Heart Failure
Introduction and Facts
Heart failure can be defined as an abnormality of heart structure or function that causes failure of the heart to distribute oxygen throughout the body. Heart failure is a progressive health problem with high mortality and morbidity rates in developed and developing countries, including Indonesia.
In Indonesia, the age of heart failure patients is relatively younger than in Europe and America, accompanied by a more severe clinical appearance. According to a study conducted by Framingham, the annual incidence in men with heart failure (per 1000 events) increased from 3 at the age of 50-59 years to 27 at the age of 80-89 years, while women had a relatively lower incidence of heart failure than in men (women one third lower).
Pathophysiology
Heart failure is a complex clinical syndrome, which can result from disturbances in myocardial function (systolic and diastolic function), valvular or pericardial disease, or things that interfere with blood flow in the presence of fluid retention, usually seen as pulmonary congestion, peripheral edema, dyspnea, and fatigue. This cycle is triggered by increased neurohumoral regulation that initially functions as a compensatory mechanism to maintain the Frank-Starling system but instead causes excessive fluid accumulation with impaired cardiac function.
Clinical Symptoms and Complications
Many patients with heart failure remain asymptomatic. Clinical symptoms can appear due to the presence of precipitating factors that cause an increase in the work of the heart and an increase in oxygen demand. Precipitation factors that often trigger heart function disorders are infection, arrhythmia, physical work, fluids, environment, excessive emotions, myocardial infarction, pulmonary embolism, anemia, thyrotoxicosis, pregnancy, hypertension, myocarditis, and infective endocarditis.
Clinically, heart failure is a complex collection of symptoms in which a person appears: symptoms of heart failure, typical signs of heart failure, and objective evidence of impaired cardiac structure or function at rest.
Symptoms and signs of heart failure, according to the ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008:
Typical symptoms of heart failure: Shortness of breath at rest or activity, fatigue, leg edema
AND
Typical signs of heart failure: tachycardia, tachypnea, pulmonary crackles, pleural effusion, increased jugular venous pressure, peripheral edema, hepatomegaly.
AND
Objective signs of structural or functional disturbance of the heart at rest, cardiomegaly, triple heart sound, heart murmur, abnormality in echocardiographic features, increased concentration of natriuretic peptide.
Meanwhile, according to the ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012, the symptoms and signs of heart failure include:
Symptom:
Typical
• Hard to breathe
• Orthopnea
• Paroxysmal Nocturnal Dyspnea
• Reduced activity tolerance
• Tired quickly
• Swelling of the ankles
Less Typical
• Cough at night/early morning
• Wheezing
• Weight gain > 2 kg/week
• Weight loss
(advanced heart failure)
• Bloating/bloating
• Decreased appetite
• Feeling confused
(especially elderly patients)
• Depression
• Pounding
• Faint
Sign:
Specific
• Improved JVP
• Hepatojugular reflux
• S3 heart sound (gallops)
• Cardiac apex shifted laterally
• Heart murmur
Less Typical
• Edema perifer
• Pulmonary crepitus
• Dullness at the lung based on percussion
• Tachycardia
• Irregular pulse
• Fast breathing
• Hepatomegaly
• Ascites
• Cachexia
Diagnosis
More specific symptoms/symptoms rarely manifest, especially in patients with mild symptoms; therefore, symptoms become less sensitive as a basis for diagnostic tests. Diagnostic tests are usually most sensitive in heart failure patients with low ejection fractions, whereas diagnostic tests are less sensitive in patients with normal ejection fractions.
Electrocardiogram (ECG)
An electrocardiogram should be performed in all patients with suspected heart failure. ECG abnormalities are common in heart failure. ECG abnormalities have little predictive value in diagnosing heart failure. If the ECG is expected, the diagnosis of heart failure, especially with systolic dysfunction, is very low (<10%).
Thoracic Photos
Chest X-ray is an essential component in the diagnosis of heart failure. Chest X-ray can detect cardiomegaly, pulmonary congestion, pleural effusion and can detect lung disease or infection that causes or exacerbates shortness of breath. Cardiomegaly may be absent in acute and chronic heart failure.
Echocardiography
The term echocardiography is used for all cardiac ultrasound imaging techniques, including pulsed and continuous wave Doppler, color Doppler, and tissue Doppler imaging (TDI). Confirmation of the diagnosis of heart failure and/or cardiac dysfunction by echocardiography is mandatory and should be performed immediately in patients with suspected heart failure.
Laboratory
Routine laboratory examinations in patients suspected of heart failure are complete peripheral blood (hemoglobin, leukocytes, platelets), electrolytes, creatinine, estimated glomerular filtration rate (eGFR), glucose, liver function tests, and urinalysis. Other additional examinations are considered according to the clinical picture. Significant hematologic or electrolyte disturbances are rare in patients with mild to moderate symptoms who have not been treated. However, mild anemia, hyponatremia, hyperkalemia, and decreased renal function are common, especially in patients treated with diuretics and/or ACE-I (angiotensin converting enzyme inhibitors), ARBs (angiotensin receptor blockers), ARNIs (angiotensin receptor nephrilysin inhibitors), or aldosterone antagonists.
Natriuretic Peptides
Plasma natriuretic peptide levels can be used to diagnose, make decisions to treat or discharge patients, and identify patients at risk for decompensation. Natriuretic peptide levels increase in response to increased ventricular wall pressure. The average concentration of natriuretic peptide before the patient was treated had a high negative predictive value. It made the possibility of heart failure as the cause of the patient's symptoms very small.
Troponin I or T
Troponin examination is performed in patients with heart failure if the suspected acute coronary syndrome accompanies the clinical picture. In patients without myocardial ischemia, mild increases in cardiac troponin levels are standard in severe heart failure or during episodes of decompensated heart failure.
Management and Treatment
A. Non-Pharmacological Management
1. Self Care Management
2. Patient adherence to treatment
3. Independent weight monitoring
4. Fluid intake
5. Weight reduction
6. Losing weight without a plan
7. Physical exercise
8. Sexual activity
B. Pharmacological Management
The goal of diagnosis and therapy of heart failure is to reduce morbidity and mortality. Prevention of worsening heart disease remains an essential part of the management of heart disease. In addition, it is essential to detect and consider the treatment of comorbid cardiovascular and non-cardiovascular comorbidities.
1. Angiotensin-Converting Enzyme Inhibitors (ACE-I)
ACE-I should be administered to all patients with symptomatic heart failure and left ventricular ejection fraction c 40% unless contraindicated. ACE-I improves ventricular function and quality of life, reduces hospitalization for worsening heart failure, and improves survival (class of recommendation I, level of evidence A).
2. Receptor Blocker-8
Unless contraindicated, blockers eight should be given to all patients with symptomatic heart failure and left ventricular ejection fraction c 40%. Blockers improve ventricular function and quality of life, reduce hospitalization for worsening heart failure, and reduce mortality.
3. Antagonist Aldoseterone
Unless contraindicated, the addition of a small dose of an aldosterone antagonist should be considered in all patients with an ejection fraction c of 35% and severe symptomatic heart failure (NYHA functional class III–IV) without hyperkalemia and severe renal impairment. Aldosterone antagonists can reduce the frequency of hospitalization for worsening heart failure and improve survival.
4. Angiotensin Receptor Blockers (ARBs)
ARBs are recommended in heart failure patients with a left ventricular ejection fraction of c40% who remain symptomatic despite ACE-I and optimal 8-dose blockers unless contraindicated, and receiving aldosterone antagonists. Treatment with ARBs can improve ventricular function and quality of life, reducing hospitalization rates for worsening heart failure. ARBs are recommended as alternatives in patients who are intolerant to ACE-I. In these patients, ARBs reduced mortality from cardiovascular causes.
5. Angiotensin Receptor – Neprilysin Inhibitor (ARNI) = Sacubitril/valsartan
In patients who are still symptomatic with doses of ACE-I/ARB, blockers 8, and MRA, a new therapy can also be given to replace ACE-I/ARB, namely Angiotensin Receptor-Neprilysin Inhibitor (ARNI), which is a molecular combination of valsartan-sacubitrile.
6. Ivabradine. Ivabradine slows the heart rate by blocking the If channels in the sinus node and is only used for patients with sinus rhythm.
7. Hydralazine and Isosorbide Dinitrate (H-ISDN)
In heart failure patients with left ventricular ejection fraction c 40%, the H-ISDN combination is used as an alternative if the patient is ACE-I/ARB/ARNI intolerant (class of recommendation IIa, level of evidence B).
8. Digoxin, in heart failure patients with atrial fibrillation, digoxin can be used to slow the rapid ventricular rate, although other drugs (such as blockers) are preferred.
9. Diuretics, diuretics are recommended in patients with heart failure with clinical signs or symptoms of congestion (class of recommendation I, level of evidence B). Diuretic administration aims to achieve a euvolemic state (dry and warm) with the lowest possible dose, which must be adjusted according to the patient's needs to avoid dehydration or retention.
C. Pharmacological Therapy in HFPEF (Heart Failure with Preserved Ejection Fraction)
To date, there is no proven therapy that can specifically reduce mortality and morbidity in patients with HFPEF. Diuretics are used to treat fluid retention and shortness of breath. Adequate treatment of myocardial ischemia and hypertension is essential in managing this disorder, including the management of pulse rate regulation, especially in patients with atrial fibrillation.
D. Non-surgical Device Therapy in HFREF (Heart Failure with Reduced Ejection Fraction)
Until now, ICD (Implantable cardioverter-defibrillator) and CRT (cardiac resynchronization therapy) are the recommended tools for symptomatic advanced heart failure who have received optimal pharmacological therapy for heart failure.
Reference:
PERKI. Guidelines for the management of heart failure. 2nd Ed. [Internet]. 2020 [cited 2021 Aug 25]. Available from: https://inaheart.org/wp-content/uploads/2021/08/Pedoman_Tatalaksana_Gagal_Jantung_2020.pd
