Congestive heart disease
Definition
A complex clinical syndrome resulting from any structural or functional cardiac abnormality that impairs the ability of the ventricle to fill with or eject blood
Because not all patients with heart failure have volume overload at the time of the initial or subsequent evaluation, the term heart failure is preferred over the older congestive heart failure term.
Suspected or known coronary artery disease and evaluation of functional impairment
* Cardiovascular stress test using treadmill
Coronary arteriosclerosis
* Coronary angiography
Suspected or known coronary artery disease
* Radionuclide study of heart
* Stress echocardiography
Evaluation of nutritional status
* Prealbumin measurement
* Nitrogen balance test
Reassessment
Laboratory Reassessment
Suspected or known heart failure
* Serum potassium measurement: The target level of serum potassium in heart failure patients ranges from 4.0 to 5.5 mmol/L; hypokalemia is independently associated with increased mortality .
Suspected or known heart failure
* Creatinine measurement, serum: Serum creatinine should be measured and followed closely in all patients with heart failure. Creatinine levels provide management guidance as well as prognostic information .
Suspected or known heart failure .
* Two dimensional echocardiography: All patients presenting with heart failure should receive echocardiographic evaluation of left ventricular ejection fraction, left and right ventricular size and function, ventricular wall thickness, valve function, and pericardial pathology .
Medical History
* Coronary arteriosclerosis
* Hypertension [Hypertension - Chronic]
* Diabetes mellitus [Diabetes mellitus - Chronic]
* Obesity [Obesity - Chronic]
* Smoking
* Alcohol Abuse
* Anemia [Anemia - Chronic]
* Family history of Cardiomyopathy
Findings
* Dyspnea - Chronic
* Fatigue
* Peripheral edema
* Respiratory crackles
* Decreased breath sounds
* Orthopnea
* Paroxysmal nocturnal dyspnea
* S3 gallop
* Jugular venous distention
* Hepatojugular reflux
* Hepatomegaly
* Ascites
* Nocturnal cough
* Nocturnal asthma
* Second heart sound split
* Tricuspid valve regurgitation
* Tachycardia
* Palpitations
* Chest pain
* Early satiety
* Nausea and vomiting
* Abdominal pain
* Cold extremities
* Confusion
* Syncope
Tests
Suspected or known heart failure
* Plain chest X-ray: Radiographic findings in heart failure may include evidence of cardiac chamber enlargement, increased pulmonary venous pressure, interstitial or alveolar edema, pleural effusions, valvular or pericardial calcification, or lung disease , but a chest x-ray should not be used as a primary test for identifying the specific cardiac dysfunction associated with HF .
Suspected or known heart failure
* 12 lead ECG: In patients with heart failure, a 12-lead ECG is frequently abnormal and may show evidence of ischemia, myocardial infarction, left ventricular hypertrophy, cardiac conduction abnormality, or cardiac arrhythmia .
Suspected or known heart failure
* Brain natriuretic peptide measurement: Acute heart failure is likely in the presence of acute dyspnea if the B-type natriuretic peptide (BNP) level is greater than 500 picog/mL or NT-proBNP is greater than 1000 picog/mL and is unlikely if BNP is less than 100 picog/mL or NT-proBNP is less than 300 picog/mL . Although levels vary, these cut-off values may still be useful to assess decompensation of chronic heart failure .
Suspected or known heart failure .
* Two dimensional echocardiography: All patients presenting with heart failure should receive echocardiographic evaluation of left ventricular ejection fraction, left and right ventricular size and function, ventricular wall thickness, valve function, and pericardial pathology .
Suspected or known heart failure
* Complete blood count
* Magnesium measurement, serum
* Serum calcium measurement
* Blood urea nitrogen measurement
* Fasting blood glucose measurement
* Liver function tests - general
* Thyroid stimulating hormone measurement
* Fasting lipid profile
Suspected or known heart failure
* Urinalysis: Urinalysis should be obtained in all patients presenting with acute heart failure to detect infection and assess renal function, especially if hypotension may have occurred .
Suspected or known heart failure
* Serum potassium measurement: The target level of serum potassium in heart failure patients ranges from 4.0 to 5.5 mmol/L; hypokalemia is independently associated with increased mortality .
Suspected or known heart failure
* Sodium measurement, serum: In heart failure, serum sodium levels below 136 mEq/L are associated with increased risk of mortality and prolonged hospitalization .
Suspected or known heart failure
* Creatinine measurement, serum: Serum creatinine should be measured and followed closely in all patients with heart failure. Creatinine levels provide management guidance as well as prognostic information .
Suspected or known heart failure
* Albumin measurement, serum
Suspected or known acute coronary syndrome
* Coronary angiography: Coronary angiography assesses risk and guides therapy in high-risk acute coronary syndrome patients, especially when invasive treatment is planned .
Differential Diagnosis
* Acute myocardial infarction - Acute
* Pulmonary embolism - Acute
* Community acquired pneumonia - Acute
* Asthma - Acute
* Chronic obstructive pulmonary disease - Chronic
* Pulmonary hypertension - Chronic
* Obstructive sleep apnea - Chronic
* Renal failure
* Liver failure - Chronic
* Obesity - Chronic
* Physical deconditioning
* Anemia
* Hypoalbuminemia
* Deficiency of macronutrients
* Anxiety
* Depression - Chronic
Treatment
Drug Therapy
First-line therapy for fluid overload and maintenance of euvolemia
FUROSEMIDE
Adults: Initial dose 20 to 40 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum total daily dose 600 mg
BUMETANIDE
Adults: Initial dose 0.5 to 1 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum daily dose 10 mg
TORSEMIDE
Adults: Initial dose 10 to 20 mg orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum daily dose 200 mg
Heart failure with hypertension or alternative diuretic therapy for mild volume overload, or combination therapy with loop diuretics for decreased diuretic response
CHLOROTHIAZIDE
Adults: Initial dose 250 mg to 500 mg orally once or twice daily; maximum total daily dose 1000 mg
CHLORTHALIDONE
Adults: Initial dose 12.5 to 25 mg orally daily; maximum daily dose 100 mg
HYDROCHLOROTHIAZIDE
Adults: Initial dose 25 mg orally daily or twice daily; maximum total daily dose 200 mg
METOLAZONE
Adults: Initial dose 2.5 mg orally once daily; maximum daily dose 20 mg
INDAPAMIDE
Adults: Initial dose 2.5 mg orally once daily; maximum daily dose 5 mg
Heart failure with reduced left ventricular ejection fraction (LVEF) or with preserved LVEF and increased cardiovascular risk
CAPTOPRIL
Adults: 6.25 mg orally 3 times daily; maximum 50 mg orally 3 times daily
ENALAPRIL MALEATE
Adults: 2.5 mg orally twice daily; maximum 10 to 20 mg twice daily
LISINOPRIL
Adults: 2.5 to 5 mg orally once daily; maximum 20 to 40 mg once daily
PERINDOPRIL ERBUMINE
Adults: Initial dose 2 mg orally once daily; maximum 8 to 16 mg once daily
RAMIPRIL
Adults: Initial dose 1.25 to 2.5 mg orally once daily; maximum 10 mg once daily
TRANDOLAPRIL
Adults: Initial dose 1 mg orally once daily; maximum 4 mg once daily
FOSINOPRIL SODIUM
Adults: Initial dose 5 to 10 mg orally once daily; maximum 40 mg once daily
QUINAPRIL HYDROCHLORIDE
Adults: Initial dose 5 mg orally twice daily; maximum 20 mg twice daily
Intolerance to ACE inhibitors or in combination with ACE inhibitors for persistent symptoms
CANDESARTAN CILEXETIL
Adults: 4 to 8 mg orally once daily; maximum 32 mg once daily
VALSARTAN
Adults: 20 to 40 mg orally twice daily; maximum 160 mg twice daily
LOSARTAN POTASSIUM
Adults: 25 to 50 mg orally once daily; maximum 50 to 100 mg once daily
Clinically stable heart failure due to reduced left ventricular systolic ejection fraction
BISOPROLOL FUMARATE
Adults: 1.25 mg orally once daily; maximum 10 mg once daily
CARVEDILOL
Adults: Initial dose 3.125 mg orally twice daily; maximum 25 mg twice daily (50 mg twice daily for patients over 85 kg)
METOPROLOL SUCCINATE
Adults (extended release tablets): Initial dose 12.5 to 25 mg orally once daily; maximum 200 mg once daily
Selective use for moderate to severe symptoms of HF and decreased left ventricular ejection fraction with recent decompensation, or LV dysfunction after myocardial infarction
SPIRONOLACTONE
Adults: Initial dose 12.5 to 25 mg orally once daily; maximum 25 mg once or twice daily
EPLERENONE
Adults: Initial dose 25 mg orally once daily; maximum 50 mg once daily
Mild to moderate heart failure with decreased left ventricular ejection fraction and persistent symptoms despite standard therapies or atrial fibrillation, or severe heart failure while awaiting response to standard therapies
DIGOXIN
Adults: 0.125 mg to 0.25 mg orally daily; target plasma concentration 0.5 to 1 nanogram/mL
Adults (over 70 years, lean body mass, or renal dysfunction): Initial dose 0.125 mg orally daily or every other day
Blacks with symptomatic heart failure with decreased left ventricular ejection fraction, and consideration for non-blacks with persistent symptoms despite standard therapies
ISOSORBIDE DINITRATE / HYDRALAZINE
Adults: Initial dose 1 tablet orally three times daily; titrate upward as tolerated to maximum 2 tablets three times daily
Prevention of ischemic stroke in heart failure complicated by atrial fibrillation
WARFARIN SODIUM
Adults: Initial dose not to exceed 5 mg orally daily ; adjust subsequent doses to achieve a target INR of 2.5 (range, 2 to 3)
Procedural Therapy
Acute coronary syndrome
* Percutaneous coronary intervention: Coronary revascularization with percutaneous coronary intervention is suitable for most high-risk patients with ST-segment elevation MI, non-ST-segment elevation MI, and unstable angina .
Dyssynchronous ventricular contraction
* Implantation of biventricular cardiac pacemaker system
Coronary artery disease
* Coronary artery bypass graft: CABG is the preferred revascularization strategy for most patients with significant left main coronary artery stenosis, 3-vessel coronary artery disease, and multivessel disease with treated diabetes or left ventricular dysfunction . It is appropriate in high-risk acute coronary syndrome when fibrinolysis or catheter-based treatment fails or is not indicated .
Severe refractory heart failure
* Transplantation of heart: Although heart transplantation is the only established surgical treatment for refractory heart failure, the procedure is available to only a limited number of patients .
Non-Procedural Therapy
Chronic heart failure
* Lifestyle Modification
* Education and Counseling
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