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SOURCE

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Source: Parker RB, Nappi JM, Cavallari LH. Chronic heart failure. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146056207. Accessed December 7, 2016.

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CONDITION/DISORDER SYNONYMS

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  • Congestive heart failure (CHF)

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DEFINITION

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  • Progressive clinical syndrome that can result from abnormality in cardiac structure or function that impairs the ability of the ventricle to fill or eject with blood.

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ETIOLOGY

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  • Systolic Heart Failure (HFrEF)

    • Reduction in muscle mass (eg, myocardial infarction [MI])

    • Dilated cardiomyopathies.

    • Ventricular hypertrophy caused by pressure overload (eg, systemic or pulmonary hypertension, aortic or pulmonic valve stenosis) or volume overload (eg, valvular regurgitation, shunts, high-output states).

  • Diastolic Heart Failure (HFpEF)

    • Increased ventricular stiffness (eg, ventricular hypertrophy, infiltrative myocardial disease, myocardial ischemia and infarction)

    • Mitral or tricuspid valve stenosis.

    • Pericardial disease (eg, pericarditis, pericardial tamponade)

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PATHOPHYSIOLOGY

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  • HFrEF

    • Neurohormonal model:

      • An initiating event (eg, acute MI) leads to decreased cardiac output.

      • HF progression is mediated largely by neurohormones and autocrine/paracrine factors:

        • Angiotensin II

        • Norepinephrine.

        • Aldosterone.

        • Natriuretic peptides.

        • Arginine vasopressin.

        • Endothelin peptides.

        • Proinflammatory cytokines such as tumor necrosis factor α and endothelin-1.

  • HFpEF

    • Impaired myocardial relaxation or increased diastolic stiffness—ventrical is unable to accept blood from the venous system, does not fill at low pressure, or is unable to maintain normal stroke volume.

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EPIDEMIOLOGY

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  • Nearly 6 million Americans have HF and 800,000 new cases are diagnosed each year.

  • Incidence and prevalence of HF is expected to increase over the next few decades as the population ages.

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PREVENTION AND SCREENING

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  • Prevention involves identifying and modifying risk factors.

    • Smoking cessation.

    • Control of hypertension.

    • Control of diabetes mellitus.

    • Control of dyslipidemia.

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RISK FACTORS

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  • Coronary artery disease.

  • Hypertension.

  • Chronic kidney disease.

  • Smoking.

  • Certain drugs (eg, negative inotropes, cardiotoxic, NSAIDs)

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Symptoms:

    • Dyspnea on exertion.

    • Fatigue.

    • Exercise intolerance.

    • Orthopnea.

    • Paroxysmal nocturnal dyspnea.

    • Tachypnea.

    • Cough.

    • Nocturia.

    • Hemoptysis.

    • Abdominal pain.

    • Anorexia.

    • Poor appetite, early satiety.

    • Ascites.

    • Nausea.

    • Mental status changes.

    • Weight gain or loss.

  • Signs:

    • Crackles.

    • S3 gallop.

    • Pulmonary edema.

    • Cool extremities.

    • Cheyne–Stokes respiration.

    • Tachycardia.

    • Narrow pulse pressure.

    • Cardiomegaly.

    • Peripheral edema.

    • Jugular venous distention.

    • Hepatojugular reflux.

    • Hepatomegaly.

    • Venous stasis changes.

    • Lateral displacement of apical impulse.

    • Cachexia.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Consider HF diagnosis in patients with characteristic signs and symptoms; perform medical history and physical examination with appropriate laboratory testing.

  • New York Heart Association Functional Classification System.

    • I: No limitation of physical activity.

    • II: Slight limitation of physical activity.

    • III: Marked limitation of physical activity.

    • IV: Unable to carry on physical activity without discomfort.

  • American ...

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