Heart Failure: Pathophysiology And Management






Introduction
A major public health issue is heart failure was viewed solely as haemodynamic disorder.
A Prevalent Condition of Heart Failure
  • In the developed world the prevalence of heart failure is high and is increasing.
  • In the US alone, it is estimated that 4.8 million Americans have heart failure.
  • In the US, there are estimated to be 400,000 new cases each year.
Increasing prevalence, hospitalizations and deaths have made heart failure a major healthcare problem. Half of all patients diagnosed with heart failure will be dead within 5 years. Despite a decrease in mortality for most cardiovascular diseases (stroke, coronary heart disease), the mortality associated with heart failure is increasing. The trend is expected to increase further as the population ages.

Neuro-Hormonal Activation
Neuro-Hormonal Activation as a significant factor contributing to progressive systolic dysfunction and programmed myocardial cell death, also called apoptosis. Neuro-Hormone Secretion in Response to Heart Failure are:
  • Nor epinephrine caused vasoconstriction, increased heart rate and myocyte toxicity.
  • Angiotensin II caused vasoconstriction, stimulates release of aldosterone and activates the sympathetic nervous system.
  • Aldosterone caused sodium and water retention.
  • Endotheline caused vasoconstriction and myocyte toxicity.
  • Antidiuretic hormone (vasopressine) caused vasoconstriction and water reabsorption.
  • Tumor necrosis factor alpha (TNF-alfa) caused direct myocite toxicity.
  • Interleukin I (IL-1) caused myocyte toxicity.
  • Neuro-hormone (atrial natriuretic peptide and brain natriuretic peptide) caused vasodilatation, excretion of sodium and antiproliferative effect on myocytes.
Common Etiologies of Heart Failure in Older Patients
  • Coronary artery disease, such as Acute Myocardium Infarct.
  • Hypertensive heart disease.
  • Valvular heart disease, such as atrial stenosis, mitral stenosis.
  • Cardiomyopathy, caused by restrictive, dilated hyperthrophic.
  • Pericardial disease.
  • High output syndrome, such as anemia, hyperthyroidism.
  • Age related diastolic syndrome.
Common Co-morbidities in Older Patients
  • Renal dysfunction.
  • Chronic lung disease.
  • Cognitive dysfunction, caused by dietary, medication.
  • Depression, social isolation.
  • Urinary incontinence.
  • Nutritional disorder.
  • Polypharmacy, such as drug interaction.
Symptoms of Chronic Heart Failure
The classic symptom of Chronic Heart Failure is shortness of breath. Specific common symptom include:
  • paroxysmal nocturnal dyspnea (awakening from sleep with shortness of breath)
  • orthopnea
  • new onset dyspnea on exertion
If history and physical examination clearly indicate a non cardiac cause for these symptoms (e.g. severe pulmonary disease) then heart failure evaluation is not necessary.
Symptoms of Chronic Heart Failure for young adult patients are dyspnea on exertion, dyspnea at rest, orthopnea, paroxismal nocturnal dyspnea (PND), fatigue, and ankle swelling.
Symptoms of Chronic Heart Failure for elderly patients are dyspnea on exertion, confusion, agitation, depression, insomnia, weakness, anorexia or nausea, and cough. 

Physical Examination Heart Failure
Systolic heart failure, classified by an ejection fraction less than 40 %, is characterized by a reduced cardiac output secondary to depressed myocardial contractility.
Diastolic heart failure, classified by a normal ejection fraction (greater than or equal to 50 %, in the presence of pulmonary congestion and other heart failure symptoms (for example, dyspnea d‘effort, paroxismal nocturnal dyspnea, fatigue, and orthopnea) and fourth heart sound.

Adapted from Lecture Note on Heart Failure by Prof. DR. dr. Moch. Fathoni,,Sp.JP Departement of Cardiology, Medical Faculty, Sebelas Maret University.
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