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T HE PREVALENCE OF
heart failure is increasing
as the number of older
Americans increases, more
people survive myocardial
infarction (MI), and more people
develop hypertension and coronary
artery disease (CAD), which are
risk factors for heart failure. About
5 million Americans have heart fail-
ure, and more than half a million
new cases are identified yearly. Yet
tricular remodeling.
Heart failure can be caused by
diastolic or systolic dysfunction. In
this article, I’ll describe practice
guidelines for managing heart fail-
ure caused by systolic dysfunction.
syndrome.
Testing, testing
The initial workup for a patient
with suspected heart failure in-
cludes lab tests, a chest X-ray,
electrocardiogram (ECG), and
echocardiogram. Let’s take a look
The American College of Cardiology/American Heart Association (ACC/AHA) staging system is based on the patient’s risk
factors, symptoms, and any cardiac structural defects, as determined by history, physical exam, and diagnostic testing. The
system aims to promote prevention as well as guide treatment.
Stage Treatment
A—Patient is at high risk for developing heart • Treat underlying hypertension or diabetes.
failure because of hypertension, atheroscle- • Control conditions that may cause cardiac injury.
rotic disease, dyslipidemia, diabetes, smok- • Regular exercise regimen
ing, history of cardiotoxic drug use, or family • Angiotensin-converting enzyme (ACE) inhibitor if indicated (such as
history, but at this point, the patient doesn’t for patients with diabetes or vascular disease)
have cardiac structural disorder or any signs • Encourage smoking cessation.
and symptoms of heart failure.
B—Patient has no heart failure symptoms, • All stage A therapies
but has structural heart disease, such as • ACE inhibitor unless contraindicated
abnormal left ventricular function, left ventric- • Beta-blocker unless contraindicated
ular hypertrophy, myocardial infarction, or • Implantable cardioverter-defibrillator (ICD) in select patients
valvular disease, and is at risk for progression
to heart failure.
C—Patient has past or current heart failure • All stage A and B therapies
symptoms associated with structural cardiac • Sodium-restricted diet
disease such as advanced ventricular remod- • Diuretic
eling. • Digoxin
• Avoid or withdraw antiarrhythmics, most calcium channel blockers,
and nonsteroidal anti-inflammatory drugs.
• Consider aldosterone antagonist, angiotensin receptor blocker,
hydralazine, and nitrates.
• ICD and biventricular pacing in select patients
D—Patient has advanced refractory heart • All therapies for stages A, B, and C
failure and is symptomatic at rest or with mini- • Mechanical assist device such as left ventricular assist device
mal exertion despite maximal medical therapy. (permanent or bridge to transplant)
• Continuous inotropic therapy
• Heart transplant
• Hospice care
The New York Heart Association (NYHA) functional classification, also widely used, is a subjective ranking based on the patient’s
functional ability. In contrast to the ACC/AHA system, in the NYHA system, the patient’s classification can change if symptoms
improve or worsen with therapy. The four NYHA classes are:
• Class I—no limitation of physical activity. Ordinary activity doesn’t cause the patient undue fatigue, dyspnea, palpitations, or
anginal pain.
• Class II—slight limitation of physical activity. The patient is comfortable at rest, but ordinary physical activity causes heart fail-
ure symptoms, including fatigue, dyspnea, palpitations, or anginal pain.
• Class III—marked limitation of physical activity. The patient is comfortable at rest, but less-than-ordinary physical activity caus-
es heart failure symptoms.
• Class IV—severe limitation. The patient has symptoms of heart failure at rest. Any physical activity increases this discomfort.
the mediastinum can lead to substance abuse. Regular exer- progression, improving survival,
restrictive cardiomyopathy and cise and a low-fat, low-sodium and minimizing risk factors. In
heart failure. Chemotherapeutic diet can help him maintain his addition to all stage A therapies,
drugs such as athracyclines and health and reduce his risk of all patients in stage B should take
trastuzumab (a monoclonal anti- dyslipidemia, diabetes, and an ACE inhibitor and a beta-
body) can cause irreversible hypertension. blocker unless contraindicated.
myocardial damage. • Angiotensin-converting enzyme
• Encourage healthy living. If the Stage B—structural trouble inhibitors stop the conversion of
patient smokes, he should stop, The treatment goals for a patient angiotensin I to angiotensin II, a
and he should avoid alcohol and in this stage are slowing disease potent vasoconstrictor. This ther-
men, recommended diet, and training as an adjunct to therapy. Donna Chojnowski is a heart failure/transplant nurse
practitioner and clinical manager of the heart failure
other guidelines can improve his and cardiac transplant program at the Hospital of the
University of Pennsylvania in Philadelphia, Pa.
functional ability, leading to a bet- Future directions
ter quality of life. As researchers learn more about The author has disclosed that she has no significant
relationship with or financial interest in any commer-
Teach the patient to weigh him- the complex cascade of heart fail- cial companies that pertain to this educational activity.
INSTRUCTIONS
Managing systolic heart failure
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1. The most useful noninvasive diagnostic tool 7. Which statement is correct about beta- b. is effective in treating heart failure after an MI.
for evaluating a patient with heart failure is blockers? c. is specifically indicated for patients who are
a. a computed tomography scan. a. They’re considered a mainstay of drug therapy symptomatic at rest.
b. an ECG. for heart failure. d. helps balance the potassium depletion caused by
c. an echocardiogram. b. They activate the sympathetic nervous system. loop diuretics.
d. a chest X-ray. c. Adverse reactions include excessive diuresis.
d. If bradycardia develops, the dose may need to 13. Which drug usually doesn’t conflict with
2. A patient with heart failure and angina be increased. heart failure therapy?
should have which test to evaluate for CAD? a. NSAIDs
a. cardiac exercise test 8. Which isn’t a goal of treatment for stage C b. thiazide diuretics
b. magnetic resonance imaging heart failure? c. antiarrhythmics
c. right-sided heart catheterization a. improve survival d. calcium channel blockers
d. coronary angiogram b. decrease symptoms
c. slow disease progression 14. Benefits of biventricular pacing include
3. Which of the following best describes d. prepare the patient for end–of-life care or hospice decreasing heart size and
stage B heart failure? a. synchronizing left atrial with LV contractions.
a. LV hypertrophy without heart failure symptoms 9. Which statement is correct about digoxin? b. increasing mitral regurgitation.
b. past heart failure symptoms with ventricular a. Digoxin is never used to treat heart failure. c. increasing ejection fraction.
remodeling b. It’s a first-line drug for heart failure. d. increasing ventricular volume.
c. LV hypertrophy with heart failure symptoms c. It’s indicated for symptomatic patients despite
d. heart failure symptoms at rest despite treatment treatment with ACE inhibitors, beta-blockers, and 15. A patient with symptomatic stage C heart
diuretics. failure and a QRS duration greater than 120
4. According to the JNC 7 guidelines, which d. It impedes the conversion of angiotensin I to milliseconds despite optimal medical treat-
BP falls within current recommendations for angiotensin II. ment is a good candidate for
a patient with type 2 diabetes? a. stopping treatment with ACE inhibitors.
a. 128/78 c. 138/88 10. Which drug is an aldosterone antagonist? b. a VAD.
b. 132/84 d. 140/90 a. spironolactone c. furosemide c. heart transplant.
b. bumetanide d. torsemide d. biventricular pacing.
5. To control BP and limit end organ damage
in a patient with diabetes and stage A heart 11. BiDil is a combination of 16. Teach a patient with heart failure that
failure, administer a. an ACE inhibitor and beta-blocker. a. fluid restriction isn’t necessary if he’s taking
a. digoxin. c. calcium channel blockers. b. furosemide and eplerenone. diuretics.
b. ACE inhibitors. d. aldosterone antagonists. c. digoxin and torsemide. b. he should weigh himself weekly and limit sodi-
d. hydralazine and isosorbide. um to 4 grams/day.
6. ACE inhibitor–induced cough is thought to c. stopping smoking and losing weight most likely
be secondary to increased endogenous 12. The main significance of BiDil is that it won’t improve heart failure.
a. leukotrienes. c. bradykinin. a. is the first heart failure medication approved for d. following a 2-gram/day sodium diet and exercis-
b. histamine. d. nitric oxide. a specific ethnic group. ing will improve his quality of life.
B. Test Answers: Darken one circle for your answer to each question.
a b c d a b c d a b c d a b c d
1. ❍ ❍ ❍ ❍ 5. ❍ ❍ ❍ ❍ 9. ❍ ❍ ❍ ❍ 13. ❍ ❍ ❍ ❍
2. ❍ ❍ ❍ ❍ 6. ❍ ❍ ❍ ❍ 10. ❍ ❍ ❍ ❍ 14. ❍ ❍ ❍ ❍
3. ❍ ❍ ❍ ❍ 7. ❍ ❍ ❍ ❍ 11. ❍ ❍ ❍ ❍ 15. ❍ ❍ ❍ ❍
4. ❍ ❍ ❍ ❍ 8. ❍ ❍ ❍ ❍ 12. ❍ ❍ ❍ ❍ 16. ❍ ❍ ❍ ❍
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