Chronic heart failure: contemporary diagnosis and management

Abstract

Chronic heart failure (CHF) remains the only cardiovascular disease with an increasing hospitalization burden and an ongoing drain on health care expenditures. The prevalence of CHF increases with advancing life span, with diastolic heart failure predominating in the elderly population. Primary prevention of coronary artery disease and risk factor management via aggressive blood pressure control are central in preventing new occurrences of left ventricular dysfunction. Optimal therapy for CHF involves identification and correction of potentially reversible precipitants, target-dose titration of medical therapy, and management of hospitalizations for decompensation. The etiological phenotype, absolute decrease in left ventricular ejection fraction and a widening of QRS duration on electrocardiography, is commonly used to identify patients at increased risk of progression of heart failure and sudden death who may benefit from prophylactic implantable cardioverter-defibrillator placement with or without cardiac resynchronization therapy. Patients who transition to advanced stages of disease despite optimal traditional medical and device therapy may be candidates for hemodynamically directed approaches such as a left ventricular assist device; in selected cases, listing for cardiac transplant may be warranted.

FIGURE 1.

Pathophysiology of chronic heart failure. LV = left ventricular; MI = myocardial infarction; RAAS = renin-angiotensin-aldosterone system; SNS = sympathetic nervous system.

FIGURE 2.

Angiotensin-converting enzyme inhibitor mortality trials: all-cause mortality results. AIRE = Acute Infarction Ramipril Efficacy; CONSENSUS = Cooperative North Scandinavian Enalapril Survival Study; SAVE = Survival and Ventricular Enlargement; SOLVD = Studies of Left Ventricular Dysfunction.

FIGURE 3.

β-Blocker mortality trials: all-cause mortality results. CIBIS II = Cardiac Insufficiency Bisoprolol Study II; COPERNICUS = Carvedilol Prospective Randomized Cumulative Survival; MERIT-HF = Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure.

FIGURE 4.

Surgical evaluation of heart failure. CABG = coronary artery bypass grafting; LVAD = left ventricular assist device; MVR = mitral valve repair; PCI = percutaneous coronary intervention; TX = heart transplant.

FIGURE 5.

Stepwise approach to heart failure care. ACC = American College of Cardiology; ACEI = angiotensin-converting enzyme inhibitor; AHA = American Heart Association; ARB = angiotensin II receptor blocker; CRT = cardiac resynchronization therapy; ICD = implantable cardioverter-defibrillator; LVAD = left ventricular assist device; NYHA = New York Heart Association.