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HEART FAILURE - CHRONIC
Heart failure is a clinical syndrome due to a structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood in order to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues.
Symptoms are caused by ventricular dysfunction secondary to abnormalities of the myocardium, pericardium, endocardium, valves, heart rhythm and conduction.
New onset heart failure refers to the first presentation of heart failure.
Transient heart failure refers to the symptomatic heart failure over a limited period of time although long-term therapy may be indicated.
Chronic heart failure is stable, worsening, or decompensated heart failure.

Diagnosis

  • Requires a thorough history and physical examination, identification of the etiology and risk factors, diagnostic examination of the cardiac structure and function

Development Stages of Heart Failure

Stage A

  • At risk for heart failure (HF) but without structural heart disease or symptoms of HF
    • Hypertension, atherosclerotic disease, diabetes, obesity, metabolic syndrome
    • Use of cardiotoxins
    • Family history of cardiomyopathies

Stage B

  • Structural heart disease but without signs or symptoms of HF
    • Previous myocardial infarction (MI), left ventricular (LV) remodelling including left ventricular hypertrophy (LVH) and low ejection fraction (EF), asymptomatic valvular disease

Stage C

  • Structural heart disease with prior or current symptoms of HF
    • Known structural heart disease
    • Shortness of breath (SOB), fatigue and decreased exercise tolerance

Stage D

  • Refractory HF
    • Marked symptoms at rest despite maximal medical therapy
    • Requires specialized interventions

Classification

Types of Heart Failure

Heart failure based on time-course

  • New onset heart failure
    • Refers to the first presentation
    • Acute or sub-acute onset
  • Transient heart failure
    • Refers to symptomatic heart failure over a limited period of time, although long-term therapy may be indicated
    • Recurrent or episodic

Chronic heart failure

  • Stable, worsening, or decompensated heart failure (HF)
  • Persistent

Heart failure based on left ventricular ejection fraction (LVEF)

  • Heart failure with preserved ejection fraction (EF) [diastolic HF]
    • with preserved systolic function; EF is defined as ≥50%
  • Heart failure with reduced EF (systolic HF)
    • EF is defined as <40%
  • Patients with an EF in the 40-49% range represent a ‘grey area’ and it is termed heart failure with mid-range EF
  • Further criteria for the diagnosis of HF with preserved and mid-range EF include presence of HF symptoms and/or signs, elevated levels of natriuretic peptides with at least 1 added criterion of either significant structural heart disease or diastolic dysfunction

Assessment

Presentation of Patients with Heart Failure

Decreased exercise tolerance

  • Dyspnea and/or fatigue occurring at rest or during exercise

Fluid retention

  • Complaints of leg or abdominal swelling as primary symptom
  • Impaired exercise tolerance not noticed by patient as it occurs gradually

No symptom or symptoms of another cardiac or other disease

  • Cardiac enlargement or dysfunction may be noted during their evaluation for a disease other than heart failure

History

  • Determine predisposition to risk factors especially in lifestyle (eg smoking, diet, alcohol consumption, substance abuse, and activities)
  • Review the past medical history
    • To identify possible cause of heart failure and presence of co-morbid illnesses (eg history of coronary artery disease or arterial hypertension)
    • Current or past standard or alternative therapies and chemotherapy (eg diuretic use, exposure to radiation or cardiotoxic drug)
  • Family history to determine familial predisposition to atherosclerotic disease, cardiomyopathy, conduction system, or tachyarrhythmias

Physical Examination

Assessment of Volume Status

  • Determines the need for diuretic treatment
  • Detects sodium excess or deficiency that may affect efficacy and reduce tolerability of drugs used to treat heart failure (HF)
  • At each visit, record the patient’s weight, vital signs especially blood pressure (BP) [sitting and standing] and other abnormal physical findings

Assessment of Functional Capacity

New York Heart Association (NYHA) Functional Classification in Patients with Heart Failure

  • Class I
    • Patient has no limitation of physical activity
    • Ordinary physical activity does not cause symptoms (eg palpitation, dyspnea or fatigue)
  • Class II
    • Patient has slight limitation of physical activity
    • They are comfortable at rest but ordinary physical activity produces symptoms
  • Class III
    • Patient has a marked limitation of physical activity
    • They are comfortable at rest but less than ordinary activity causes symptoms
  • Class IV
    • The patient is unable to carry out any physical activity without discomfort
    • Symptoms are present at rest and any physical activity will cause an increase in discomfort

Laboratory Tests

  • Lab testing will confirm the presence of heart failure (HF) and may show the presence of disorders that can lead to or exacerbate heart failure (HF)

Tests to consider in all patients

  • Initial evaluation includes, but is not limited to, the following:
    • Complete blood count (CBC), serum electrolytes (include sodium, potassium, calcium, and magnesium), blood urea nitrogen (BUN), creatinine (Cr)/estimated glomerular filtration rate (eGFR), albumin, cardiac enzymes, liver enzymes, bilirubin, ferritin, total iron-binding capacity (TIBC), blood lipids, blood glucose, international normalized ratio (INR), C-reactive protein (CRP), thyroid function, and urinalysis
  • 12-lead Electrocardiogram (ECG)
    • Most common findings are nonspecific repolarization abnormalities (ST-T wave changes)
    • Abnormalities are usually nonspecific [include left ventricular (LV) hypertrophy, Q wave, sinus tachycardia, and atrial fibrillation]
    • Conduction abnormalities may also be seen (eg left bundle branch block, first degree atrioventricular block, left anterior hemiblock, and nonspecific intraventricular conduction delays)
    • Information obtained can assist in treatment planning and is of prognostic importance
    • Normal ECG makes the diagnosis of heart failure due to LV systolic dysfunction less likely
  • Chest radiography (X-ray)
    • Useful to determine the heart size, presence of pulmonary congestion, detection of pulmonary and other diseases, and proper placement of implanted cardiac device
    • Normal chest x-ray does not exclude the diagnosis of heart failure (HF)
    • Common abnormal findings are pulmonary venous redistribution with upper lobe blood diversion
  • Transthoracic echocardiography
    • Most useful investigation performed immediately to confirm the diagnosis in patients suspected with heart failure
    • Evaluates cardiac structure and function (eg chamber volumes/sizes, ventricular systolic and diastolic function, wall thickness, and valvular structure and function), assists in treatment management, and obtains prognostic information
    • Excludes correctable causes of heart failure

Tests to consider in selected patients

  • Natriuretic peptides [B-type natriuretic peptide (BNP) ≥35 pg/mL, N-terminal pro B-type natriuretic peptide (NT-proBNP) ≥125 pg/mL, or mid-regional atrial natriuretic peptide (MR-proANP)]
    • Not performed routinely in clinical practice
    • Useful for differentiating dyspnea caused by heart failure from dyspnea due to other causes
    • Used in patients in whom the diagnosis of heart failure is uncertain and when an echocardiogram cannot be performed
    • Also helpful in establishing disease severity and obtaining prognostic information
    • Recommended biomarker to be used to screen high-risk patients for heart failure
  • Cardiac magnetic resonance imaging (CMRI)
    • Performed in select patients, it evaluates cardiac structure and function, measures left ventricular ejection fraction (LVEF), characterizes cardiac tissue especially in patients with inadequate echocardiographic images or where there are inconclusive or incomplete echocardiographic findings
    • Useful in the work-up of patients suspected with cardiomyopathy, arrhythmias, cardiac tumors or cardiac involvement by a tumor, pericardial disease, and complex congenital heart disease
  • Coronary angiography
    • Recommended in patients with angina pectoris, who are suitable for coronary revascularization, to evaluate the coronary anatomy
    • Also considered in patients with evidence of reversible myocardial ischemia on non-invasive testing, especially if the ejection fraction is decreased
  • Cardiac catheterization
    • Considered in patients who are being evaluated for heart transplantation or mechanical circulatory support
    • Evaluates the cardiac function and pulmonary arterial resistance
  • Myocardial perfusion/ischemia imaging [eg echocardiography, CMRI, single photon emission computed tomography (SPECT), or positron emission tomography (PET)]
    • Alternative imaging modality in patients with unsatisfactory echocardiographic findings or when the degree of LVEF influences treatment management
    • Considered in patients who are suspected to have coronary artery disease (CAD) and who are suitable for coronary revascularization
  • Exercise testing
    • Detects reversible myocardial ischemia
    • Used in the objective evaluation of exercise capacity and exertional symptoms to aid in prescribing an exercise training program
    • Also used for evaluating patients for heart transplantation and mechanical circulatory support and to obtain prognostic information
  • Endomyocardial biopsy
    • May be indicated rarely in patients with dilated cardiomyopathy with recent onset of symptoms, and where heart failure has been excluded by angiography
    • May also be used in patients with rapidly progressive clinical heart failure or ventricular dysfunction despite appropriate medical treatment and those who are suspected of having myocarditis or infiltrative diseases (eg amyloidosis)
  • Spirometry and pulmonary function test
    • Assess the potential contribution of lung disease to the patient’s dyspnea
    • Demonstrate or exclude concomitant smoking related or other respiratory causes of airway limitation
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