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Heart failure – Cardiac insufficiency: Definition, Etiology, Classification, Symptoms/clinic, Diagnostics, Therapy/treatments, and Prognosis

source: www.medicalnewstoday.com


    Heart failure (Cardiac insufficiency) is referred to when the pumping function of the heart is no longer sufficient to maintain the bloodstream, resulting in a backlog in the veins with the consequences of water retention throughout the body (edema of the legs, cardiopulmonary stasis (shortness of breath)). So that the symptomatic treatment by drainage is running.


    • Systolic ventricular dysfunction: impaired cardiac contractility due to myocardial infarction, coronary heart disease (CHD), or myocarditis
    • Valvular heart disease such as aortic valve insufficiency (excessive ejection performance)
    • Arterial hypertension or valvular heart disease such as aortic valve stenosis (increased pumping resistance)
    • Diastolic ventricular dysfunction with a reduced filling of the ventricles
    • Arrhythmia
    • Rarer aetiologies: cardiomyopathy, cardiac involvement in systemic diseases, drugs, adverse drug reactions, renal cardiac syndromes, electrolyte imbalances, endocardial diseases
    • The most common cause of heart failure: hypertension and coronary heart disease

    source: centralgaheart.com


    New York Heart Association (NYHA) classification: Subjectively feeling discomfort: I (no physical limitation), II (moderate physical exercise eg climbing stairs), III (mild physical exercise), IV (discomfort at rest)

    Classification of the ESC (European Society of Cardiology) 2016:
    • Reduced Left Ventricular Ejection Fraction (EF): HFmrEF (Heart Failure with Moderate EF), HFrEF (Heart Failure with Reduced EF)
    • Obtained Left Ventricular Ejection Fraction (EF) (HFpEF)

    Further classifications:
    • Systolic heart failure, diastolic heart failure, or combined systolic and diastolic ventricular dysfunction (according to pathophysiology)
    • Compensated or decompensated, acute or chronic (according to course)
    • Left heart failure, right heart failure, or global insufficiency (according to affected heart part)

    Symptoms / clinic

    General symptoms
    Nocturia, Increased sympathetic effect (tachycardia), performance kink

    Symptoms of left heart failure
    • Backward failure: dyspnea due to cardiopulmonary congestion, pleural effusions, to pulmonary edema, asthma cardial (especially nocturnal coughing fits)
    • Forward failure: cardiorenal syndrome, cerebral hypoperfusion

    Symptoms of Right Heart Failure
    Increased hydrostatic pressure causes leg edema, upper congestion, hepatic congestion, congestive gastritis


    • Physical examination: moist rales (pulmonary edema?), Evidence of valvular heart disease? leg edema
    • ECG: a sign of cardiac disease?
    • Echocardiography: belongs to the basic diagnostic of any heart failure
    • Left Ventricular Ejection Fraction (LVEF), Wall Movement Disorders ?? systolic/diastolic dysfunction? Cardiac valve disorders/heart defects? Right heart failure ??
    • X-ray Thorax: Pulmonary stasis signs? Cardiomegaly ?? Pleural effusion ??
    • Sonography (supplementary): intravascular volume? Kidney? Liver?
    • Laboratory Diagnostics: BNP (Brain Natriuretic Peptide) / NT-proBNP (N-terminal per BNP) (release due to ventricular overload), blood counts, ferritin, renal retention parameters, electrolytes, urine status (proteinuria?), Liver cholestasis and transaminase parameters, HbA1c, optionally troponin
    • Invasive diagnostics (coronary angiography/left heart catheterization): coronary heart disease ??

    Therapy of chronic heart failure

    Causal therapy: treatment of the underlying disease e.g. coronary artery disease, arterial or pulmonary hypertension, anemia diagnosis
    Diet: fluid restriction, weight loss, weight reduction
    Drug-Leveled Therapy
    • ACE inhibitor (prognosis improving): in NYHA I, II, III, IV. In case of intolerance (irritating cough): AT1-Blocker
    • Aldosterone antagonists (improving prognosis): EF <35% in NYHA II, III, IV. Spironolactone (in case of intolerance: eplerenone)
    • Beta-blocker (improving prognosis): EF ≤40% in NYHA II, III, IV. In the post-myocardial infarction from NYHA stage I
    • Diuretics (loop diuretics, thiazides) (symptom-improving, lower hospitalization rate): Always seek combination with ACE inhibitor, Indication: Always in the presence of edema or hypertension.
    • Neprilysin inhibitors (ARNI) (combination of valsartan and sacubitril): CAVE: not in combination with ACE inhibitors (ACE inhibitor must be discontinued before 36 to 48 hours), Indication: replacement for ACE inhibitors in EF <35% with no recompensation despite therapy with ACE inhibitors, aldosterone antagonists, diuretic, and beta-blockers
    • Digitalis (symptom-improving, lower hospitalization rate): In NYHA II, III, IV. Indication: for frequency and symptom control in atrial fibrillation if beta-blocker monotherapy is insufficient
    • Ivabradine: For NYHA II, III, IV. Indication: for beta-blocker intolerance and sinus rhythm with HF> 70 / min.

    Invasive therapy
    • Implantable Cardioverter Defibrillator (ICD)
    • Cardiac Resynchronization Therapy (CRT): Indication: EF ≤35% despite optimal drug therapy with complete left bundle branch block in sinus rhythm (greatest benefit with QRS width> 150 ms).
    • Patients symptomatically classified in NYHA II-IV who require a pacemaker will benefit from the implantation of a CRT-P system regardless of QRS duration if EF ≤35% is present.
    • Coronary Revascularization: PTCA or Bypass Surgery. (coronary artery bypass graft (CABG)
    • Heart transplant: contraindications: advanced lung disease, acute pulmonary embolism, active infection, florid gastric or duodenal ulcer, advanced renal insufficiency, severe arterial vascular disease, palliative malignancies, severe nicotine, alcohol or drug abuse. Emotional instability and untreated psychiatric disorders, severe systemic diseases (e.g., amyloidosis)


    1- year mortality depending on the NYHA stage
    • I <10%
    • II about 15%
    • III about 25%
    • IV about 50%

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