Heart Failure a.

This patient has a classic history for diastolic

heart failure, or heart failure with preserved
CLINICAL CASE PROBLEM 1 ejection fraction (HFpEF) in the 2013 updated
A 78-Year-Old Woman with Shortness of definitions of heart failure by the American
Breath College of Cardiology Foundation
A 78-year-old woman comes to the emergency (ACCF)/AHA. An estimated 40% to 71% of
department with a 6-month history of fatigue and patients with clinical heart failure have
shortness of breath, aggravated with performance preserved or normal systolic function.
of any exertional activity including activities of In these patients, contraction is normal, but
daily living. She has found that occasionally she diastole (relaxation phase) is abnormal. During
has to get up at night to open the window to get air. exertion, normal filling during diastole does
There has been a weight gain of 15 lbs during the 6 not occur, resulting in a decrease in LV
months, and there has been gradual swelling of her volume, and cardiac output is impaired and
ankles and legs. Her history reveals no previous progressively limited. Dyspnea is particularly
myocardial infarction or heart disease, but it does profound during exertion. Dyspnea at rest or
reveal the presence of type 2 diabetes for 15 years, on exertion is the most common sign of both
severe hypertension for 30 years, and obesity for 8 systolic and diastolic heart failure. Initially, the
years. Although the shortness of breath has been a dyspnea is present only with moderate
significant problem for only 6 months, she does amounts of exertion, but as the severity of the
mention having “some breathing problems” heart failure increases, the shortness of breath
intermittently for at least 4 years, and she has been may occur with minimal exertion, at rest, lying
treated for intermittent atrial fibrillation and down, or in sleep. Other common symptoms of
moderate chronic obstructive pulmonary disease. heart failure are fatigue, weakness, and
She is taking glyburide, hydrochlorothiazide, swelling. Patients with diastolic heart failure
diltiazem, Coumadin, ipratropium, and captopril. are, like the patient presented, frequently
On physical examination, the patient’s blood elderly and female, with a history of
pressure is 140/90 mm Hg. The respiratory rate is hypertension, diabetes, or obesity. Atrial
28 breaths per minute, and the pulse is 98 beats per fibrillation, if present, is usually paroxysmal,
minute and regular; she is afebrile. Head, ears, and a fourth heart sound (S4 gallop) is often
eyes, nose, and throat are unremarkable; there is no present if the patient is in sinus rhythm. In
elevated jugular venous distention (JVD). Both S1 systolic heart failure, or heart failure with
and S2 are normal, but a fourth heart sound is reduced ejection fraction (HFrEF), which can
present; there are no murmurs. Chest examination occur in all ages and more often in males, atrial
reveals bibasilar rales in both lung bases with fibrillation tends to be more persistent, a third
dullness. Abdominal examination is benign; the heart sound is present (S3 gallop), and there is
hepatojugular reflux is negative. Extremities reveal often a history of previous myocardial
bilateral 3+ pitting edema to both knees. Pulse infarction. In both forms of failure, lying flat is
oximetry shows an O2 saturation of 90% on room often followed by increasing shortness of
air. The electrocardiogram (ECG) reveals normal breath (orthopnea). Paroxysmal nocturnal
sinus rhythm, no acute changes, and left ventricular dyspnea is suggestive of heart failure. On
(LV) hypertrophy. You suspect a form of heart careful questioning, the patient often describes
failure and order a chest radiograph. the bouts as marked breathlessness—a
“suffocating feeling”—and these symptoms
SELECT THE BEST ANSWER TO THE are often accompanied by significant anxiety.
FOLLOWING QUESTIONS The patient has to sit upright or even stand up
1. Your working hypothesis, based on the history to breathe and may have the urge to rush to an
and physical examination, is that the patient open window to relieve the suffocating feeling.
has which of the following? Extra pillows are often needed to reduce the
a. diastolic heart failure number and severity of attacks. Some patients
b. systolic heart failure even have to resort to sleeping upright in a
c. biventricular heart failure chair at all times.
d. cor pulmonale
e. heart failure secondary to pulmonary 2. Based on the type of failure this patient has,
fibrosis what is most likely to be found on the chest
radiograph?
a. normal chest
 b. congestion and cardiomegaly
c. pulmonary edema b. This patient has diabetes; as a result,
d. congestion with or without cardiomegaly evidence-based guidelines suggest targeting a
e. cardiomegaly systolic blood pressure of less than 140 mmHg
and a diastolic blood pressure of less than 80
d. Patients with diastolic failure will present mmHg to reduce mortality and morbidity. All
with congestion with or without cardiomegaly patients with diabetes mellitus with
on the chest radiograph. Do not be fooled into hypertension or CHF should be treated with a
thinking that the absence of cardiomegaly rules regimen including an ACE inhibitor or an
out failure. In systolic failure, in contrast, ARB. Currently, it is unclear exactly how
cardiomegaly almost always is present. Heart much the systolic blood pressure should be
failure also can be distinguished by which lowered below 140 mm Hg. Various groups
ventricle is failing the most. Although LV have targets of 135 or 130 mm Hg for systolic
cardiac failure is manifested by symptoms blood pressure. The ACCORD (Action to
such as shortness of breath, right ventricular Control Cardiovascular Risk in Diabetes)
cardiac failure is manifested by signs such as blood pressure study was designed explicitly to
enlargement of the liver, positive hepatojugular test the benefit of lowering systolic blood
reflux, and elevated jugular venous pressure. pressure to less than 140 mm Hg. In patients
In severe cases of elevated right-sided atrial with type 2 diabetes at high risk for
pressure, splanchnic engorgement may cardiovascular events, systolic blood pressure
accompany anorexia, nausea, vomiting, ascites, of less than 120 mmHg compared with less
and eventually cachexia. In most instances of than 140 mm Hg did not reduce composite
chronic failure, however, both ventricles are outcome from all fatal or nonfatal
usually involved, making the distinction less cardiovascular events of all types, including
useful. The most common cause of right heart failure.
ventricular failure is LV failure.
CLINICAL CASE PROBLEM 2
3. The chest radiograph is consistent with the A 62-Year-Old Man with Exertional Dyspnea,
history and physical examination and your Orthopnea, and Wheezing
diagnosis of diastolic failure. The patient is A 62-year-old man, with a long history of smoking
admitted for therapy. You order two packs of cigarettes a day, presents to your
echocardiography. Again, based on the type of office with a history of worsening shortness of
failure this patient has, what is this likely to breath with exertion for the past 3 weeks. He also
show? relates recent onset of fatigue, two-pillow
a. normal LV cavity size orthopnea, and scattered wheezes on climbing a
b. an ejection fraction of greater than 40% flight of stairs. Five years ago, he had an anterior
c. a dilated left ventricle wall myocardial infarction but had been doing well
d. an ejection size of less than 40% until his recent symptoms. He has no other medical
e. a and b problems. He takes a baby aspirin and carvedilol
daily. On examination, his vital signs are as
e. A cardinal feature of diastolic heart failure is follows: pulse, 100 beats per minute and regular;
the presence on echocardiography of a normal respiration, 24 breaths per minute; blood pressure,
LVEF and a usually normal LV cavity size. 129/89 mm Hg; afebrile. Weight has increased by
Concentric LV hypertrophy is usually present 10 lbs since the last visit 6 months ago. There is
as well. In systolic heart failure, LVEF is JVD at 30 degrees of elevation, rales a third of the
usually less than 40%, and the ventricular way up in both lung fields, moderate hepatic
cavity is dilated. congestion, and a positive hepatojugular reflux.
Heart examination reveals an S4 but no murmurs.
4. The targeted range of the diastolic blood There is also 1+ pitting edema in both legs to his
pressure in this patient should be: mid-calves. You obtain an ECG, which shows
a. less than 90 mm Hg sinus rhythm and no acute changes but poor R-
b. less than 80 mm Hg wave progression in the anterior leads. The chest
c. between 80 and 90 mm Hg radiograph reveals cardiomegaly and pulmonary
d. it does not matter vascular congestion.
e. greater than 90 mm Hg to maintain
perfusion
5. Which of the following medications is (are) reflux is absent. The cardiac examination is
appropriate for acute management? unchanged. There is trace pitting edema in his
a. furosemide ankles bilaterally. He has lost 10 lbs. Results of
b. captopril echocardiography are pending.
c. diltiazem
d. labetalol 7. At this time, which of the following is (are)
e. a, b, and c appropriate medication(s) to consider
instituting?
a. The most appropriate acute a. an angiotensin-converting enzyme (ACE)
pharmacotherapeutic intervention is the inhibitor or angiotensin receptor blocker
administration of diuretics, particularly loop (ARB)
diuretics, preferably intravenously. b. a second beta blocker
Careful attention should be given to the c. a calcium channel blocker
patient’s urine output and weight as a measure d. digitalis
of successful diuresis. Reasonable e. a and d
investigations in acute heart failure include the
following: 12-lead ECG; chest radiograph; a. Two drugs have been shown to be
blood chemistries including blood urea particularly useful in the treatment of chronic
nitrogen (BUN), creatinine, glucose, and heart failure: ACE inhibitors and beta blockers,
electrolytes; brain natriuretic peptide (BNP); the latter of which this patient is already
complete blood count (CBC); thyroid- taking. Only three beta blockers (bisoprolol,
stimulating hormone (TSH); liver function carvedilol, and sustained-release metoprolol
tests and lipids; urinalysis for protein and succinate) have been proven to reduce
glucose; and echocardiography. Diuresis mortality in patients with chronic heart failure
should be accomplished with careful attention with reduced ejection fraction. ACE inhibitor
to electrolytes, especially potassium, with drugs such as captopril, enalapril, or lisinopril
adequate replenishment of depleted salts. have been shown to reduce both morbidity and
Oxygen should be administered to correct any mortality in patients with LVEF of less than
hypoxia, especially in the face of right 40% (Strength of Evidence = A). Little
ventricular failure. outcome difference exists between those taking
higher or lower doses, so the lower dose is
6. The nonpharmacologic treatments(s) of choice preferred to reduce potential side effects. For
for this condition may include which of the patients who cannot tolerate ACE inhibitors,
following? ARBs are a reasonable alternative, although no
a. salt restriction studies have produced evidence that they
b. fat restriction should be used as a first-line agent in chronic
c. water restriction CHF. Beta blockers should be initiated at a low
d. none of the above dosage and titrated gradually, typically at 2-
e. a, b, and c week intervals in patients with LVEF of less
than 40% (Strength of Evidence = B). Beta
e. Nonpharmacologic therapy for heart failure blockers, when they are used with caution and
involves the following in order of importance: introduced carefully, also have had a positive
bed rest, salt restriction (2 or 3 g sodium/day) effect on mortality and morbidity in multiple
(Strength of Evidence = C), fluid restriction (2 studies and are thought to work primarily by
L/24 hours, related to sodium restriction) countering the harmful effects of the
(Strength of Evidence = C), and fat restriction sympathetic nervous system. Initiation often
(as a reasonable approach to a healthy lifestyle may exacerbate symptoms. The addition of an
using the AHA Step 1 diet, which is 300 mg of ARB should be considered in patients with
cholesterol, 30% of total calories from fat, and heart failure attributable to LVEF of less than
10% of calories from saturated fat). 40% who have persistent symptoms or
progressive clinical worsening despite
The patient described here is treated with the optimized therapy with an ACE inhibitor and a
appropriate medication and improves. He returns in beta blocker (Strength of Evidence = A).
2 weeks with dyspnea and fatigue, although it is not Because the results of echocardiography are
as severe as before. Vital signs are normal. At this pending, it is uncertain whether digoxin is
time, the JVD has resolved and the hepatojugular appropriate in this patient. Calcium channel
 blockers have not demonstrated effectiveness inhibitor, diuretics, and a beta blocker
for the management of heart failure. (Strength of Evidence = B). Physicians should
be aware of drug interactions that may increase
8. Which of the following pathophysiologic digoxin levels. These include use of digoxin
mechanisms may underlie heart failure in this with verapamil, quinidine, procainamide,
patient and should be searched for as part of a nifedipine, or amiodarone. Physicians should
comprehensive evaluation? also be aware of electrolyte abnormalities
a. LV chamber remodeling (hypokalemia and hypomagnesemia) induced
b. coronary artery disease by diuretics and overdosage in the elderly, who
c. valvular heart disease may have decreased renal clearance.
d. abnormal excitation-contraction coupling
e. all of the above 10. Which of the following is (are) correct about
the effects of digitalis on patients with this
e. Heart failure is a syndrome in which a large condition?
number of pathophysiologic mechanisms may a. digoxin reduces long-term mortality
underlie the symptoms and signs of impaired b. digoxin decreases rates of worsening of
ventricular filling or ejection of blood. Some of heart failure in patients with reduced left
these include structural abnormalities of the ventricular ejection fraction (LVEF)
myocardium, LV chamber, and coronary c. lower digoxin maintenance doses may be
arteries and functional abnormalities of the as effective as higher doses
valves and electrical systems as well as of the d. digoxin use reduces hospitalizations
respiratory tree. In this patient, a e. b, c, and d
comprehensive evaluation would include a
search for evidence of LV chamber e. True statements about the use and effects of
remodeling, coronary artery disease, valvular digoxin include the following: digoxin
heart disease, abnormal excitation-contraction decreases the symptoms of worsening heart
coupling, and arrhythmias. Coexisting failure; lower digoxin maintenance doses (0.25
noncardiac diseases also should be identified mg or less) are as effective as higher doses;
and treated. That would include search for and and digoxin use in appropriate patients reduces
control of tobacco addiction, alcohol abuse, the rate of hospitalizations in CHF. Elderly
diabetes, hypertension, obesity, anemia, sleep patients and those with renal insufficiency are
apnea, and renal disease. also more susceptible to the toxic effects of the
drug. Remember that the primary indications
9. What is (are) the current indication(s) for the for its use are for those patients with CHF and
use of digitalis in this condition? both a low ejection fraction and atrial
a. a dilated left ventricle fibrillation with rapid ventricular rate.
b. an S3 or S4 gallop
c. decreased ejection fraction 11. In evaluating a patient for systolic dysfunction,
d. atrial fibrillation with a rapid ventricular the most important characteristic found on
rate echocardiography is
e. c and d a. myocardial hypertrophy
b. valvular heart disease
e. The use of digitalis (in the form of digoxin) c. cor pulmonale
has come full circle. This drug, isolated from d. low ejection fraction
the fox-glove plant, used to be the mainstay for e. wall motion abnormalities
treatment of CHF. For various reasons, it then
fell into disfavor, to the point at which it was d. In evaluating patients for systolic
virtually never used. The completion of the dysfunction, the most important characteristic
circle has resulted once again in the extensive found on echocardiography is the ejection
use of digoxin. Its primary indications are in fraction, which is usually less than 40% in
cases of CHF with a reduced ejection fraction systolic LV heart failure. Although myocardial
and in atrial fibrillation with a rapid ventricular hypertrophy, valvular heart disease, and wall
rate. Digoxin should be considered for rate motion abnormalities may be found, it is the
control of atrial fibrillation in patients with ejection fraction that defines systolic
LVEF of less than 40% while they are dysfunction.
receiving standard therapy with an ACE
12. Which of the following correctly define(s) the e. calcium channel blockers
American Heart Association (AHA) stages of
heart failure? e. Calcium channel blockers are the exception
a. stage A: asymptomatic patients at high in this list of interventions that have been
risk but with no identifiable structural found to be effective in reducing
abnormalities hospitalizations and mortality.
b. stage B: asymptomatic patients with
identifiable structural abnormalities 14. Which other risk factors are associated with
c. stage C: symptomatic patients with the development of heart failure?
structural abnormalities a. age
d. stage D: end-stage patients refractory to b. sex
standard therapy c. sleep-disordered breathing
e. all of the above d. chronic renal failure
e. all of the above
e. The AHA has developed a classification
system that defines the different stages of heart e. Special considerations in heart failure
failure, thereby emphasizing the preventive include the prevalence of risk with advancing
although usually progressive nature of the age, especially in individuals older than 60
condition. In stage A heart failure, years. Hypertension in this group confers an
asymptomatic patients are at high risk but with increased risk factor for all hypertension-
no identifiable structural abnormalities. In related morbidity and mortality including heart
stage B heart failure, asymptomatic patients failure. Likewise, women are at increased risk
have identifiable structural abnormalities. In for development of hypertension and obesity,
stage C, patients are symptomatic with especially if socioeconomically disadvantaged.
structural abnormalities. In stage D, end-stage Sleep-disordered breathing is an important risk
patients are refractory to standard therapy with factor for heart failure. In the Sleep Heart
symptoms at rest. Patients assigned to stage A Health Study, the presence of obstructive sleep
should have risk factor reduction, such as apnea was associated with a 2.4 relative risk
treatment of hypertension, dyslipidemia, or factor for the development of heart failure
diabetes, and patient and family education. independent of other known risk factors.
Patients assigned to stage B should be treated Chronic renal failure with activation of the
with ACE inhibitors or ARBs (all patients) and renin-angiotensin system and sympathetic
beta blockers (in selected individuals). Patients nervous system plays an important role in the
assigned to stage C should all be taking ACE initiation and progression of both renal disease
inhibitors and beta blockers; should be treated and heart failure. Renal insufficiency and
with dietary sodium restriction, diuretics, and microalbuminuria are recognized independent
digoxin (selectively, if indicated); may be risk factors for new-onset heart failure.
candidates for cardiac resynchronization if
bundle branch block is present; may be
revascularized or have correction of valvular
heart disease (if present); and may be treated
with an aldosterone antagonist. Stage D
refractory disease may be treated with all of
the previously mentioned methods as
appropriate plus the use of inotropes,
transplantation, ventricular assistive devices, or
hospice.

13. All of the following have been shown to

reduce hospitalizations and mortality in
selective patients with congestive heart failure
(CHF) except:
a. beta blockers
b. spironolactone
c. ACE inhibitors
d. biventricular pacing
 during diastole does not occur, and cardiac
output is hence impaired. Therefore, dyspnea
is particularly profound during exertion, and as
the severity of the heart failure increases, the
SUMMARY shortness of breath may occur with only
Heart failure is a complex clinical syndrome minimal exertion or even at rest. In systolic
that results from any structural or functional heart failure, the historically better studied
impairment of ventricular filling or ejection of form of heart failure, systolic function is
blood. The cardinal manifestations of heart impaired and the cardiac systolic ejection
failure are dyspnea and fatigue, which may fraction is diminished (less than 40%) as
limit exercise tolerance, and fluid retention, measured by echocardiography.
which may lead to pulmonary and/or Patients with diastolic cardiac failure are
splanchnic congestion and/or peripheral frequently elderly and female, with a history of
edema. Because some patients present without hypertension, diabetes, and obesity. Atrial
signs or symptoms of volume overload, the fibrillation, if present, is usually paroxysmal,
term “heart failure” is increasingly preferred and a fourth heart sound (S4 gallop) is often
over “congestive heart failure.” Some of the present in periods of normal sinus rhythm. In
pathophysiologic mechanisms underlying heart systolic heart failure, which can occur in all
failure include structural abnormalities of the ages and more often in males, atrial fibrillation
myocardium, LV chamber, and coronary tends to be persistent, a third heart sound is
arteries, and functional abnormalities of the present (S3 gallop), and there is often a history
valves and electrical systems. A of previous myocardial infarction. Classic
comprehensive evaluation includes a search for signs of both types of failure include
evidence of diminished pump function, LV tachypnea, tachycardia (with pulsus alternans),
chamber remodeling, coronary artery disease, JVD, rales, hepatojugular reflux, ascites,
valvular heart disease, abnormal excitation- edema, hepatosplenomegaly, cephalization and
contraction coupling, and arrhythmias. congestion of pulmonary markings on chest
Coexisting noncardiac diseases should also be radiography with or without cardiomegaly, and
identified and treated. That would include a diminished oxygen saturation on pulse
search for and control of tobacco addiction, oximetry. Reasonable investigations in acute
alcohol abuse, diabetes, hypertension, obesity, failure include the following: 12-lead ECG;
anemia, sleep apnea, and renal disease. chest radiograph; blood chemistries including
The AHA has developed a classification BUN, creatinine, glucose, and electrolytes;
system that defines the different stages of heart BNP; CBC; TSH; liver function tests and
failure, thereby emphasizing the preventive lipids; urinalysis for protein and glucose;
although usually progressive nature of the echocardiography; and pulse oximetry.
condition. In stage A heart failure, With stage A disease, patients should have risk
asymptomatic patients are at high risk but with factor reduction, such as treatment of
no identifiable structural abnormalities; in hypertension, dyslipidemia, or diabetes, and
stage B heart failure, asymptomatic patients patient and family education. Patients assigned
have identifiable structural abnormalities; in to stage B should be treated with ACE
stage C, patients are symptomatic with inhibitors or ARBs (all patients) and beta
structural abnormalities; and in stage D, end- blockers (in selected individuals). Patients
stage patients are refractory to standard assigned to stage C are symptomatic; in
therapy. addition to oxygen, the most appropriate acute
Dyspnea at rest or on exertion is the most pharmacotherapeutic intervention is the
common symptom of both systolic and administration of diuretics, particularly loop
diastolic heart failure, or HFrEF and HFpEF, diuretics, preferably intravenously. Careful
respectively. Other common symptoms of attention should be given to the patient’s urine
heart failure are fatigue, weakness, orthopnea, output and weight as a measure of successful
and paroxysmal nocturnal dyspnea. An diuresis. In addition, all stage C patients should
estimated 40% to 71% of patients have be taking ACE inhibitors and beta blockers and
diastolic heart failure with preserved or normal should be treated with dietary sodium
systolic function. In these patients, contraction restriction. Other therapies include the use of
is normal, but diastole (diastolic relaxation) is chronic diuretics, digoxin (selectively, if
abnormal. During exertion, normal filling indicated), aldosterone antagonists, cardiac
resynchronization if bundle branch block is
present, and revascularization or correction of
valvular heart disease (if present). The 2014
PARADIGM-HF (Prospective Comparison of
ARNI with ACEI to Determine Impact on
Global Mortality and Morbidity in Heart
Failure) trial showed a novel approach to heart
failure therapy, angiotensin receptor and
neprilysin inhibition with LCZ696, a
combination of sacubitril and valsartan, and
reduced cardiovascular mortality by 20% and
overall morality by 16%, as compared with
enalapril. Neprilysin is a neutral endopeptidase
involved in the metabolism of a number of
vasoactive peptides, and the inhibitor used in
the trial blocks the action of neprilysin,
resulting in higher levels of peptides such as
natriuretic peptides, which have vasodilator
properties, facilitate sodium excretion, and
most likely have effects on remodeling. Stage
D refractory disease may be treated with all of
the previously mentioned methods as
appropriate plus the use of inotropes,
transplantation, ventricular assistive devices, or
hospice.