Heart Failure

Key Points such as reduced LVEF or valve disease or

 Heart failure is best defined as a clinical other structural disorder, raised natriuretic
syndrome, a recognizable cluster of typical peptide concentration).
signs and symptoms related to venous
congestion and reduced organ perfusion. Clinical Definition of Heart Failure
 Typical signs and symptoms of the clinical
syndrome heart failure have limited sensitivity In clinical practice, the following simplified definition
and specificity. can serve as an orientation for the 4 Stages of Heart
Failure.
 Heart failure diagnosis should be classified by
left-ventricular ejection fraction (reduced vs.
HEART PUMP INSUFFICIENCY RESULTING IN
preserved ejection fraction).
SYMPTOMS
Heart Pump:
1. Definitions and Classification A complete description of the heart includes vascular,
1.1. Definitions electrical, hormonal, and structural components. For
Heart failure is not a single diagnosis, but rather a heart failure to be present, however, there must be
syndrome of multiple etiologies. The 2013 impairment of the heart to move blood in the
ACCF/AHA Heart Failure Guidelines defined heart circulation. A way to define impaired heart pump
failure as “a complex clinical syndrome that results function is the inability of the heart to supply blood
from any structural or functional impairment of flow to meet the needs of the body either at rest or with
activity, or to do so with increased left or right
ventricular filling or ejection of blood.”
ventricular flling pressures. If importance, this may
Heart failure is defined as the occur with either a reduced or preserved ventricular
pathophysiologic state in which impaired cardiac ejection fraction.
function is unable to maintain an adequate
circulation for the metabolic needs of the tissues of Insufficiency:
the body. It may be acute or chronic. The term The word “failure” implies a cessation of function, as in
congestive heart failure (CHF) is used for the patients with “renal failure” who are either on or in
chronic form of heart failure in which the patient imminent need of dialysis. In heart failure, heart pump
has evidence of congestion of peripheral circulation insuficiency does not, in general, require complete
and of lungs (page 90). CHF is the end-result of replacement therapy. This semantic difference may be
important to emphasize to patients or families with a
various forms of serious heart diseases.
new diagnosis of “heart failure.”
Heart failure is a complex clinical
syndrome that results from any structural or
Resulting In:
functional impairment of ventricular filling or
Risk factors or asymptomatic cardiac dysfunction often
ejection of blood. There is a consequent failure to precede the first symptoms of heart failure. Advances in
deliver oxygen according to metabolic understanding neurohumoral mechanisms that impel
requirements, despite normal filling pressures (or this progression over time have let to significant
only at the expense of increased filling pressures). therapies for heart failure with reduced ejection
Patients have the following features:  fraction.
 Typical symptoms (breathlessness at rest or
on exercise, fatigue, tiredness, ankle Symptoms:
oedema), and Stages A and B of the American College of
Cardiology/American Heart Association classification
 Typical signs (tachycardia, tachypnoea,
of heart failure are asymptomatic and considered pre-
pulmonary rales, pleural effusion, raised
heart failure. A clinical definition of heart failure,
jugular venous pressure, peripheral oedema, however, is confined to Stages C and D, characterized
hepatomegaly, and by current or previous symptoms associated with heart
 Objective evidence of a structural or pump insufficiency. Common symptoms are shortness
functional abnormality of the heart at rest of breath associated with lung congestion and
(cardiomegaly, third heart sound, cardiac peripheral edema.
murmurs, abnormality on the echocardiogram,
1.2. Classification

1
Heart failure with reduced ejection fraction hospital discharges in 2010.
(<40%) (HFrEF)  In the Medicare population, heart failure is the
Also referred to as systolic HF. Randomized most common cause for hospitalization.
clinical trials have mainly enrolled patients with  After heart failure discharge, readmission rates for
recurrent heart failure or other causes are 24%
HFrEF, and it is only in these patients that
within the first month and 50% within the first 6
efficacious therapies have been demonstrated
months.
to date.
 In 2012, direct and indirect medical costs
associated with heart failure were $30.7 billion.
Heart failure with preserved ejection fraction  One in 9 deaths includes heart failure on the death
(>40%) (HFpEF) certificate.
Also referred to as diastolic HF (Figure 31.1). To
date, efficacious therapies have not been identified.
The ACC/AHA have further subdivided this 2. Etiology
category into: Heart failure may be caused by one of the
 HFpEF, borderline 41–49%. Borderline or following either singly or in combination:
intermediate group with characteristics, 1. INTRINSIC PUMP FAILURE. The most
treatment patterns, and outcomes similar to common and most important cause of heart
those of patients with HFpEF. failure is weakening of the ventricular muscle
 HFpEF, improved >40%. A subset of due to disease so that the heart fails to act as an
patients with HFpEF who previously had efficient pump. The various diseases which
HFrEF. These patients with improvement or may culminate in pump failure by this
recovery in EF may be clinically distinct from mechanism are as under:
those with persistently preserved or a. Ischaemic heart disease
reduced EF. b. Myocarditis
c. Cardiomyopathies
Heart failure with recovered ejection fraction d. Metabolic disorders e.g. beriberi
(HF-recovered) refers to recovery of LV function e. Disorders of the rhythm e.g. atrial
accomplished by optimal medical therapy, devices, fibrillation and flutter
or revascularization. These patients have a better
event-free survival than HFpEF, but abnormalities 2. INCREASED WORKLOAD ON THE
in biomarkers and hospitalizations still occur. HEART. Increased mechanical load on the
heart results in increased myocardial demand
FAST FACTS resulting in myocardial failure. Increased load
on the heart may be in the form of pressure
 Heart failure diagnosis is usually based on load or volume load.
Framingham criteria: either two major, or one a. Increased pressure load may occur in the
major and two minor criteria. Less severe heart
following
failure can manifest without fulfilling these
1) Systemic and pulmonary arterial
criteria.
hypertension.
 The ACCF/AHA 4 Stages (A, B, C, D) and the
New York Heart Association functional 2) Valvular disease e.g. mitral stenosis,
classifications of heart failure (I-IV) are aortic stenosis, pulmonary stenosis.
complementary. 3) Chronic lung diseases.
b. Increased volume load occurs when a
In the United States: ventricle is required to eject more than
 Heart failure annual incidence increased from normal volume of the blood resulting in
250,000 cases in 1970 to 825,000 cases in 2010, cardiac failure. This is seen in the
contributing to a prevalence of 5.1 million following conditions:
individuals ≥ 20 years of age. 1) Valvular insufficiency
 Lifetime risk for developing heart failure at the age 2) Severe anaemia
of 40 years and greater is 1 in 5 in both men and
3) Thyrotoxicosis
women.
4) Arteriovenous shunts
 Between 1979 and 2010, annual heart failure
hospitalization rates tripled, with 1,023,000 5) Hypoxia due to lung diseases.

2
3. IMPAIRED FILLING OF CARDIAC structural heart  obesity
CHAMBERS. Decreased cardiac output and disease or  metabolic syndrome
cardiac failure may result from extracardiac symptoms of  exposure to cardiotoxins
heart failure.  family history of
causes or defect in filling of the heart:
a) Cardiac tamponade e.g. cardiomyopathy
haemopericardium, hydropericardium Stage B: Patients with:
Structural heart  previous myocardial infarction
b) Constrictive pericarditis.
disease but  left-ventricular hypertrophy
without signs or  reduced ejection fraction
Table 1. SELECTED CAUSES OF CONGESTIVE
symptoms of  asymptomatic valvular disease
HEART FAILURE
heart failure.  other structural heart disease
Myocardial Injury Stage C: Patients with:
 Adriamycin Structural heart  known structural heart disease
 Alcohol use disease with and
 Cocaine prior or current  shortness of breath and fatigue,
 Ischemic cardiomyopathy (atherosclerotic symptoms of reduced exercise tolerance
coronary artery disease) heart failure.
 Rheumatic fever Stage D: Patients with:
Refractory heart  marked symptoms at rest
 Viral myocarditis
failure requiring despite optimal medical
Chronic Pressure Overload
specialized therapy
 Aortic stenosis
interventions.  recurrent hospitalizations
 Hypertension
despite optimal medical
Chronic Volume Overload
therapy
 Mitral regurgitation
Infiltrative Diseases
Table 3. New York Heart Association Classification by
 Amyloidosis
Symptoms
 Hemochromatosis
Chronic Tachyarrhythmia or Bradyarrhythmia
NYHA Patient Symptoms
Class
Heart Failure Classification Class I No limitation of physical activity. Ordinary
In 1928, the New York Heart Association (NYHA) physical activity does not cause undue
functional classification was proposed to classify fatigue, palpitation, or dyspnea (shortness
the severity of heart failure based on symptoms. In of breath).
this system, severity ranges from no limitation of Class II Slight limitation of physical activity.
functional activity (Class I), slight limitation of Comfortable at rest, but ordinary physical
activity results in fatigue, palpitation, or
functional activity (Class II), marked limitation of
dyspnea.
functional activity (Class III), to the presence of
Class III  IIIA: Marked limitation of physical
symptoms at rest (Class IV). Although useful, to
activity.
characterize a patient’s functional impairment at Comfortable at rest, but less than
any point in time and provide an index that ordinary activity causes fatigue,
correlates with prognosis, the system is limited by palpitation, or dyspnea.
the potential for a patient’s class to either worsen or  IIIB: Marked limitation of physical
improve rapidly in response to acute exacerbations activity.
or treatments Comfortable at rest, but minimal
exertion causes fatigue, palpitation, or
Table 2. ACC/AHA Staging Classification dyspnea.
Class IV Unable to carry out any physical activity
Stage Description without discomfort. Symptoms of cardiac
Stage A: Patients with: insufficiency are present at rest. If any
At high risk for  hypertension physical activity is undertaken, discomfort
heart failure but is increased.
 atherosclerotic disease
without  diabetes

3
Tabel 1. American College of Cardiology/American Heart Association (ACC/AHA) Stages of Heart Failure (HF) Compared
to the New York Heart Association (NYHA) Functional Classification

When the diagnosis of HF is suspected,

the goals of the clinical assessment is to determine Tabel 2. Estimates of population-attributable risk (%) for
whether HF is present, define the underlying development of heart failure for common risk factors.
etiology and the type of heart failure (HFrEF versus The population-attributable risk estimates the proportion
of the population that would be free of heart failure if the
HFpEF), assess the severity of HF, and identify
risk factor were eliminated from the population.
comorbidities that can influence the clinical course
Accordingly, if the risk factors listed in this table were
and response to treatment. Although the diagnosis eliminated from a given population, the cumulative effect
of HF can be straightforward when the patient would be a reduction in heart failure by >50%
presents with a constellation of the classic signs
and symptoms in the appropriate clinical setting
(Tables 21.2 and 21.3), no sign or symptom alone Hypertension
can define the presence or severity of HF. Coronary
Furthermore, detection of diagnostic physical artery
findings of HF is imprecise, often requiring other disease
diagnostic tools. Thus, as depicted in Fig. 21.2, the Obesity
clinical assessment of HF most often depends on Diabetes
information that is gleaned from a variety of mellitus
sources, including the history (both past and Smoking
present), physical examination, laboratory tests,
cardiac imaging, and functional studies. Pathophysiology of Heart Failure

Risk Factors and Natural History of Heart Key Points

Failure  Heart failure is a pathophysiological state in
which oxygen delivery by the heart is
Heart failure is a common cardiac disease affecting insufficient to meet the metabolic needs of
between 5–6 million persons in the United States. active tissues at normal cardiac filling
Most cases of heart failure are associated with the pressures.
presence of other chronic cardiovascular diseases  Myocardial injury or overload induces changes
that lead to cardiac injury (most often in the form in ventricular structure and function that adapt
of myocardial infarction) or increased cardiac to changing loading conditions in order to
workload (most often in the form of hypertension). preserve stroke volume. This process is called
Hypertension is the most common risk factor for ventricular remodeling.
heart failure. Hypertension is thought to be causally  Increased myocardial wall stress and activation
associated with development of heart failure, but of neurohormonal and inflammatory systems
defi nitive studies of a causal link are lacking. stimulate myocellular signaling pathways for
Myocardial infarction has been causally linked to hypertrophy, fibrosis, and apoptosis, and
the development of heart failure in experimental promote ventricular remodeling and disease
studies and is associated with a lifelong increased progression.
risk of heart failure after an index event.

4
 The ventricular remodeling process may be Heart failure may be present when an individual
favorably altered by treatment interventions has physical limitations at rest or with activity due
that alter cardiac loading conditions and to inadequate cardiac output or increased left or
attenuate biological effects of pathological right ventricular filling pressures. The Framingham
activation of neurohormonal signaling study defined useful clinical criteria to identify
pathways. patients with heart failure. Blood levels of
 The clinical syndrome of heart failure is biomarkers, such as B-type natriuretic peptide
attributable to a combination of pathological (BNP), supplement clinical findings to characterize
changes in ventricular pump function the presence and severity of heart failure.
(ventricular remodeling) coupled with
alterations in peripheral oxygen utilization Table 4. Framingham diagnostic criteria for heart
associated with secondary changes in vascular failure. The diagnosis of heart failure, in the
Framingham heart failure study, required two major or
and skeletal muscle function.
one major and two concurrent minor criteria. Minor
criteria cannot be attributed to another medical condition.

Major Criteria Minor Criteria

Acute pulmonary edema Dyspnea on exertion
Paroxysmal nocturnal Night cough
dyspnea or orthopnea Tachycardia (> 120
Neck-vein distention beats/min)
Rales Pleural effusion
S3 gallop Hepatomegaly
Abdominojugular reflux Ankle edema
Cardiomegaly on chest x- Vital capacity decrease
ray (1/3 from max)
Gambar 1. Effects of left-ventricular remodeling on
Increased venous pressure Weight loss*
stroke volume. Increased leftventricular end-diastolic
(> 16 cm H2O)
volume preserves left-ventricular stroke volume in the
Weight loss*
setting of reduced ejection fraction. Cardiac output *Weight loss > 4.5 kg 5 days into treatment can be
reserve is theoretically normal at this stage of classified as a major or minor criterion
remodeling, but the remodeling process is inherently
pathological and eventually leads to progressive
Epidemiology
hypertrophy, fi brosis, and apoptosis, with resultant
loss of cardiac output reserve, and clinical heart failure.

Gambar 3. Prevalence and outcomes of heart failure

(HF) in the United States. A, Prevalence of HF by sex and
age (National Health and Nutrition Examination Survey:
2007–2010). B, Neslon-Aalen plots of cumulative hazard
Gambar 2. Pathophysiology of heart failure: response ratios for the development of congestive heart failure
to myocardial injury and/or overload leads to (CHF) by racial or ethnic group, in the Multi-Ethnic Study
ventricular remodeling and disease progression, and of Atherosclerosis (MESA) study. (A, Modified from Go
eventually clinical heart failure syndrome. This model AS, Mozaffarian D, Roger VL, et al. Heart disease and
of disease is the basis for clinical staging of disease stroke statistics—2013 update: a report from the
(Chapter 4) and treatment strategies. American Heart Association. Circulation 2013;127:e6-
245; B, From Bahrami H, Kronmal R, Bluemke DA, et al.
Differences in the incidence of congestive heart failure
Clinical Criteria of Heart Failure by ethnicity: the Multi-Ethnic Study of Atherosclerosis.
Arch Intern Med 2008;168:2138-45.)

5
 In a patient with a history of heart failure who
Acute and Chronic Presentations of Heart presents in a decompensated state, the priority is
Failure less to make a diagnosis of the etiology of heart
failure (this is usually known) and more to identify
the precipitating factors for the decompensation. A
patient may have pulmonary edema, systemic
congestion, or both. Findings of low cardiac output,
including fatigue, poor mentation, hypotension, and
hepatic and renal dysfunction, may coexist.

Figure 1. New-onset heart failure. This chest x-ray

shows a 49-year-old man with acute anterior myocardial
infarct and new-onset heart failure. Pulmonary
congestion is present with a relatively normal-sized
cardiac silhouette. Urgent percutaneous coronary
revascularization and diuretics led to improvement. Figure 3. Acute-on-chronic heart failure with reduced
EF. The chest x-ray shows a 60-years-old man with
Compensated Chronic Heart Failure history of ischemic cardiomyopathy, moderate renal
In a patient with compensated heart failure, there insufficiency, and increasing shortness of breath. Marked
are few active symptoms by definition; after cardiomegaly is obscured by pulmonary congestion and
treating causes of cardiac dysfunction, the priority bilateral pleural effusions.
may be to delay or reverse progression of structural
heart disease by blunting neurohumoral activation.

Figure 4. Acute-on-chronic heart failure with preserved

EF. This x-ray shows a 79-year-old female presenting
with acute shortness of breath and atrial fibrillation with
rapid ventricular response associated with history of
previous HF-pEF, coronary artery bypass surgery,
hypertension, and diabetes. Left ventricular ejection
fraction was 70%. Diuresis and slowing of heart rate led
to resolution of pulmonary edema in 3 days.

Figure 2. Compensated chronic nonischemic

cardiomyopathy. In this 24-year-old man, heart size is Approach to the Patient with Suspected Heart
increased, but lung fields are clear. An implantable Failure
cardioverter-defibrillator (ICD) device is present with
leads in the right atrium and right ventricle. A complete medical history and carefully focused
physical examination are the foundation of the
Acute-On-Chronic Heart Failure assessment in HF patients, providing important

6
information regarding etiology of HF, identifying make the most judicious use of additional tests.
possible exacerbating factors, and lending pivotal Further, the history helps to evaluate incongruent
data for proper management (see Chapter 10). The results that may emerge during the diagnostic
information obtained guides the further direction of process, and it can obviate the need for needless
the patient’s evaluation and enables the clinician to further testing.

Tabel 3. Signs and Symptoms of Heart Failure

Related to Venous Congestion Related to Reduced Organ Perfusion

Symptoms Dyspnea on exertion Dyspnea on exertion
Cough Fatigue
Paroxysmal nocturnal dyspnea Lethargy
Orthopnea Generalized weakness
Abdominal swelling Impaired concentration
Abdominal fullness Depression/dysthymia
Abdominal pain Agitation/anxiety
Lower extremity swelling Anorexia
Physical Elevated jugular venous pressure Tachycardia
Findings Rales Hypotension
Decreased breath sounds Narrow pulse pressure
Basilar dullness to percussion Thready pulse
S3 gallop Pulsus alternans
Hepatomegaly Cool extremities
Hepatojugular reflux
Ascites
Lower extremity edema
Diagnostic Pulmonary vascular congestion on chest X-ray Azotemia
Testing Pulmonary edema on chest X-ray Lactic acidosis
Findings Pleural effusion on chest X-ray
Abnormal liver function tests
Dilutional anemia
Hyponatremia
Elevation of brain natriuretic peptide levels

History accuracy only modestly (c-statistic, 0.83 versus

Both exertional and resting symptoms should be 0.86).
investigated. Common signs and symptoms include
dyspnea, fatigue, exercise limitation, orthopnea, Tabel 4.
and edema. In a review of 22 studies of adult
patients presenting to an emergency department Symptoms Associated with HF Include:
Fatigue
with dyspnea, the probability of heart failure was
Shortness of breath at rest or during exercise
best predicted by a past history of heart failure (LR,
Dyspnea
5.8; 95% CI, 4.1 to 8.0), paroxysmal nocturnal Tachypnea
dyspnea (LR, 2.6; 95% CI, 1.5 to 4.5), a third heart Cough
sound (LR, 11; 95% CI, 4.9 to 25), or AF (LR, 3.8; Diminished exercise capacity
95% CI, 1.7 to 8.8). An initial clinical impression Orthopnea
of heart failure as noted by a physician was one of Paroxysmal nocturnal dyspnea
the stronger clinical predictors of this diagnosis Nocturia
(LR, 4.4; 95% CI, 1.8 to 10.0). With the exception Weight gain/weight loss
Edema (of extremities, scrotum, or elsewhere)
of paroxysmal nocturnal dyspnea, these same
Increasing abdominal girth or bloating
features also predicted heart failure when there was
Abdominal pain (particularly if confined to right upper
concomitant pulmonary disease. The addition of quadrant)
testing for N-terminal pro–B-type natriuretic Loss of appetite or early satiety
peptide (NT-pro- BNP) increases diagnostic Cheyne-Stokes respirations (often reported by family
rather than patient)

7
 Somnolence or diminished mental acuity Dullness and diminished breath sounds at one or both
Historical Information Helpful in Determining if lung bases
Symptoms Are Caused by HF Rales, rhonchi, and/or wheezes
A past history of HF Apical impulse displaced leftward and/or inferiorly
Cardiac disease (e.g., coronary artery disease, valvular Sustained apical impulse
or congenital disease, previous myocardial infarction) Parasternal lift
Risk factors for heart failure (e.g., diabetes, Third and/or fourth heart sound (either palpable and/or
hypertension, obesity) audible)
Systemic illnesses that can involve the heart (e.g., Tricuspid or mitral regurgitant murmur
amyloidosis, sarcoidosis, inherited neuromuscular Hepatomegaly (often accompanied by right upper
diseases) quadrant discomfort)
Recent viral illness or history of HIV infection or Ascites
Chagas disease Presacral edema
Family history of HF or sudden cardiac death Anasarca*
Environmental and/or medical exposure to cardiotoxic Pedal edema
substances Chronic venous stasis changes
Substance abuse *Indicative of more severe disease.
Noncardiac illnesses that could affect the heart
indirectly, including high-output states (e.g., anemia, Jugular Venous Pressure
hyperthyroidism, arteriovenous fistulas)
Third and Fourth Heart Sounds
Physical Examination
In most patients with heart failure who require Rales and Edema
hospitalization, the reason for admission is volume
overload; failure to relieve it has negative
prognostic impact. Four signs are commonly used
to predict elevated filling pressures: jugular venous
distention/abdominojugular reflex, presence of an
S3 and/or S4, rales, and pedal edema. In general,
the use of a combination of findings, rather than
relying on isolated clinical findings, improves
diagnostic accuracy. Some clinicians advocate
assessment of the patient with heart failure along
two basic axes—volume status ( “dry” or “wet”)
and perfusion status (“warm” or “cold”)—as a
useful guide to therapy (see Figure 23-2). This
approach has prognostic usefulness, particularly in
assessing patients at discharge after admission for
heart failure. For example, such patients discharged
with a “wet” or “cold” profile experience worse
outcomes (HR, 1.5; 95% CI, 1.1 to 12.1; P = 0.017)
compared with those discharged “warm and dry”
(HR 0.9; 95% CI, 0.7 to 2.1; P = 0.5). Advanced
training may be required to achieve this level of
diagnostic precision with the physical examination.

Tabel 5. Physical Findings of Heart Failure

Figure 5. Common signs of heart failure.
Tachycardia
Extra beats or irregular rhythm
Narrow pulse pressure or thready pulse* Table 5. Symptoms and signs of Right and left-
Pulses alternans*
sided heart failure
Tachypnea
Cool and/or mottled extremities* Symptom or sign Right-sided Left-sided
Elevated jugular venous pressure heart failure heart failure

8
 Peripheral oedema Prominent Not Prominent cardiomegaly. Pleural effusions are a common sign but
Oedema Systemic Pulmonary have many non-cardiac causes.
Organomegaly Liver Cardiac
Raised jugular Prominent Not Prominent
venous pressure
Dyspnoea Not Prominent Prominent
Gastrointestinal Prominent Not Prominent

The Electrocardiogram
The electrocardiogram should be examined for
clues to the possible presence of structural heart
disease such as atrial and ventricular arrhythmias,
conduction abnormalities, atrial enlargement,
ventricular hypertrophy, evidence of active
myocardial ischemia/injury, or evidence of
myocardial infarction.
Common abnormalities include:
 Evidence of ischaemic heart disease; Q waves,
T wave inversion, bundle branch block
 Left ventricular hypertrophy; especially in
HFPEF Figure 7. Chest X-ray features of heart failure: 1
 Prolonged QRS duration (bundle branch Kerley B lines 2 upper lobe venous diversion 3 ill-
defined peri-hilar (batswings) shadowing 4 fluid in the
block); as a marker of prognosis
oblique and horizontal fissures 5 pleural effusions 6
 Rhythm abnormalities; atrial fibrillation, increased cardiothoracic ratio, where the width of the
paroxysmal ventricular arrhythmias heart shadow (H) is >50% of the width of the lung fields
(L).
A normal ECG makes the diagnosis of heart failure
unlikely.
Blood tests
Chest X-ray Blood tests are performed for a variety of reasons
Signs of heart failure are visible (Figures  6.1 and such as assessing severity and ruling out other
6.6). These findings can also support a diagnosis causes (Table  6.6). For example, concentrations
such as pulmonary fibrosis or COPD. BNP increase with the severity of heart failure and
fall with successful treatment, while anaemia is an
alternative cause of dyspnoea.

Table 6. Blood tests used in heart failure

Blood tests Purpose

Full blood Anaemia causes highoutput heart
count failure
Urea and Assess renal function
electrolytes Abnormalities reflect congestion
Liver function (rightsided failure)
tests Check for hypo/hyperthyroidism
Thyroid Hyperlipidaemia causes ischaemic
function tests heart disease
Lipids Check for diabetes
Glucose BNP elevated in heart failure
Natriuretic
Figure 6. Chest X-ray showing signs of pulmonary peptides
oedema (perihilar, batwing shadows). The increased
cardiothoracic ratio (where the cardiac silhouette is Echocardiography
>50% of the total width of the lungs) indicates

9
Transthoracic echocardiography should be All patients should be encouraged to improve their
performed as soon as heart failure is suspected to: lifestyle. This includes:
 measure the ejection fraction to distinguish  Exercise: in stable patients regular, structured,
HFREF from HFPEF aerobic exercise is safe. This improves
 assess for valve disease functional capacity and quality of life, and
 measure chamber dimensions reduces morbidity and hospitalisation. This is
 identify left ventricular hypertrophy best achieved through a tailored rehabilitation
programme which offers education and
Echocardiograms that show normal systolic psychological support
function do not exclude heart failure. Patients with  Alcohol: abstinence is vital in alcohol-related
normal systolic function can still have severe valve cardiomyopathy and all patients should drink
disease, severe diastolic dysfunction, pericardial in moderation
disease or high output heart failure .  Smoking: all patients should stop smoking
 Salt and water restriction: useful in advanced
Other tests heart failure. Typical targets are <1.5 L/day of
Other tests useful in assessing heart failure include: fluid and <6 g/day of salt
 6 minute walk test; used to objectively assess  Vaccination: against influenza (annually) and
functional capacity and monitor response to pneumococcus (once only)
therapy  Driving: patients should be aware of the legal
 Cardiopulmonary exercise testing; used to driving restrictions, especially those with large
assess exercise capacity and predict outcome in goods or passenger carrying licenses (see page
patients with heart failure, it asses the 318)
pulmonary, cardiovascular and skeletal muscle
systems in combination and is used in those Management of Asymptomatic Left-Ventricular
being considered for heart transplantation. Dysfunction
 Coronary angiography; used to diagnose
coronary artery disease, the commonest cause Key Points
of HFREF  Asymptomatic patients with evidence of left-
 Cardiac MRI; high resolution functional ventricular systolic dysfunction (left-
imaging modality used to assess ventricular ventricular ejection fraction <50% and/or left-
volumes and wall thickness, cardiac chamber ventricular hypertrophy) are at increased risk
dimensions, ventricular systolic function and for cardiovascular morbidity and mortality.
demonstrate myocardial ischaemia. It may also  Asymptomatic left-ventricular systolic
support the cause of heart failure by revealing dysfunction (left-ventricular ejection fraction
myocardial scar location or infiltrative disease. <50%) is most often identified after an index
myocardial infarction.
Management  Asymptomatic left-ventricular hypertrophy
A heart failure management plan should be agreed (determined by echocardiography or cardiac
with a heart failure team, including a cardiologist magnetic resonance imaging) is most often
and specialist nurse. The major aims of identified in patients with a history of
management are to: hypertension and/or chronic kidney disease.
 treat the underlying cause  A report of “diastolic dysfunction” on an
 improve prognosis echocardiogram or modestly elevated brain
 improve quality of life natriuretic peptide is not sufficient to make a
 reduce symptoms diagnosis of asymptomatic heart failure with
 reduce aggravating factors preserved ejection fraction.
 A combined neurohormonal antagonist
This is achieved by a combination of lifestyle regimen (angiotensin-converting enzyme
modifications, pharmacological and device therapy. inhibitor and beta-adrenergic receptor blocker)
is reasonable to consider for asymptomatic
Lifestyle Modification patients with reduced ejection fraction.

10
 A multi-drug regimen including inhibitors of Management of Chronic Symptomatic Heart
the renin-angiotensin aldosterone system is Failure
reasonable to control blood pressure in
asymptomatic left-ventricular hypertrophy in Key Points
patients with preserved ejection fraction.  Functional class and signs and symptoms of
congestion should be assessed at each office
visit.
Management of New-Onset Symptomatic Heart  Diuretic regimen should be adjusted as needed
Failure to maintain optimal volume status at each visit
for all patients with heart failure.
Key Points  Neurohormonal antagonists and eligibility for
 Early manifestations of symptomatic heart device therapy should be assessed and
failure are often mistaken for other common optimized at each encounter for patients with
clinical syndromes. heart failure and reduced ejection fraction.
 Typical physical findings of congestion are  Anti-hypertension therapy should be assessed
often absent at the time of clinical presentation. and optimized at each encounter for patients
 High index of suspicion in at-risk patients and with heart failure and preserved ejection
recognition of atypical presentations leads to fraction with history of hypertension.
faster and more accurate diagnosis.  Lifestyle modifications, including smoking
 Recognition of symptoms is critical for cessation, daily low-level aerobic exercise as
appropriate treatment strategy. tolerated, and reduction in dietary sodium,
should be discussed at each patient encounter.
 Education in patient self-management should
be provided to all patients to enhance their
adherence to medical therapy and lifestyle
recommendations.

Treatment Strategies
The treatment goal in the management of chronic
symptomatic heart failure is to apply the
information acquired from history, physical
examination, imaging, and laboratory results in
order to optimize the treatment regimen for each
patient.
Gambar 4. Algorithm for assessment of cardiac cause of
lower extremity edema. This algorithm does not Tabel 6. Diuretic oral dosing guidelines
present an exhaustive differential diagnosis for edema,
Medication Initial Maximum Frequency
but highlights the more common causes of edema
dose (mg) dose (mg)
encountered in clinical practice. See reference 5 for full
Loop Diuretics
discussion of differential diagnosis of edema. For
Furosemide 20-40 200 QD-BID
patients with likely heart failure, confirmatory testing is
Bumetinide 0.5-1.0 5 QD-BID
necessary (as described in the text) to rule out other
Torsemide 10-20 100 QD-BID
non-cardiac diseases associated with both elevated JVP
Thiazide diuretics
(jugular venous pressure) and edema. HCTZ 25 100 QD to Q7d
Metolazone 2.5 10 Qd to Q7d

11
Gambar 5. Strategy for optimization of therapy for patients with heart failure and reduced ejection fraction.

Daftar Pustaka

12