Heart Failure

Contents

Preface xiii

Howard J. Eisen

Epidemiology of Heart Failure and Scope of the Problem 1

Longjian Liu and Howard J. Eisen

Heart failure (HF) is typically a chronic disease, with progressive deterioration occur-ring over a period of years or even decades. HF poses an especially large publichealth burden. It represents a new epidemic of cardiovascular disease, affectingnearly 5.8 million people in the United States, and over 23 million worldwide. Inthe present article, our goal is to describe the most up-to-date epidemiology ofHF in the United States and worldwide, and challenges facing HF prevention andtreatment.

Pathophysiology and Etiology of Heart Failure 9

Frances L. Johnson

Heart failure is a clinical syndrome that is heterogeneous in both pathophysiologyand etiology. This article describes some of the common mechanisms underlyingheart failure, and reviews common causes. Informative diagnostic testing isreviewed.

The Renin-Angiotensin-Aldosterone System and Heart Failure 21

Gabriel Sayer andGeetha Bhat

The renin-angiotensin-aldosterone system (RAAS) plays a critical role in the patho-physiology of heart failure with reduced ejection fraction (HFrEF). Targeting compo-nents of the RAAS has produced significant improvements in morbidity andmortality. Angiotensin-converting enzyme (ACE) inhibitors remain first-line therapyfor all patients with a reduced ejection fraction. Angiotensin-receptor blockersmay be used instead of ACE inhibitors in patients with intolerance, or in conjunctionwith ACE inhibitors to further reduce symptoms. Recent data support broader indi-cations for aldosterone antagonists in heart failure, and the combination of an ACE-inhibitor and aldosterone antagonist has become the preferred strategy for dualblockade of the RAAS.

The Sympathetic Nervous System and Heart Failure 33

David Y. Zhang and Allen S. Anderson

Heart failure (HF) is a syndrome characterized by upregulation of the sympatheticnervous system and abnormal responsiveness of the parasympathetic nervoussystem. Studies in the 1980s and 1990s demonstrated that inhibition of the renin-angiotensin-aldosterone system with angiotensin-converting enzyme inhibitorsimproved symptoms and mortality in HF resulting from systolic dysfunction, thusproviding a framework to consider the use of b-blockers for HF therapy, contraryto the prevailing wisdom of the time. Against this backdrop, this article reviewsthe contemporary understanding of the sympathetic nervous system and the failingheart.

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Evaluation of Patients with Heart Failure 47

Maria Patarroyo-Aponte andMonica Colvin-Adams

Heart failure is one of the most prevalent cardiovascular diseases in the UnitedStates, and is associated with significant morbidity, mortality, and costs. Promptdiagnosis may help decrease mortality, hospital stay, and costs related to treatment.A complete heart failure evaluation comprises a comprehensive history and physicalexamination, echocardiogram, and diagnostic tools that provide information regard-ing the etiology of heart failure, related complications, and prognosis in orderto prescribe appropriate therapy, monitor response to therapy, and transitionexpeditiously to advanced therapies when needed. Emerging technologies andbiomarkers may provide better risk stratification and more accurate determinationof cause and progression.

Management of ACCF/AHA Stage A and B Patients 63

Faiz Subzposh, Ashwani Gupta, Shelley R. Hankins, and Howard J. Eisen

Heart failure remains a major health problem in the United States, affecting 5.8 millionAmericans. Its prevalence continues to rise due to the improved survival of patients.Despite advances in treatment, morbidity and mortality remain very high, with amedian survival of about 5 years after the first clinical symptoms. This articledescribesthe causes, classification, and management goals of heart failure in Stages A and B.

Management of ACCF/AHA Stage C Heart Failure 73

Sasikanth Adigopula, Rey P. Vivo, Eugene C. DePasquale, Ali Nsair, and Mario C. Deng

ACC Stage C heart failure includes those patients with prior or current symptomsof heart failure in the context of an underlying structural heart problem who are pri-marily managed with medical therapy. Although there is guideline-based medicaltherapy for those with heart failure with reduced ejection fraction (HFrEF), therapiesin heart failure with preserved ejection fraction (HFpEF) have thus far proven elusive.Emerging therapies such as serelaxin are currently under investigation and mayprove beneficial. The role of advanced surgical therapies, such as mechanicalcirculatory support, in this population is not well defined. Further investigation iswarranted for these therapies in patients with Stage C heart failure.

Management of the ACC/AHA Stage D Patient: Cardiac Transplantation 95

Michelle M. Kittleson and Jon A. Kobashigawa

Over the last 4 decades, cardiac transplantation has become the preferred therapyfor select patients with end-stage heart disease. Heart transplantation is indicatedin patients with heart failure despite optimal medical and device therapy, manifestingas intractable angina, refractory heart failure, or intractable ventricular arrhythmias.This article provides an overview of heart transplantation in the current era, focusingon the evaluation process for heart transplantation, the physiology of the trans-planted heart, immunosuppressive regimens, and early and long-term complications.

Management of the ACC/AHA Stage D Patient: Mechanical Circulatory Support 113

David A. Baran and Abhishek Jaiswal

From humble beginnings in 1963 with a single desperately ill patient, mechanical cir-culatory support has expanded exponentially to where it is a viable alternative for

Contents ix

advanced heart failure patients. Some of these patients are awaiting transplant butothers will have a mechanical heart pump as their ultimate treatment. The history ofMCS devices is reviewed, along with the 4 trials that define the modern era ofcirculatory support. The practical aspects of life with an MCS device are reviewedand common problems encountered withMCS devices. Future trends includingmin-iaturization and development of completely contained MCS systems are reviewed.

Arrhythmias and Heart Failure 125

Heath E. Saltzman

Atrial fibrillation and ventricular tachyarrhythmias are frequently seen in patients withheart failure, and complicate the management of such patients. Both types ofarrhythmia lead to increasedmorbidity andmortality, and often prove to be challeng-ing issues to manage. The many randomized studies that have been performed inpatients with these conditions and concomitant heart failure have helped in design-ing optimal treatment strategies.

Sudden Cardiac Death in Heart Failure 135

Liviu Klein andHenry Hsia

Sudden cardiac deaths account for 350,000 to 380,000 deaths in the United Statesannually. Implantable cardioverter-defibrillators have improved sudden death out-comes in patients with heart failure, but only a minority of patients with defibrillatorsreceives appropriate therapy for ventricular arrhythmias. The risk prediction forsudden death and selection of patients for defibrillators is based largely on left ven-tricular ejection fraction and heart failure symptoms because there are no other riskstratification tools that can determine the individual patients who will derive thegreatest benefit. There are several other pharmacologic strategies designed to pre-vent sudden death in patients with heart failure.

Managing Acute Decompensated Heart Failure 145

Daniel F. Pauly

Acute decompensated heart failure may occur de novo, but it most often occurs asan exacerbation of underlying chronic heart failure. Hospitalization for heart failure isusually a harbinger of a chronic disease that will require long-term, ongoing medicalmanagement. Leaders in the field generally agree that repeated inpatient admissionsfor treatment reflect a failure of the health care delivery system to manage the dis-ease optimally. Newer management strategies focus on ameliorating symptomsby optimizing the hemodynamics, restoring neurohormonal balance, and makingfrequent outpatient adjustments when needed.

Heart Failure with Preserved Ejection Fraction: An Ongoing Enigma 151

Lisa J. Rose-Jones, John J. Rommel, and Patricia P. Chang

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndromebased on traditional heart failure symptoms with documentation of increased leftventricular filling pressures and preserved left ventricular ejection fraction. The exactmechanisms that induce HFpEF are not known. End-diastolic ventricular stiffnessdoes not seem to be acting alone. Substantial mortality exists compared with healthyage-matched controls, as well as significant health care expenditures on hospitaliza-tions and readmissions. This article reviews the epidemiology, pathophysiology, and

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treatment of heart failure with preserved ejection fraction (HFpEF). Current practiceguidelines focus on remedying volume overload, aggressively controlling hyperten-sion, and treatment of comorbid conditions that contribute to decompensation.

Adjunctive Therapy and Management of the Transition of Care in Patients withHeart Failure 163

Scott Feitell, Shelley R. Hankins, and Howard J. Eisen

Heart failure is a costly and difficult disease to treat. However, new metrics make itan imperative to keep these patients out of the hospital. Implementing and maintain-ing patients on successful treatment plans is difficult. A multitude of factors maketransitioning care to the outpatient setting difficult. A careful and well-orchestratedteam of cardiologists, general practitioners, nurses, and ancillary support staff canmake an important difference to patient care. A strong body of literature supportsthe use of pharmacologic therapy, and evidence-based therapies can improvemortality and quality of life, and reduce hospital admissions. Adjunctive therapiescan be equally important.

Index 175