Chapter 27 Heart Failure and Valvular Heart Disease
1 What are the causes of cardiomyopathy resulting in the syndrome of heart failure (HF)?
2 What are the causes of HFREF besides ischemic heart disease or MI?
| Type | Cause |
|---|---|
| Myocarditis | Infectious (viral) or inflammatory (e.g., systemic lupus erythematosus) giant cell (may require transplant) |
| Toxins | EtOH, cocaine, cancer chemotherapy, radiation |
| Stress-induced cardiomyopathy | Catecholamine surge from stress, apical ballooning (takotsubo syndrome) |
| Genetic | Idiopathic, familial (multiple mutations) |
| Valvular disease | Aortic, mitral (see valvular disease section) |
| Other | Peripartum, sustained tachycardia, HTN, DM, endocrine or nutritional, acidosis, sepsis |
DM, Diabetes mellitus; EtOH, ethyl alcohol; HTN, hypertension.
3 How do we classify HF by functional status or stage?
Table 27-2 Classifying Heart Failure by Functional Status/Stage
| NYHA Functional Classification | |
| Class I (mild) | No limitation of physical activity |
| Class II (mild) | Slight limitation of physical activity |
| Class III (moderate) | Marked limitation of physical activity |
| Class IV (severe) | Unable to carry out any physical activity without discomfort, symptoms at rest |
| ACC-AHA Staging System | |
| Stage A | Patients at high risk for development of HF in the future but no functional or structural heart disease |
| Stage B | Structural heart disease but no symptoms |
| Stage C | Previous or current symptoms of HF in the context of underlying structural heart disease, adequately managed with medical treatment |
| Stage D | Advanced disease requiring hospital-based support, heart transplantation or mechanical support, or palliative care |
ACC, American College of Cardiology; AHA, American Heart Association; NYHA, New York Heart Association.
5 How is acute decompensated HF treated?
Treatment is based on systemic perfusion and evidence of vascular congestion. See Table 27-3.
Congestion: dyspnea, orthopnea, crackles, elevated venous pressure, ascites, peripheral edema
Impaired perfusion: reduced pulse pressure, cold extremities, altered mentation
The numbers in Table 27-3 can be defined as follows:
1. Normal and requires no intervention.
2. Pump failure without pulmonary edema. Usually represents end-stage HF. Patients require inotropic support: dobutamine (β1-adrenergic agonist), milrinone (phosphodiesterase inhibitor), mechanical support (intraaortic balloon pump [IABP], LV assist device); consider cardiac transplantation.
3. Adequate perfusion with volume overload and increased filling pressures. The treatment focus is intravenous loop diuretics (most commonly furosemide) or bedside ultrafiltration. Reduction of preload with intravenous vasodilators (morphine sulfate, nitroglycerin or nitroprusside, angiotensin-converting enzyme inhibitors [ACEIs]) is another option.
4. Volume overload with pump failure. These patients require inotropes, vasodilators, diuretics, and consideration of mechanical support.
