Heart Failure

Shannon Winakur, M.D.
Hospital of the University of Pennsylvania

Mariell Jessup, M.D.
University of Pennsylvania School of Medicine

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

• A clinical syndrome resulting from a structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or to eject blood sufficient to meet the needs of the body
• Primarily a disease of the elderly
• Coronary artery disease responsible for two thirds of cases in U.S.

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Differential Diagnosis

Classification by Disorder

• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Perioral dermatitis
• Restrictive cardiomyopathy
• Arrhythmogenic right ventricular cardiomyopathy

Classification by Underlying Disease Process

• Ischemic heart disease
• Valvular disease
• Hypertension
• Diabetes mellitus
• Inflammatory/infectious disease
  • Coxsackievirus infection
  • HIV infection
  • Rheumatic fever
• Metabolic disorders
  • Endocrine disorders
  • Electrolyte deficiencies
  • Nutritional deficiencies
  • Glycogen storage disease
• Connective tissue diseases
• Muscular dystrophies
• Neuromuscular disease
• Toxins
  • Alcohol
  • Cocaine
  • Chemotherapeutic agents
  • Radiation
• Tachycardia
• Genetic/familial disorders
• Pregnancy

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Best Tests

• Physical examination
  • Patient weight
  • Jugular venous pressure
  • Hepatojugular reflux
  • Presence of gallop rhythm
  • Peripheral edema
• Identification of patients at risk
  • Stage A
    • High risk but no structural heart disease or symptoms of heart failure
      • CAD
      • Hypertension
      • Diabetes
      • History of alcohol abuse
      • Exposure to cardiotoxic drugs
      • History of rheumatic fever
      • Family history of cardiomyopathy or sudden death
  • Stage B
    • Structural disease but no symptoms of heart failure
      • Left ventricular hypertrophy or dilation
      • Valvular disease
      • Wall motion abnormalities indicative of previous MI
  • Stage C
    • Structural heart disease with prior or current symptoms of heart failure
  • Stage D
    • Refractory heart failure requiring specialized interventions
• Tests for evaluation of stage A and stage B patients
  • Echocardiography
    • Consider in stage A patients with strong family history of cardiomyopathy or with history of exposure to cardiotoxic therapies
    • Diagnostic tool of choice in stage B patients
• Tests for evaluation of stage C and stage D patients
  • ECG
  • Chest x-ray
  • 2-D echocardiogram with Doppler flow studies
    • May also aid in establishing diagnosis of diastolic dysfunction
  • Laboratory studies
    • Exclude other causes of fatigue and dyspnea
      • CBC
      • Serum chemistries
      • Liver function tests
      • TSH
      • Urinalysis
  • Coronary angiography
    • Most useful in patients with angina

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Best Therapy

General Management

Stage A

• Prevent structural disease by controlling risk factors
  • Treat hypertension
  • Encourage smoking cessation
  • Treat lipid disorders
  • Encourage regular exercise
  • Discourage alcohol intake, illicit drug use
  • Prescribe ACE inhibitors if appropriate
    • Alternatively, prescribe angiotensin receptor blockers (ARBs) if ACE inhibitors not tolerated because of cough or angioedema

Stage B

• All measures used for stage A
• Prescribe ACE inhibitors (or ARBs) if appropriate
• Prescribe beta blockers if appropriate

Stage C

• All measures used for stage A
• Drugs for routine use
  • ACE inhibitors (or ARBs)
  • Beta blockers
• Dietary salt restriction

Stage D

• All measures used for stages A, B, and C
• Mechanical assist devices
• Heart transplantation
• Continuous (if not intermittent) intravenous inotropic infusions for palliation
• Hospice care

Drug Therapy

Loop Diuretics

• Frequent first choice in symptomatic stage C and stage D patients
• Titrate to achieve dry weight
• Monitor serum potassium, creatinine
• Bumetanide
  • Initial dose: 0.5–1 mg q.d. or b.i.d. (up to daily maximum 10 mg)
  • Cost/mo: $78
• Furosemide
  • Initial dose: 20–40 mg q.d. or b.i.d. (up to daily maximum 400 mg)
  • Cost/mo: $16.50
• Torsemide
  • Initial dose: 10–20 mg q.d. or b.i.d. (up to daily maximum 200 mg)
  • Cost/mo: $152

Aldosterone Inhibitors

• Monitor serum potassium
• Spironolactone
  • Initial dose: 25 mg q.d. (up to daily maximum 50 mg)
  • Cost/mo: $20
• Epleronone
  • Fewer estrogenic side effects than spironolactone
  • Initial dose: 25 mg q.d. (up to daily maximum 50 mg)
  • Cost/mo: $118

ACE Inhibitors

• Monitor serum potassium, creatinine
• Captopril
  • Initial dose: 6.25 mg t.i.d. (up to daily maximum 50 mg t.i.d.)
  • Cost/mo: $15
• Enalapril
  • Initial dose: 2.5 mg b.i.d. (up to daily maximum 10–20 mg b.i.d.)
  • Cost/mo: $22
• Fosinopril
  • Initial dose: 5–10 mg q.d. (up to daily maximum 40 mg)
  • Cost/mo: $30
• Lisinopril
  • Initial dose: 2.5–5 mg q.d. (up to daily maximum 20–40 mg)
  • Cost/mo: $25
• Quinapril
  • Initial dose: 10 mg b.i.d. (up to daily maximum 40 mg b.i.d.)
  • Cost/mo: $44
• Ramipril
  • Initial dose: 1.25–2.5 mg q.d. (up to daily maximum 10 mg)
  • Cost/mo: $50

Beta Blockers

• Titrate over 2- to 4-week interval, monitor for fluid overload
• Bisoprolol
  • Initial dose: 1.25 mg (up to daily maximum 10 mg)
  • Cost/mo: $35
• Carvedilol
  • Initial dose: 3.125 mg b.i.d. (up to daily maximum 25 mg b.i.d.; 50 mg b.i.d. for patients > 85 kg)
  • Cost/mo: $95
• Metoprolol succinate extended release
  • Initial dose: 12.5–25 mg q.d. (up to daily maximum 200 mg)
  • Cost/mo: $59

Angiotensin Receptor Blockers

• Use in patients who cannot tolerate ACE inhibitors because of cough or angioedema
• Candesartan
  • Initial dose: 8 mg (up to daily maximum 32 mg)
  • Cost/mo: $60
• Irbesartan
  • Initial dose: 75 mg (up to daily maximum 300 mg)
  • Cost/mo: $53
• Losartan
  • Initial dose: 25 mg (up to daily maximum 100 mg)
  • Cost/mo: $65
• Valsartan
  • Initial dose: 80 mg (up to daily maximum 320 mg)
  • Cost/mo: $67

Invasive Therapies

Revascularization Procedures

• Relief of anginal symptoms
• May improve ejection fraction

Mitral Valve Replacement

• In stage C and stage D with low ejection fraction; no definitive trials proving efficacy

Mechanical Devices to Reduce Ventricular Wall Stress

• Investigational

Surgical Excision of Infarcted Tissue

• Investigational

Implantable Devices

• Biventricular pacing systems
• Implantable cardioverter/defibrillators

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Best References

Gomberg-Maitland M, et al: Arch Intern Med 161:342, 2001 [PMID 11176759]

Hunt SA, et al: Circulation 112:e154, 2005 [PMID 16160202]

McMurray J, et al: Circulation 105:2099, 2002 [PMID 11980691]

McMurray J, et al: Circulation 105:2223, 2002 [PMID 11994259]

Shannon Winakur, M.D., has no commercial relationships with manufacturers of products or providers of services discussed in this module. Mariell Jessup, M.D., has received grants for clinical research from, and served as an advisor or consultant to, Acorn Cardiovascular, Inc.; Medtronic, Inc.; Guidant Corporation; GlaxoSmithKline, Inc.; AstraZeneca Pharmaceuticals LP; and Scios, Inc.

March 2006