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SOURCE

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.

CONDITION/DISORDER SYNONYMS

  • Congestive heart failure (CHF)

DEFINITION

  • 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.

ETIOLOGY

  • 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)

PATHOPHYSIOLOGY

  • 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.

EPIDEMIOLOGY

  • 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.

PREVENTION AND SCREENING

  • Prevention involves identifying and modifying risk factors.

    • Smoking cessation.

    • Control of hypertension.

    • Control of diabetes mellitus.

    • Control of dyslipidemia.

RISK FACTORS

  • Coronary artery disease.

  • Hypertension.

  • Chronic kidney disease.

  • Smoking.

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

CLINICAL PRESENTATION

SIGNS AND SYMPTOMS

  • 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.

DIAGNOSIS

MEANS OF CONFIRMATION AND DIAGNOSIS

  • 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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