HEART FAILURE

Manifestations of congestive heart failure are common in patients

with chronic CAD. Heart failure may be the dominant clinical feature
in some patients, especially those who have sustained prior
myocardial infarction(s), in whom ischemic areas have become
replaced with a fibrous scar, leading to disappearance or reduction
of the angina. The three most common causes of congestive heart
failure are (1) an inadequate quantity of normally contracting
myocardium, (2) left ventricular aneurysm, and (3) mitral
regurgitation due to papillary muscle dysfunction. The first is the
most common of the three.
Ischemic Cardiomyopathy
In 1970 Burch and colleagues first used the term ischemic
cardiomyopathy to describe the condition in which CAD results in
severe myocardial dysfunction, with clinical manifestations often
indistinguishable from those of primary dilated cardiomyopathy (see
[For More Information] ). Symptoms of heart failure, caused by
ischemic myocardial dysfunction (hibernation), diffuse fibrosis, and
multiple infarctions, alone or in combination, may dominate the
clinical picture of CAD. In some patients with chronic CAD, angina
may be the principal clinical manifestation at one time, but later this
symptom diminishes or even disappears as heart failure becomes
more prominent. Other patients with ischemic cardiomyopathy have
no history of angina or myocardial infarction (type I silent ischemia),
and it is in this subgroup that ischemic cardiomyopathy is often
confused with dilated cardiomyopathy.
As discussed earlier in this chapter (see [For More Information]
), in patients with CAD and stable angina, left ventricular
dysfunction and overt heart failure may be due to a localized infarct,
scattered fibrosis, ischemic noncontractile (hibernating)
myocardium, or some combination of these. A similar situation
exists in patients without angina who present with heart failure and
little or no angina as their primary manifestation of CAD. It is
important to recognize hibernating myocardium in patients with
ischemic cardiomyopathy because symptoms resulting from chronic
left ventricular dysfunction may be incorrectly thought to result
from necrotic and scarred myocardium rather than from a reversible
ischemic process. Hibernating myocardium may be present in
patients with known or suspected CAD with a degree of cardiac
dysfunction or heart failure not readily accounted for by prior
myocardial infarctions.
The outlook for patients with ischemic cardiomyopathy treated
medically is quite poor, and revascularization or cardiac
transplantation may be considered. The prognosis is particularly
poor in patients in whom the ischemic cardiomyopathy is secondary
to multiple myocardial infarctions and in those with associated
ventricular arrhythmias. On the other hand, patients whose heart
failure, even if severe, is secondary to large segments of reversibly
injured but viable (hibernating) myocardium have a better prognosis
following revascularization. Thus, the key to the management of
patients with ischemic cardiomyopathy is to assess the extent of
residual viable myocardium with a view to coronary
revascularization. Techniques for detecting hibernating myocardium
are described on .