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Congestive Heart Failure

Congestive heart failure is one of the top discharge diagnoses from acute hospitals in this country. It also accounts for a large percentage of readmissions to the hospital. In the elderly populations seeing primary care physicians, CHF is a common condition and is associated with significant morbidity and heart failure.

This issue deals with the major pharmacological and surgical interventions found to be useful in the management of CHF and ranks these interventions in light of recent scientific clinical studies. Although not specifically addressed in this issue, patient compliance with salt and fluid restriction has always been a hallmark of treatment.

Definition of the Problem

Every year nearly 400,000 people in the United States experience the onset of congestive heart failure (CHF). Of the 4.7 million people with CHF (1.5% of the total U.S. population), 900,000.

Pathophysiology of Congestive Heart Failure

Congestive heart failure occurs when the heart is unable to generate an adequate forward cardiac output to meet the metabolic needs of the body at normal filling pressures. When the cardiac output.


Work-Up of a Patient with CHF

Before initiating therapy, physicians must recognize that CHF is a non-specific syndrome that requires careful evaluation to: a) confirm that CHF is present; and b) clarify the etiology. Steps in evaluating a patient are outlined below.

History and physical examination: This is a vital part of the evaluation of any patient who presents with CHF.

Exercise intolerance, primarily manifested by subjective dyspnea, is the hallmark of heart failure and is often the first symptom. It is very important to differentiate dyspnea due to CHF from other causes of shortness of breath such as COPD, asthma, etc. Other, more advanced, symptoms of CHF include orthopnea, paroxysmal nocturnal dyspnea, edema (which usually indicates the presence of right heart failure but may also be secondary to medications [eg, calcium channel blockers]), cough.

CHF due to Coronary Artery Disease (CAD)

CHF secondary to coronary artery disease: In the United States, probably 40% of all CHF patients have CAD, and patients who develop CHF secondary to coronary artery disease.

Myocardial stunning: Myocardial stunning occurs after either a single or multiple brief episodes of coronary insufficiency. There is essentially a down regulation of myocardial function in response.

Hibernating myocardium: Hibernating myocardium occurs when there is a reduction of coronary perfusion, which leads to persistent left ventricular dysfunction. Studies have shown that ventricular function can be improved by restoring flow.

Evaluation for hibernating myocardium: Heart failure patients with coronary artery disease must be evaluated for possible myocardial viability in areas of hypoperfusion. A search for a history.

Treatment of CHF

Once the diagnosis of CHF has been made and the severity of heart failure ascertained, then treatment should be begun immediately. The following discussion will be divided into the medical and surgical managements of CHF.

Medical Management of CHF

ACE inhibitors: These are the first-line drugs in patients with CHF. Most, if not all, patients with symptomatic or asymptomatic left ventricular dysfunction should be started on ACE inhibitors.

In patients who are asymptomatic (Class I NYHA), enalapril has been shown to reduce hospitalizations for heart failure and shows a trend toward reduced mortality from CHF. Enalapril had no effect on sudden death when compared to placebo.

When compared to the vasodilator combination of hydralazine-isosorbide dinitrate, enalapril decreased mortality by 11%. The benefit was greatest during the first two years of therapy.22 The benefit during the first two years was thought to be secondary to a reduction in the risk.