Lesson topic №27 ХСН (Сhronic heart failure )

Сhronic heart failure in the outpatient setting

Gerasimenko I.A. Department of polyclinic therapy with course of general medical practice (family medicine)

Heart failure

Heart failure is not a single pathological diagnosis, but a clinical syndrome consisting of cardinal symptoms (e.g. breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, and peripheral oedema). It is due to a structural and/or functional abnormality of the heart that results in elevated intracardiac pressures and/or inadequate cardiac output at rest and/or during exercise.

Causes of heart failure

Cause	Examples of presentations
Coronary artery disease	Myocardial infarction
	Angina or “angina-equivalent”
	Arrhythmias
Hypertension	Heart failure with preserved systolic function Malignant
	hypertension/acute pulmonary oedema
Valve disease	Primary valve disease e.g., aortic stenosis Secondary
	valve disease, e.g. functional regurgitation
	Congenital valve disease
Arrhythmias	Atrial tachyarrhythmias
	Ventricular arrhythmias
CMPs	Dilated
	Hypertrophic
	Restrictive
	ARVC
	Peripartum
	Takotsubo syndrome
	Toxins: alcohol, cocaine, iron, copper

Causes of heart failure

Cause	Examples of presentations
Congenital heart disease	Congenitally corrected/repaired transposition of great
	arteries
	Shunt lesions
	Repaired tetralogy of Fallot Ebstein’s anomaly
Infective	Viral myocarditis
	Chagas disease
	HIV
	Lyme disease
Drug-induced	Anthracyclines
	Trastuzumab
	VEGF inhibitors
	Immune checkpoint inhibitors
	Proteasome inhibitors
	RAF+MEK inhibitors
Infiltrative	Amyloid
	Sarcoidosis
	Neoplastic

Causes of heart failure

Cause	Examples of presentations
Storage disorders	Haemochromatosis
	Fabry disease
	Glycogen storage diseases
Endomyocardial disease	Radiotherapy
	Endomyocardial fibrosis/eosinophilia Carcinoid
Pericardial disease	Calcification Infiltrative
Metabolic	Endocrine disease
	Nutritional disease (thiamine, vitamin B1 and selenium
	deficiencies)
	Autoimmune disease
Neuromuscular disease	Friedreich’s ataxia
	Muscular dystrophy

Heart failure

Traditionally, HF has been divided into distinct phenotypes based on the measurement of left ventricular ejection fraction (LVEF)

Heart failure

Reduced LVEF is defined as ≤40%, i.e. those with a significant reduction in LV systolic function. This is designated as Heart failure with reduced ejection fraction (HFrEF).

Patients with a LVEF between 41% and 49% have mildly reduced LV systolic function, i.e. HFmrEF.

Patients with symptoms and signs of HF, with evidence of structural and/or functional cardiac abnormalities and/or raised natriuretic peptides (NPs), and with an LVEF ≥50%, have Heart failure with preserved ejection fraction (HFpEF).

Classification

The simplest terminology used to describe the severity of HF is the New York Heart Association (NYHA) functional classification.

Classification

HF stages (by VasilenkoStrazhesko)

Stage I - the initial stage the latent heart failure, marked only with exertion (dyspnea, palpitations, fatigue). Hemodynamics is normal.

Stage II - a long standing, severe form of heart failure. Overt hemodynamic abnormalities are present at rest.

Substage A – hemodynamic abnormalities are moderate and are present only in one (large or small) circulation circle, i.e. one ventricular (left or right) failure.

Substage B – hemodynamic abnormalities are severe and are present throughout the cardiovascular system (manifested in the large AND small circulation circles), i.e. biventricular failure.

Stage III - the final, dystrophic stage with severe hemodynamics impairment, significant disorders of metabolism and irreversible changes in the structure of tissues and organs.

Diagnosis of chronic heart failure

The diagnosis of CHF requires the presence of symptoms and/or signs of HF and objective evidence of cardiac dysfunction.

The diagnosis of CHF is made more likely in patients with a history of MI, arterial hypertension, CAD, diabetes mellitus, alcohol misuse, chronic kidney disease (CKD), cardiotoxic chemotherapy, and in those with a family history of CMP or sudden death.