2012 Heart Failure Update By george cohen, MD
2012 Heart Failure Update: All the Things You Wanted to Know, But Were Afraid to Ask The hieroglyphs of the Ebers papyrus probably represent the first clinical description of the syndrome of heart failure. They describe a heart that is “over flooded and weakened. The body parts are all together weak.” The best early description of heart failure, however, dates to the Roman writer Aulus Cornelius Celsus (25 B.C.E. – 50 C.E.) (De Medicina). “…….when moderate and without any choking, it is called dyspnoea; when more severe, asthma; but when in addition the patient can hardly draw his breath except with the neck outstretched, orthopnea. Of these, the first can last a long time, while the two following are as a rule acute. …..blood letting is the remedy unless anything prohibits….as the body becomes depleted by the measures the patient begins to draw his breath more easily. Moreover, even in bed the head is to be kept raised.” We’ve come a long since ancient Egypt and Rome. Since the early 1990s, our patients have benefited from clinical studies, which have tested and validated the concept of neurohormonal suppression. In 2012, the use of ACE inhibitors, angiotensin receptor blockers, aldosterone receptor blockers and beta blockers has become accepted therapy and is now class 1A recommendation, the gold standard for the modern treatment of congestive heart failure (CHF). The use of these medications has been supported by multiple randomized control trials dating from
the Studies of Left Ventricular Dysfunction (SOLVD) trial in 1992. All of these trials have focused on patients with “a bad ventricle,” individuals with so called systolic dysfunction. These patients are more likely to be male, have coronary disease and be younger. It is these individuals for whom development of device therapy such as biventricular pacing and defibrillator implantation has been added to our armamentarium of heart failure therapy. It is this group of patients for whom cardiac transplantation and/or the artificial heart are applicable when all else fails. In fact, our medical heart failure therapy has been so successful that the heart transplant waiting list has shrunk significantly over the past decade. That is the good news. The bad news is that with the aging of our population, we are now seeing an increasing number of patients with heart failure who have “a good ventricle.” They have a thick, stiff left ventricle with normal systolic function, but abnormal filling in diastole, so called “diastolic dysfunction.” The common acronym used is HFpEF, Heart Failure with preserved Ejection Fraction. These patients are more likely to be older, female and hypertensive, with multiple co-morbidities. Because they are able to generate sudden increase in left ventricular filling pressure that is transmitted back to their lungs, their presentation is usually that of acute pulmonary edema, giving rise to multiple emergency department visits and subsequent hospital admissions.
This latter group of patients can be more difficult to manage than patients with systolic dysfunction. The same interventions of neurohormonal suppression are employed, but randomized trial data have not shown similar survival benefits. Critical to the management of these patients is effective control of blood pressure with appropriate antihypertensives and careful control of volume status with loop diuretics, such as furosemide. In the case of a heart that is stiff, small increases in volume produce large increases in filling pressure, resulting in acute pulmonary edema. Conversely, even mild overdiuresis can lead to under filling of the ventricle and prerenal azotemia. Home based monitoring of blood pressure and weight with specialty focused nursing intervention can help balance volume status and prevent multiple hospital admissions. Finally, the end must come to all things. Whether CHF is systolic or diastolic in origin, some patients with truly end-stage heart failure become refractory to medical management. If it is decided that neither transplantation nor device therapy is appropriate, redefinition of the goals of therapy is important. Patient and family education regarding the role of palliative and hospice care services is of the utmost importance. With the ultimate goal of patient comfort, the array of options for end-of-life care and defibrillator inactivation should be discussed with the patient and the family. In this we show that we truly “care” for our heart failure patients. Dr. Cohen is board certified in cardiology and practices in Burlingame.
SAN MATEO COUNTY PHYSICIAN | page 13