Best of heart failure

1 Management of Advanced Heart Failure: An Overview Ghulam Murtaza and William G. Cotts Introduction With current estimates of heart failure (HF) prevalence at 25 million, HF presents itself globally as both a significant healthcare challenge and economic burden. In the USA alone, nearly 6,000,000 people are plagued with HF, and nearly 600,000 new cases are diagnosed each year [1]. HF is the most common Medicare diagnosis and its overall prevalence has increased as the US population ages [2]. It is estimated that nearly 250,000 people in the USA suffer from advanced HF. The annual cost of caring for HF patients in the USA is nearly 39 billion dollars which places a significant burden on our healthcare system. HF carries a significant mortality and is responsible for nearly three million hospitalizations annually [3]. One-year mortality for advanced HF is nearly 50% [4]. Definition and Staging HF is considered a clinical diagnosis with a broad range of severity of symptoms. Symptoms vary considerably among patients with some who are virtually asymptomatic while others struggle to walk a few steps despite being on multiple medications. As such, criteria have been established to help classify these patients into categories to help with management and follow-up. The American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines categorizes patients into four stages (Table 1). Stage D, in particular, classifies patients into refractory HF with structural disease and progressive worsening of symptoms including dyspnea at rest, inability to carry out daily activities, and multiple hospitalizations for fluid overload while receiving optimal HF therapy. Recurrent hospitalizations portend a poor prognosis, as the European EPICAL registry of more than 2000 patients with advanced HF revealed that patients were admitted to the hospital an average of 2.05 times per year and spent nearly 28 days per year in the hospital [5, 6]. Stage D patients include those with symptoms at rest despite being on medical therapy. These patients may benefit from intravenous (IV) inotropic therapy, ventricular assists devices (VAD), and heart transplantation. Similarly, New York Heart Association (NYHA) class separates patients into class I–IV based on the severity of symptoms. Class III and IV, in particular, are noted by marked limitation of physical activity and an inability to carry out any physical activity without discomfort, respectively. Advanced HF patients typically fall into NYHA Class III–IV categories and ACC Stage D [7] (Tables 1 and 2). Etiology When a patient presents with signs and symptoms of HF, it is imperative to find the underlying precipitant. While the etiology of HF is extensive, some of the common etiologies include the following: viral infections, thyroid dysfunction, ischemia, alcohol, atrial fibrillation, sleep apnea, obesity, and hypertension. Of note, however, is that ischemia accounts for more than 50% of cases [8]. In some studies, 75% of HF cases had antecedent hypertension. An increased ratio of total cholesterol to HDL cholesterol is associated with increased risk of developing HF [9]. In one study, 49% of the subjects who had underlying sleep apnea had HF [10]. Furthermore, noncompliance with HF medications, poor diet including high consumption of salt and fatty foods, can contribute to worsening of HF. Assessment of the Heart Failure Patient A number of criteria should be taken into consideration when assessing the patient with advanced HF including the number of previous admissions, presence of hypotension, intolerance to angiotensin converting enzyme (ACE)/angiotensin receptor blockers (ARB), and beta blockers, widening of the QRS complex, unresponsiveness to biventricular pacing, worsening exertional tolerance, worsening renal function, elevated HF biomarkers, and psychosocial factors. Common symptoms inHF patients include fatigue and dyspnea on exertion. Dyspnea can range from shortness of breath with mild exertion to orthopnea and paroxysmal nocturnal dyspnea. As such, patients report improvement or worsening in dyspnea marked by inability to walk a few blocks or a few flight of stairs as they move through the different classes of NYHA. Other common symptoms include lower extremity swelling, abdominal bloating, decreased appetite, early satiety, drowsiness, and overall lack of energy. Abdominal bloating and peripheral edema are common G. Murtaza Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA W. G. Cotts (  ) Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, IL, USA e-mail: William.cotts@advocatehealth.com © Springer International Publishing AG, part of Springer Nature 2018 C. Desai et al. (eds.), Ventricular-Assist Devices and Kidney Disease, https://doi.org/10.1007/978-3-319-74657-9_1