Case Report (CHF ec CAD)

CHAPTER I

Heart failure is the pathophysiologic state in which the heart, via an abnormality of cardiac
function (detectable or not), fails to pump blood at a rate commensurate with the
requirements of the metabolizing tissues or is able to do so only with an elevated diastolic
filling pressure.
Heart failure (see the images below) may be caused by myocardial failure but may also occur
in the presence of near-normal cardiac function under conditions of high demand. Heart
failure always causes circulatory failure, but the converse is not necessarily the case, because
various noncardiac conditions (eg, hypovolemic shock, septic shock) can produce circulatory
failure in the presence of normal, modestly impaired, or even supranormal cardiac function.
To maintain the pumping function of the heart, compensatory mechanisms increase blood
volume, cardiac filling pressure, heart rate, and cardiac muscle mass. However, despite these
mechanisms, there is progressive decline in the ability of the heart to contract and relax,
resulting in worsening heart failure.
Signs and symptoms of heart failure include tachycardia and manifestations of venous
congestion (eg, edema) and low cardiac output (eg, fatigue). Breathlessness is a cardinal
symptom of left ventricular (LV) failure that may manifest with progressively increasing
severity.
Heart failure can be classified according to a variety of factors (see Heart Failure Criteria and
Classification). The New York Heart Association (NYHA) classification for heart failure
comprises 4 classes, based on the relationship between symptoms and the amount of effort
required to provoke them, as follows[4] :

Class I patients have no limitation of physical activity

Class II patients have slight limitation of physical activity

Class III patients have marked limitation of physical activity

Class IV patients have symptoms even at rest and are unable to carry on any physical
activity without discomfort

The American College of Cardiology/American Heart Association (ACC/AHA) heart failure

guidelines complement the NYHA classification to reflect the progression of disease and are
divided into 4 stages, as follows[5, 6] :

Stage A patients are at high risk for heart failure but have no structural heart disease or
symptoms of heart failure
Stage B patients have structural heart disease but have no symptoms of heart failure

Stage C patients have structural heart disease and have symptoms of heart failure

Stage D patients have refractory heart failure requiring specialized interventions

Laboratory studies for heart failure should include a complete blood count (CBC),
electrolytes, and renal function studies. Imaging studies such as chest radiography and 2dimensional echocardiography are recommended in the initial evaluation of patients with
known or suspected heart failure. B-type natriuretic peptide (BNP) and N-terminal pro-Btype natriuretic peptide (NT-proBNP) levels can be useful in differentiating cardiac and
noncardiac causes of dyspnea. (See the Workup Section for more information.)
In acute heart failure, patient care consists of stabilizing the patient's clinical condition;
establishing the diagnosis, etiology, and precipitating factors; and initiating therapies to
provide rapid symptom relief and survival benefit. Surgical options for heart failure include
revascularization procedures, electrophysiologic intervention, cardiac resynchronization
therapy (CRT), implantable cardioverter-defibrillators (ICDs), valve replacement or repair,
ventricular restoration, heart transplantation, and ventricular assist devices (VADs). (See the
Treatment Section for more information.)
The goals of pharmacotherapy are to increase survival and to prevent complications. Along
with oxygen, medications assisting with symptom relief include diuretics, digoxin, inotropes,
and morphine. Drugs that can exacerbate heart failure should be avoided (nonsteroidal antiinflammatory drugs [NSAIDs], calcium channel blockers [CCBs], and most antiarrhythmic
drugs). (See the Medication Section for more information.)

United States statistics

According to the American Heart Association, heart failure affects nearly 5.7 million
Americans of all ages[30] and is responsible for more hospitalizations than all forms of cancer
combined. It is the number 1 cause of hospitalization for Medicare patients. With improved
survival of patients with acute myocardial infarction and with a population that continues to
age, heart failure will continue to increase in prominence as a major health problem in the
United States.[31, 32, 33, 34]
Analysis of national and regional trends in hospitalization and mortality among Medicare
beneficiaries from 1998-2008 showed a relative decline of 29.5% in heart failure
hospitalizations[35] ; however, wide variations are noted between states and races, with black
men having the slowest rate of decline. A relative decline of 6.6% in mortality was also
observed, although the rate was uneven across states. The length of stay decreased from 6.8
days to 6.4 days, despite an overall increase in the comorbid conditions.[35]
Heart failure statistics for the United States are as follows:

Heart failure is the fastest-growing clinical cardiac disease entity in the United States,
affecting 2% of the population
Heart failure accounts for 34% of cardiovascular-related deaths[30]

Approximately 670,000 new cases of heart failure are diagnosed each year[30]

About 277,000 deaths are caused by heart failure each year[30]

Heart failure is the most frequent cause of hospitalization in patients older than 65
years, with an annual incidence of 10 per 1,000[30]

Rehospitalization rates during the 6 months following discharge are as much as

50%[36]

Nearly 2% of all hospital admissions in the United States are for decompensated heart
failure, and the average duration of hospitalization is about 6 days

In 2010, the estimated total cost of heart failure in the United States was $39.2 billion,
[37]
representing 1-2% of all health care expenditures

The incidence and prevalence of heart failure are higher in blacks, Hispanics, Native
Americans, and recent immigrants from developing nations, Russia, and the former Soviet
republics. The higher prevalence of heart failure in blacks, Hispanics, and Native Americans
is directly related to the higher incidence and prevalence of hypertension and diabetes. This
problem is particularly exacerbated by a lack of access to health care and by substandard
preventive health care available to the most indigent of individuals in these and other groups;
in addition, many persons in these groups do not have adequate health insurance.
The higher incidence and prevalence of heart failure in recent immigrants from developing
nations are largely due to a lack of prior preventive health care, a lack of treatment, or
substandard treatment for common conditions, such as hypertension, diabetes, rheumatic
fever, and ischemic heart disease.
Men and women have the same incidence and the same prevalence of heart failure. However,
there are still many differences between men and women with heart failure, such as the
following:

Women tend to develop heart failure later in life than men do

Women are more likely than men to have preserved systolic function

Women develop depression more commonly than men do

Women have signs and symptoms of heart failure similar to those of men, but they are
more pronounced in women

Women survive longer with heart failure than men do

The prevalence of heart failure increases with age. The prevalence is 1-2% of the population
younger than 55 years and increases to a rate of 10% for persons older than 75 years.
Nonetheless, heart failure can occur at any age, depending on the cause.

International statistics
Heart failure is a worldwide problem. The most common cause of heart failure in
industrialized countries is ischemic cardiomyopathy, with other causes, including Chagas
disease and valvular cardiomyopathy, assuming a more important role in developing
countries. However, in developing nations that have become more urbanized and more
affluent, eating a more processed diet and leading a more sedentary lifestyle have resulted in
an increased rate of heart failure, along with increased rates of diabetes and hypertension.
This change was illustrated in a population study in Soweto, South Africa, where the
community transformed into a more urban and westernized city, followed by an increase in
diabetes, hypertension, and heart failure.[38]

In terms of treatment, one study showed few important differences in uptake of key therapies
in European countries with widely differing cultures and varying economic status for patients
with heart failure. In contrast, studies of sub-Saharan Africa, where health care resources are
more limited, have shown poor outcomes in specific populations.[39, 40] For example, in some
countries, hypertensive heart failure carries a 25% 1-year mortality rate, and human
immunodeficiency virus (HIV)associated cardiomyopathy generally progresses to death
within 100 days of diagnosis in patients who are not treated with antiretroviral drugs.
While data regarding developing nations are not as robust as studies of Western society, the
following trends in developing nations are apparent:

Causes tend to be largely nonischemic

Patients tend to present at a younger age

Outcomes are largely worse where health care resources are limited

Isolated right heart failure tends to be more prominent, with a variety of causes having
been postulated, ranging from tuberculous pericardial disease to lung disease and
pollution