LV wall motion abnormality and reduced ejection fraction (EF) in the coronary artery disease patient following myocardial infarction (MI). Stage C is heralded by the onset of symptoms related to heart failure,...