Congestive heart failure natural history: Difference between revisions
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* If left untreated, heart failure may result in death due to complications associated with the condition. Heart failure is a progressive disease with a major impact on the patient's quality of life. | * If left untreated, heart failure may result in death due to complications associated with the condition. Heart failure is a progressive disease with a major impact on the patient's quality of life. | ||
* Heart failure resulting from atherosclerotic coronary artery disease has been shown to be associated with higher incidence of fatal events compared to heart failure that results from other cardiac diseases | * Heart failure resulting from atherosclerotic coronary artery disease has been shown to be associated with higher incidence of fatal events compared to heart failure that results from other cardiac diseases | ||
* Initiation of therapy for heart failure may lead to stabilization of the patient's clinical condition which is referred to as the stability phase. | * Initiation of therapy for heart failure may lead to stabilization of the patient's clinical condition which is referred to as the stability phase.<ref name="pmid27371510">{{cite journal |vauthors=Chaudhry SP, Stewart GC |title=Advanced Heart Failure: Prevalence, Natural History, and Prognosis |journal=Heart Fail Clin |volume=12 |issue=3 |pages=323–33 |date=July 2016 |pmid=27371510 |doi=10.1016/j.hfc.2016.03.001 |url=}}</ref> | ||
* Months to years following the stability phase, the patient functional status may decline resulting in multiple hospitalizations and eventually the condition may become refractory to treatment whn ventricular remodeling sets in. | * Months to years following the stability phase, the patient functional status may decline resulting in multiple hospitalizations and eventually the condition may become refractory to treatment whn ventricular remodeling sets in.<ref name="pmid22392529">{{cite journal |vauthors=Allen LA, Stevenson LW, Grady KL, Goldstein NE, Matlock DD, Arnold RM, Cook NR, Felker GM, Francis GS, Hauptman PJ, Havranek EP, Krumholz HM, Mancini D, Riegel B, Spertus JA |title=Decision making in advanced heart failure: a scientific statement from the American Heart Association |journal=Circulation |volume=125 |issue=15 |pages=1928–52 |date=April 2012 |pmid=22392529 |pmc=3893703 |doi=10.1161/CIR.0b013e31824f2173 |url=}}</ref> | ||
* Once refractory, heart failure may be managed titration of pharmacological therapy and by the use to left ventricular assist devices and cardiac transplantation. | * Once refractory, heart failure may be managed titration of pharmacological therapy and by the use to left ventricular assist devices and cardiac transplantation. | ||
==Complications== | ==Complications== | ||
Revision as of 19:54, 28 January 2020
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Resident Survival Guide |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Saleh El Dassouki, M.D. [3]; Atif Mohammad, M.D.
Overview
Heart failure is associated with significantly reduced physical and mental health, resulting in a markedly decreased quality of life.[1][2] Congestive heart failure is also associated with a poor prognosis. With the exception of heart failure caused by reversible conditions, the condition usually worsens with time. Although some people survive many years, progressive disease is associated with an overall annual mortality rate of 10%.[3] In the Framingham experience, 80% of men and 70% of women with heart failure who were under 65 years of age had died within 8 years of the diagnosis.
Natural History
- If left untreated, heart failure may result in death due to complications associated with the condition. Heart failure is a progressive disease with a major impact on the patient's quality of life.
- Heart failure resulting from atherosclerotic coronary artery disease has been shown to be associated with higher incidence of fatal events compared to heart failure that results from other cardiac diseases
- Initiation of therapy for heart failure may lead to stabilization of the patient's clinical condition which is referred to as the stability phase.[4]
- Months to years following the stability phase, the patient functional status may decline resulting in multiple hospitalizations and eventually the condition may become refractory to treatment whn ventricular remodeling sets in.[5]
- Once refractory, heart failure may be managed titration of pharmacological therapy and by the use to left ventricular assist devices and cardiac transplantation.
Complications
1. Cardiac Arrhythmias:
- Ventricular tachycardia and ventricular fibrillation can occur as serious complications of heart failure when its pump function is severely impaired. This further worsens the cardiac output and even possible death.
- Atrial fibrillation which is rapid beating of atrium without optimal forward pumping of blood is another complication of heart failure which occurs as a result of resistance to blood flow from atrium to ventricles. These patients are at increased risk of stroke.
- Left bundle branch block is an abnormality in electrical conduction in the heart.
2. Pulmonary Congestion:
- Pulmonary congestion which occur in left ventricular failure can cause pulmonary edema.
- Venous stasis and pedal edema can occur as a complication of right heart failure. These conditions predispose patients to venous ulcers, infections and cellulites.
- Cardiac cirrhosis occurs as a result of hepatic venous congestion. This can lead to coma and even death [6].
3. Angina and myocardial infarction: Cardiac ischemia and infarction can also occur when heart failure patients undergo exertion. With LV dilation, LV wall stress increases, and this increases the risk of angina. Autopsy studies demonstrate that plaque rupture and coronary thrombosis is a common mode of death in patients with congestive heart failure.
4. Renal failure: Renal impairment can occur secondary to decreased renal perfusion. This further worsens heart failure by fluid retention.
5. Cardiac cachexia: Unintentional rapid weight loss (a loss of at least 7.5% of normal weight within 6 months) can occur in chronic heart failure[7]. This is a bad prognostic factor.
Prognosis
Risk Stratification Tools
The prognosis in patients with heart failure can be assessed using a variety of risk stratification tools and cardiopulmonary exercise testing. Clinical prediction rules use a composite of clinical factors such as lab tests and blood pressure to estimate prognosis. Among several clinical prediction rules for assessing the prognosis in acute heart failure, the 'EFFECT rule' slightly outperformed other rules in stratifying patients and identifying those at low risk of death during hospitalization or within 30 days.[8] Other simpler methods for identifying low risk patients include the:
- ADHERE Tree rule which indicates that patients with blood urea nitrogen < 43 mg/dl and systolic blood pressure at least 115 mm Hg have less than 10% chance of inpatient death or complications.
- BWH rule indicates that patients with systolic blood pressure over 90 mm Hg, respiratory rate of 30 or less breaths per minute, serum sodium over 135 mmol/L, no new ST-T wave changes have less than 10% chance of inpatient death or complications.
A very important method for assessing prognosis in advanced heart failure patients is cardiopulmonary exercise testing (CPX testing). CPX testing is usually required prior to heart transplantation as an indicator of prognosis. Cardiopulmonary exercise testing involves measurement of exhaled oxygen and carbon dioxide during exercise. The peak oxygen consumption (VO2 max) is used as an indicator of prognosis. As a general rule, a VO2 max less than 12-14 cc/kg/min indicates a poor survival and suggests that the patient may be a candidate for a heart transplant. Patients with a VO2 max<10 cc/kg/min have clearly poorer prognosis. The most recent International Society for Heart and Lung Transplantation (ISHLT) guidelines[9] also suggest two other parameters that can be used for evaluation of prognosis in advanced heart failure, the heart failure survival score and the use of a criterion of VE/VCO2 slope > 35 from the CPX test. The heart failure survival score is a score calculated using a combination of clinical predictors and the VO2 max from the cardiopulmonary exercise test.
Mortality Associated with Heart Failure
Based on the 44-year follow-up of the NHLBI’s Framingham Heart Study:
- 80% of men and 70% of women under age 65 who have heart failure will die within following 8 years.
- In people diagnosed with heart failure, sudden cardiac death occurs at 6 to 9 times the rate of the general population.
- One in eight deaths has heart failure mentioned on the death certificate.
References
- ↑ Juenger J, Schellberg D, Kraemer S; et al. (2002). "Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables". Heart. 87 (3): 235–41. doi:10.1136/heart.87.3.235. PMC 1767036. PMID 11847161. Unknown parameter
|month=ignored (help) - ↑ Hobbs FD, Kenkre JE, Roalfe AK, Davis RC, Hare R, Davies MK (2002). "Impact of heart failure and left ventricular systolic dysfunction on quality of life: a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population". Eur. Heart J. 23 (23): 1867–76. doi:10.1053/euhj.2002.3255. PMID 12445536. Unknown parameter
|month=ignored (help) - ↑ Neubauer S (2007). "The failing heart — an engine out of fuel". N Engl J Med. 356 (11): 1140–51. doi:10.1056/NEJMra063052. PMID 17360992.
- ↑ Chaudhry SP, Stewart GC (July 2016). "Advanced Heart Failure: Prevalence, Natural History, and Prognosis". Heart Fail Clin. 12 (3): 323–33. doi:10.1016/j.hfc.2016.03.001. PMID 27371510.
- ↑ Allen LA, Stevenson LW, Grady KL, Goldstein NE, Matlock DD, Arnold RM, Cook NR, Felker GM, Francis GS, Hauptman PJ, Havranek EP, Krumholz HM, Mancini D, Riegel B, Spertus JA (April 2012). "Decision making in advanced heart failure: a scientific statement from the American Heart Association". Circulation. 125 (15): 1928–52. doi:10.1161/CIR.0b013e31824f2173. PMC 3893703. PMID 22392529.
- ↑ Moussavian SN, Dincsoy HP, Goodman S, Helm RA, Bozian RC (1982). "Severe hyperbilirubinemia and coma in chronic congestive heart failure". Digestive Diseases and Sciences. 27 (2): 175–80. PMID 7075414. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Freeman LM (2009). "The pathophysiology of cardiac cachexia". Current Opinion in Supportive and Palliative Care. 3 (4): 276–81. doi:10.1097/SPC.0b013e32833237f1. PMID 19797959. Retrieved 2011-04-30. Unknown parameter
|month=ignored (help) - ↑ Auble TE, Hsieh M, McCausland JB, Yealy DM (2007). "Comparison of four clinical prediction rules for estimating risk in heart failure". Annals of emergency medicine. 50 (2): 127–35, 135.e1–2. doi:10.1016/j.annemergmed.2007.02.017. PMID 17449141.
- ↑ Mandeep R. Mehra; et al. "Evaluation of listing criteria for cardiac transplantation". Journal of Heart and Lung Transplantation. Retrieved 8 April 2010.