Best of heart failure

20 clear reasons, and they are stem. Recently, the advent inhibitor (ARNI) sacubi- rmacologic approach that al endopeptidase enzyme concomitantly blocks the ith valsartan). of ARNI with ACEI to rtality and Morbidity in tudy [ 31 ], a double-blind, patients with Class II–IV tion of 40% or less were itril/valsartan (at a dose of ectively) or enalapril (at a rimary outcome of death rt failure rehospitalization ARNI arm (21.8%) com- 01). Cardiovascular death % CI, 0.71; 0.89)) and risk n by 21% (HR 0.79 (95% lity was reduced by 16% HR 0.84 (95% CI, 0.76; y stopped because of the en compared to ACEI. ere reported in more than study, and these included gh, dizziness, and renal dema was also higher in pared to enalapril (0.5% in the black population). be encountered more fre- double-blind period of by a single-blind run-in ed if they could not toler- I. en tested in CHF patients . These include endothelin agents, and growth hor- terventions that modulate he neprilysin enzyme (in only proven treatment to patients with congestive t in treating patients with bradine, an HCN channel n normal sinus rhythm and or on maximum tolerable was tested in The Systolic inhibitor ivabradine Trial 505 patients with chronic bradine versus placebo on t. Patients had to be in rt rate of more or equal ss or equal 35%, and have N. W. Shammas 460 normalized to 56%, and she was completely asymptomatic. She was maintained on her carvedilol and lisinopril, and at 2-year follow-up, she continued to have stable left ventricu- lar function. Patient was presumed to have a viral cardiomyopathy and experienced excellent recovery of car- diac function (Fig. 24.4 ). 24.6 Conclusion Treatment of heart failure starts with controlling risk factors, management of asymptomatic systolic dysfunction, and aggressive treatment of symptomatic failure with diuretics, beta blockers, ACEI (or ARB or ARNI), and aldosterone antagonists. The use of IV inotropes should be discouraged except for hemodynamic stability. Eligible patients need to receive biventricular pacing, ICD, or LVAD. Diastolic dys- function is often a neglected cause of CHF, and diagnosis needs to be considered when CHF is present in the setting of normal left ventricular systolic function. HFNEF diagnosis is a relatively new entity that needs to be considered in the symptomatic heart failure patient. References 1. Brush C. Doppler tissue analysis of mitral annular velocities: evi- dence for systolic abnormalities in patients with diastolic heart failure. J Am Soc Echocardiogr. 2003;16:1031–6. 2. Haney S, Sur D, Xu Z. Diastolic heart failure: a review and pri- mary care perspective. J Am Board Fam Pract. 2005;18:189–98. 3. Hunt SA, Baker DW, Chin MH, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure); International Society for Heart and Lung Transplantation; Heart Failure Society of America. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): Developed in Collaboration With the International Society for Heart and Lung Transplantation; Endorsed by the Heart Failure Society of America. Circulation. 2001;104:2996–3007. 4. O’Connell JB, Bristow M. Economic impact of heart failure in the United States: time for a different approach. J Heart Lung Transplant. 1993;13:S107–12. 5. Senni M, Tribouilloy CM, Rodeheffer RJ, et al. Congestive heart failure in the community. A study of al incident cases in Olmsted County, Minnesota, in 1991. Circulation. 1998;98:2282–9. 6. Kitzman DW, Gardin JM, Gottdiener JS, et al. Importance of heart failure with preserved systolic function in patients ≥ 65 years of age. Am J Cardiol. 2001;87:413–9. 7. Maeder MT, Kaye DM. Heart failure with normal left ventricular ejection fraction. J Am Coll Cardiol. 2009;53:905–18. 8. Stewart S, MacIntyre K, Capewell S, McMurray JJ. Heart failure and the aging population: an increasing burden in the 21st cen- tury? Heart. 2003;89:49–53. 9. Senni M, Tribouilloy CM, Rodeheffer RJ, et al. Congestive heart failure in the community: trends in incidence and survival in a 10-year period. Arch Intern Med. 1999;159:29–34. 10. Young JB, Dunlap ME, Pfeffer MA, et al. Mortality and mor- bidity reduction with Candesartan in patients with chronic heart failure and left ventricular systolic dysfunction: results of the Dyspnea, chest pain, fatigue, fluid overload, poor exercise tolerance, reduced functional capacity If no improvement and class IV failure consider LVAD/transplant Consider ICD or biventricular pacing/ICD if meet criteria Assess LV systolic function by an echocardiogram or an isotope ventriculogram Evaluate coronary anatomy (conventional or CT angiography), thyroid function, tachycardia- induced, connective tissue disease, infiltrative disease, viral etiology, anemia, alcohol-induced, hypertension, diabetes, familial cardiomyopathy Evaluate for diastolic dysfunction, coronary artery disease (stress imaging tests) and non cardiac etiologies Ischemic Revascularization Reassess LV function 3–6 months post optimal treatment Correct primary etiology, b -blockade, ACEI or ARB and aldosterone antagonists for post MI or Class III–IV failure EF ≥ 50% EF £ 35% EF > 35% EF < 50% Fig. 24.4 Algorithm N. W. Shammas