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LEARNING OBJECTIVE

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  1. Conduct a comprehensive follow-up visit for a patient with heart failure using appropriate history-taking techniques, physical examination, and laboratory tests. The visit includes assessment of disease control, assessment and support of compliance with lifestyle modifications and medication regimens, plus evaluate patients for complications from the disease and medication regimen.

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INTRODUCTION

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Heart failure (HF), also known as congestive or chronic heart failure, is a significant complication of essential hypertension and atherosclerotic cardiovascular disease. In 2010, more than 6 million people had a diagnosis of heart failure. Pharmacists in a primary care or disease management role routinely assist patients in managing their diabetes, hypertension, and dyslipidemia, all contributing factors to the development of heart failure as a complication of their chronic diseases. Therefore, it is important for pharmacists to understand the clinical course and pathophysiology and to be able to identify signs and symptoms of heart failure.

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ETIOLOGY

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President Franklin D. Roosevelt suffered from severe hypertension. During World War II, he developed congestive heart failure as a complication of his uncontrolled hypertension and eventually died of a massive stroke. In his time, hypertension was almost the sole cause of congestive heart failure. However, as we developed drugs to treat hypertension and focused on controlling elevated blood pressure, it became apparent that heart failure had multiple causes. While more than three-fourths of all patients with HF have a history of hypertension, it is now known that heart failure is a complex syndrome where any structural or functional cardiac damage can impair the ability of the ventricles to fill with or eject blood. Heart failure is the result of continual overactivation of the sympathetic nervous system, the renin-angiotensin-aldosterone (RAA) system, as well as the release of other neurohormones, such as B-type natriuretic peptide (BNP), all of which contribute to the pathophysiology of heart failure. The terms preload and afterload are frequently used when discussing heart failure and other cardiovascular diseases. Preload is defined as the amount of blood presented to the heart for pumping. Preload is increased in heart failure. Diuretics, a mainstay of the treatment of heart failure, decrease blood volume presented to the heart for pumping and, therefore, decrease preload. Afterload is defined as the amount of peripheral resistance the heart pumps blood against, i.e. arterial hypertension. Afterload is generally increased in heart failure in the form of hypertension. Many antihypertensives decrease afterload through their effects on reducing peripheral resistance caused by the sympathetic and RAA systems. This combination of increased preload and afterload in heart failure causes a cyclical worsening of heart failure. Both the sympathetic and RAA systems cause remodeling of the ventricles, which eventually leads to left ventricular enlargement, and ventricular wall stiffness and reduced cardiac output.

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Patients with heart failure are currently classified as having systolic or diastolic cardiac dysfunction based on left ventricular ejection fraction (LVEF). In both types of heart ...

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