Best of heart failure

3 is that ischemia accounts for more than 50% of cases [ 8 ]. In s HF cases had antecedent hypertension. An increased ratio of HDL cholesterol is associated with increased risk of develo study, 49%of the subjects who had underlying sleep apnea hadH noncompliance with HF medications, poor diet including high 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 with advanced HF including the number of previous admission tension, intolerance to angiotensin converting enzyme (ACE)/ blockers (ARB), and beta blockers, widening of the QRS co ness to biventricular pacing, worsening exertional tolerance, w tion, elevated HF biomarkers, and psychosocial factors. Common symptoms in HF patients include fatigue and d Dyspnea can range from shortness of breath with mild exerti paroxysmal nocturnal dyspnea. As such, patients report im ening in dyspnea marked by inability to walk a few block stairs as they move through the different classes of NY symptoms include lower extremity swelling, abdominal appetite, early satiety, drowsiness, and overall lack of energ ing and peripheral edema are common manifestations of flu more prevalent in the advanced HF population. Some o advanced HF include the following: need for inotropic sup medications, persistent hyponatremia, NYHA III–IV symp hospitalizations, and worsening renal function [ 6 , 11 ]. Sin disease, many patients adapt to their symptoms by decreasin duration of their activities of daily living. Because this occur of time, it is possible for HF patients to have advanced H significant symptoms or signs of HF. Physical exam findings associated with advanced HF inclu ular venous distention, rales on auscultation, hypotension, a The presence of jugular venous pressure (JVP) in HF patients ing. Data suggest that JVP is a reasonably good assessment o pressures in chronic HF patients. Sensitivity and specificity fo predict a pulmonary capillary wedge pressure >18 approac 80%, respectively [ 12 ]. JVP is a good prognostic marker as w analysis, elevated JVP was associated with an increased risk fo HF and increased risk of overall mortality. Presence of an S3 associated with worse outcomes [ 13 ]. Although the presence of is suggestive of severe HF and volume overload, the absence o 1 Management of Advanced Heart Failure: An Overview along with myocyte degeneration and reduced coronary reserve. The presence of myocardial ischemia in this patient population can also contribute to the presence of elevation in troponin [16]. Nevertheless, persistent elevation of cardiac troponins serves as a worse prognostic marker in these patients [15]. Lastly, B-type natriuretic peptide (BNP), which is secreted by the heart in response to increased wall stress, serves as a prognostic marker. An elevated BNP is often associated with increased congestion and an increase in mortality. An electrocardiogram is done to check for any arrhythmias, evidence of ischemia, new bundle branch blocks that could have precipitated HF. Vascular congestion on chest x-ray is commonly seen in HF. However, the absence of congestion on x-ray may exist in the presence of significant HF. An echocardiogram is performed to assess for diastolic and systolic function, wall motion abnormalities, valvular function, ventricular chamber size, and to compare previous echocardiograms to check for response to medical therapy. Certain patients may benefit from invasive hemodynamic monitoring with a pulmonary artery (PAC) catheter. Although the ESCAPE trial demonstrated no survival advantage with invasive monitoring in patients with acute decompensated HF, there still may be indications for such monitoring [15]. Examples include the patient in cardiogenic shock, or the advanced HF patient with worsening renal function despite optimal medical therapy who may benefit from inotropic therapy, mechanical assistance or heart transplantation. In such situations, hemodynamics can be optimized. At times, differentiating etiologies of hypotension, renal and pulmonary disease may be better assessed by invasive hemodynamic monitoring. Furthermore, patients who are candidates for heart transplant or LVAD require a PAC for evaluation to assess pulmonary vascular resistance and right sided heart function [15]. Cardiorenal Syndrome Renal dysfunction in HF is very common with prevalence of nearly 30% among patients with acute decompensated HF. The existence of both simultaneously, commonly referred to as “cardiorenal syndrome” (CRS), carries a very poor prognosis. In a study which evaluated outpatients with Class IV HF, 40% of patients had chronic kidney disease (CKD) stage 4 or worse. Renal function in the setting of HF, therefore, is an important prognostic marker [17]. Numerous mechanisms have been implicated in CRS including low cardiac output and elevated central venous pressures. However, the pathophysiology of CRS is complex as worsening renal function has been noted in the presence of normal cardiac output and adequate renal perfusion. Furthermore, it is important to recognize that an elevated creatinine or decreased glomerular filtration rate (GFR) is not always the result of cardiac dysfunction and that the presence of CRS requires that other causes of renal dysfunction are ruled out. When evaluating for CRS, it is important to look at GFR as compared to creatinine because the former is a more sensitive marker and correlates better with prognosis. At times, creatinine can be normal in HF exacerbation in the setting of reduced GFR [18]. Management of the Heart Failure Patient Nonmedical management: Nonmedical management of the HF patient can be as important as medical management. A low- salt diet of 2 g is recommended for patients at risk for volume overload. Exercise has not been proven to worsen HF and hence should be encouraged. Avoidance of certain medications such as nonsteroidal anti-inflammatory drugs should be routine in 4 out sig ifica tly elevated pulmonary capillary wedge pressures (PCWP). I one study, ulmonary r les were auscultated i only 19% of patients and lower extrem- ity edema was onl present d in 23% f the patients with PCWP >22 mmHg [ 12 ]. As a result, a patient with advanced HF can present without any evidence of fluid overload on physical examination and yet still have an elevated pulmonary capillary wedge pressure and an elevated central venous pressure. Therefore, it is important to keep in mind the potential role for invasive assessment of hemodynamics in this population. Although there are limitations to the physical exam, it should not be aban oned in the patient with heart failure. As such, it i useful to cl ssify p tients into four quadrants of HF as proposed by Lynn Warner Stevenson to aid in the assessment of advanced HF patients (Fig. 1.1 ). This cl s ification takes into account the pres- ence or absence of elevated filling res and adequate or limited organ perfu- sion. Briefly, it is interpreted s follow : warm and dry, indi ating a equate perfusion and vo ume status; warm and w t, ndicating adeq ate perfusion but cong stion; cold and dry, indicating inadequate perf sion and normal filling pressures; nd, cold and wet, indicating both inadequate perfus on and ongestion [ 14 , 15 ]. F example, a warm and wet patient is unlikely to need any inotropes and may only require diuresis and subsequent escalation of medical therapy. The cold patient, however, may require inotropic support or mechanical support. Therapy can be tailored to each patient’s specific hemodynamic profile as well as comorbid conditions and on the severity of HF. Congestio at r st? Low perfusion at rest? I. Warm and dry PCWP normal CI normal Optimize meds III. Warm and wet PCWP elevated CI normal Consider increasing diur sis II. Dry and cold PCWP normal/flow CI decreased Consider inotropes IV. Wet and cold PCWP elevated CI decreased Consider vasodilators and inotropic therapy No No Yes Yes PCWP pulmonary capillary wedge pressure, CI cardiac index Fig. 1.1 Classification of patients presenting with heart failure G. Murtaza and W. G. Cotts Fig. 1: Classification of patients presenting with heart failure.