2017年12月30日 星期六

Heart Failure

Types:
Heart failure with reduced ejection fraction (HFrEF, LVEF<40%)
left-ventricular systolic dysfunction
MI: Ischaemic heart disease,  Cardiomyopathy
Valvular dysfunction(mitral/aortic/tricuspid/pulmonary)

Heart failure with preserved ejection fraction (HFpEF, LVEF>50%)
Usually occurs in older hypertensive patients
older people, more women and more often have HTN or AF, while the history of myocardial infarction is less common.

HFmrEF, LVEF 40-49%

EF%=(EDV-ESV)/EDV x100%
一般人：EF約50-70%

Aims of management for chronic heart failure:
  • To reduce mortality 
  • To delay disease progression  
  • To control symptoms and improve quality of life

Aetiology病因 (ESC Guideline 2016)
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Diagnosis
Signs and symptoms
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Investigations

  • Bloods (FBC, U&Es, β - natriuretic peptide)
  • Chest X ray (ABCDE) 
  1. Alveolar shadowing (Bats wings sign) 
  2. B-lines (interstitial oedema) 
  3. Cardiomegaly 
  4. Diversion of blood to upper lobe
  5. Effusion 
  • ECG (may indicate/suggest cause e.g. ischaemia, ventricular hypertrophy)
  • Echocardiography 
Diagnostic algorithm for a diagnosis of heart failure of non-acute onset


Management

Lifestyle change
  • Stopping smoking 
  • Making dietary changes, such as moderating salt intake, increasing fruit and vegetable intake, reducing saturated fat 
  • Losing weight (if obese)
  • Increasing physical activity, aiming for at least 30 minutes of exercise on most days of the week 
  • Moderating alcohol intake to below recommended limits (patients with alcoholic cardiomyopathy should be advised to abstain from alcohol entirely)



Pharmacological treatments

  1. 1 st line: ACE-inhibitor + beta-blocker , + diuretic (e.g. furosemide, bumetanide) if peripheral/pulmonary oedema 
  2. 2 nd line: add aldosterone antagonist (e.g. spironolactone, eplerenone) 
  3. 3 rd line: add digoxin

Non-pharmacological treatments 
  1. Cardiac Resynchronisation Therapy (CRT) device 
  2. implantable cardioverter defibrillator (ICD)




Therapeutic algorithm for a patient with symptomatic heart failure with reduced ejection fraction. Green indicates a class I recommendation; yellow indicates a class IIa recommendation. ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARNI = angiotensin receptor neprilysin inhibitor; BNP = B-type natriuretic peptide; CRT = cardiac resynchronization therapy; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; H-ISDN = hydralazine and isosorbide dinitrate; HR = heart rate; ICD = implantable cardioverter defibrillator; LBBB = left bundle branch block; LVAD = left ventricular assist device; LVEF = left ventricular ejection fraction; MR = mineralocorticoid receptor; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; OMT = optimal medical therapy; VF = ventricular fibrillation; VT = ventricular tachycardia. aSymptomatic = NYHA Class II-IV. bHFrEF = LVEF <40%. cIf ACE inhibitor not tolerated/contra-indicated, use ARB. dIf MR antagonist not tolerated/contra-indicated, use ARB. eWith a hospital admission for HF within the last 6 months or with elevated natriuretic peptides (BNP > 250 pg/ml or NTproBNP > 500 pg/ml in men and 750 pg/ml in women). fWith an elevated plasma natriuretic peptide level (BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL, or if HF hospitalization within recent 12 months plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL). gIn doses equivalent to enalapril 10 mg b.i.d. hWith a hospital admission for HF within the previous year. iCRT is recommended if QRS ≥ 130 msec and LBBB (in sinus rhythm). jCRT should/may be considered if QRS ≥ 130 msec with non-LBBB (in a sinus rhythm) or for patients in AF provided a strategy to ensure bi-ventricular capture in place (individualized decision). For further details, see Sections 7 and 8 and corresponding web pages.

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