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Heart failure is a complex syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. It is classified as due to reduced ejection fraction (HFrEF), or systolic HF, and preserved faction (HFpEF), or diastolic HF.
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Symptoms (due to fluid accumulation and/or poor cardiac output)
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Dyspnoea → exertional dyspnoea → dyspnoea at rest → orthopnoea → paroxysmal nocturnal dyspnoea
Dry irritating cough—mainly nocturnal
Lethargy/fatigue/weakness
Weight change: gain (mainly) or loss
Dizzy spells/syncope
Palpitations
Ankle oedema
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Investigations Apart from routine investigations, left ventricular function should be measured by echocardiography (the most important test) or nuclear gated blood pool scanning to determine the ejection fraction, which is usually very low in heart failure. B-type natriuretic peptide is a marker of the severity of CHF. Differentiate between systolic (commonest) and diastolic failure.
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Treatment The treatment of heart failure includes appropriate patient education, determination and treatment of the cause, removal of any precipitating factors, general non-pharmaceutical measures and drug treatment. Studies have shown the benefit of a multidisciplinary approach.
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Prevention The emphasis on prevention is very important since the onset of heart failure is generally associated with a very poor prognosis. Approx. 50% of patients with severe heart failure die within 2–3 years of diagnosis.
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General non-pharmacological management
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Refer for a rehabilitation program with interdisciplinary care
Physical activity: rest if symptoms severe; moderate activity when symptoms are absent or mild
Weight reduction, if patient obese
Salt restriction: advise no-added-salt diet (<2 g or 60–100 mmol/d)
Encourage no smoking and limited alcohol (1 SD/d)
Water restriction: water intake should be limited to ≤1.5–2 L/d in patients with advanced heart failure, esp. when the serum sodium falls below 130 mmol/L
Fluid aspiration if a pleural effusion or pericardial effusion is present
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Drug therapy of systolic heart failure Any identified underlying factor should be treated. Initial drug therapy should consist of an ACE inhibitor and a β-blocker and usually a diuretic. Loop diuretics such as frusemide are preferred for acute episodes although other diuretics may be used for long-term maintenance therapy. Atrial fibrillation should be treated with amiodarone or digoxin (limited use). Vasodilators are widely used for heart failure and ACE inhibitors are currently the most favoured vasodilator.
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Note: Monitor and maintain potassium level in all patients.
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ACE inhibitors, β-blockers and spironolactone have been shown to improve survival in CHF and in combination are the gold standard.
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Initial therapy of chronic heart failure
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ACE inhibitor (start low, go slow, aim high)
Dosage of ACE inhibitor: start with ¼ to ½ lowest recommended therapeutic dose and then adjust for the individual patient by gradually increasing it to the maintenance or max. dose (Table H6). Once-daily agents are preferred. Use ...