CONTINUING EDUCATION Figure 3: Comparison of ACCF/AHA and D patients. (See Appendix B.)6,7Stages of Heart Failure and NYHA Functional Classifications6, 7 ACC/AHA STAGES OF HEART FAILURE At high risk for A HF - without structural heart disease or symptoms Structural B heart disease - without signs of symptoms of heart failure Structural heart C disease with prior or cyrrent symptoms of heart failure
NYHA FUNCTIONAL CLASS None
i
i
ii
iii
iv
D
Refractory heart failure requiring specialized interventions
iv
No limitation of physical activity, Ordinary physical activity does not cause symptoms of heart failure No limitation of physical activity, Ordinary physical activity does not cause symptoms of heart failure Slight limitation of physical activity. Comfortable at rest, ordinary physical activity causes symptoms of heart failure Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of heart failure Unable to carry out any physical activity without symptoms of heart failure or symptoms of heart failure at rest Unable to carry out any physical activity without symptoms of heart failure or symptoms of heart failure at rest
Risk Factors Associated with Heart Failure There are many known risk factors associated with heart failure, so it is important to recognize and treat each to prevent structural heart disease and the onset of heart failure.2,6 (See Figure 4.) Figure 4: Risk Factors Associated with Heart Failure
DIABETES MELLITUS ANEMIA
CARDIOMYOPATHIES
ATRIAL FIBRILLATION
RISK FACTORS ASSOCIATED WITH HEART FAILURE
ATHEROSCLEROTIC DISEASE
HYPERTENSION
METABOLIC SYNDROME
1. Atrial Fibrillation (AF) – Patients with irregular heart rates (too fast, too slow, or irregular rhythms) are said to have 20 |
Insight
arrhythmias.18 Atrial Fibrillation (AF), the most common type of arrhythmia, occurs when the heart beats in a disorganized rapid pace, causing blood to pool in the atria. This can lead to stroke and/or HF.6 The goal of therapy is to prevent thromboembolic events and mitigate symptoms.6,18 Nondihydropyridine calcium antagonists, such as diltiazem, should be used with caution in those with depressed EF because of their negative inotropic effect (weakening the force of muscular contractions).6 2. Anemia – Patients with HF often have iron deficient anemia (ferritin < 100ng/mL or 100 to 300ng/mL if transferrin saturated is < 20 percent).9 Anemia occurs when the blood has a diminished number of red blood cells or reduced hemoglobin (required for carrying oxygen from the lungs to the rest of the body), contributing to weakness, fatigue, shortness of breath, dizziness, and headaches.19 It is important to correct this imbalance with intravenous iron supplements to improve exercise capacity and quality of life (QOL).6,9 The use of erythropoietin stimulating agents has not been useful in this situation.6,9 3. Hypertension (HTN) – Patients with increased diastolic pressure (when the heart is at rest between beats) and especially increased systolic pressure (when the heart beats while pumping blood) are at a much greater risk of developing HF.19 Advanced age, duration of hypertension, and higher levels of blood pressure increase the incidence of HF.6 Control of blood pressure can reduce the risk of HF by 50 percent. The target goal for blood pressure is about 130/80 mm/ Hg.6,9 4. Diabetes Mellitus – The inability to produce insulin, coupled with obesity, increases the risk of developing HF and negatively impacts the prognosis of those that have HF. Patients with NYHA class II through IV HF should avoid thiazolidinediones (e.g., rosiglitazone) as they are associated with fluid retention and can worsen the condition.6,13,14 5. Metabolic Syndrome – Metabolic syndrome is associated with an increased risk of developing HF. This condition includes at least three of the following: abdominal adiposity, hypertriglyceridemia, low high-density lipoprotein, hypertension, and high fasting blood sugar. It is imperative that patients with hypertension, diabetes mellitus (DM), and dyslipidemia receive treatment to reduce the incidence of HF. 6. Atherosclerotic Disease – The narrowing of the arteries due to plaque buildup reduces blood flow to the heart muscle.6 Vascular risk factors must be controlled to reduce the risk of HF.6 7. Cardiomyopathies – These diseases cause the heart muscle to become enlarged, thick, or ridged. As the disease progresses, the heart weakens.16 The condition can be acquired or inherited. While obesity, DM, hyperthyroidism, acromegaly, and growth hormone deficiency have been associated with the condition, the cause is often unknown.6 Toxins such as alcohol or cocaine, when abused, similarly contribute to this condition. It is associated with antineo-