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HEART FAILURE
Andrew Ying-Siu Lee, MD,PhD.
When the heart cannot pump efficiently so as to maintain good circulation to supply nutrients and metabolic needs for the body, heart failure is said to occur, which is the end-stage of all kinds of cardiovascular diseases. No matter are there coronary artery disease, valvular heart disease, myocarditis, hypertension, autoimmune disease, infection, metabolic disease, or congenital diseases, end-stage heart disease will develop into refractory heart failure.
Common symptoms of heart failure include: dyspnea, decreased exercise tolerance, exertional dyspnea, dyspnea when lying flat, weakness, edema, abdominal fullness, palpitation, dizziness or fainting etc. Are there precipitating factors such as incompliance, emotional disturbance, cardiac arrhythmias, infection, anemia, uncontrolled hypertension, or concurrent diseases such as thyroid , pulmonary , gastrointestinal and renal diseases, heart failure may worsen to death.
According to New York Heart Association, the severity of heart failure can be classified into :-
Grade 1 : there are no symptom of heart failure such as weakness, palpitation,
dyspnea, chest discomfort etc upon ordinary activity.
Grade 2 : ordinary activity will elicit symptoms of heart failure
Grade 3 : less than ordinary activity will elicit symptoms of heart failure
Grade 4 : symptoms of heart failure occur at rest
And the 5-year mortality of heart failure :-
Grade 2-3 34%
Grade 4 82%
Factors to assess severity and prognosis of heart failure include:-
Clinical: age, male, coronary artery disease, New York Heart Association class, exercise capacity, heart rate at rest, systolic arteral pressure,
cardiac cachexia, history of hospitalization
Hemodynamic: ejection fraction, cardiac output
Biochemical: plasma norepinephrine, renin, vasopressin, atrial and brain natriuetic peptides, endothelin, interleukin, sodium, potassium, magnesium
Electrophysiological: LBBB, wide QRS, arhyhmias
Therapy of heart failure include: (1) symptomatic treatment, to relieve whatever symptoms the patients have. However, heart failure continues to worsen and eventually leads to end-stage heart disease (refractory heart failure), (2) treatment of causes, to explore and treat the etiological factors of heart failure such as coronary artery disease, valvular heart disease, diabetes mellutis, thyroid disease etc. This may relieve or cure heart failure if the etiological factors can be well controlled, (3) device therapy such as ultrafiltration, resynchronization, implantable defibrillation, ventricular assist device, artificial heart etc. (4) heart transplantation. Therefore treatment of causes of heart failure is preferable.
CASE 1:
63 years old male, a case of coronary artery disease with severe heart failure, was admitted to intensive care unit because of chest discomfort and dyspnea. Although inotropic agents and mechanical ventilator were used, patient was still in cardiogenic shock (blood pressure 72/55 mmHg), coma, oxygen saturation 75%, cold extremities, cold sweating. Chest X-ray showed huge cardiomegaly and pulmonary edema. Cardiac echo showed severe heart failure, with ejection fraction (EF) only 10-15%. He was discharged after 2 weeks. Two months later at the OPD, his EF became 20-25% after treatment of etiological factors.
CASE 2 :
72 years old male, a case of old myocardial infarction with severe heart failure, was admitted to intensive care unit because of pneumonia. Cardiac echo showed severe heart failure, with EF 20%. He was discharged after 10 days. Half year later at the OPD, his EF because 40% after treatment of etiological factors.
EF is the ejection fraction of the heart, a fraction of systolic over diastolic volumes. Normal value is above 50%. EF is an important prognostic factor of heart failure. One should follow the EF regularly, because a higher or normal EF will improve symptoms and prognosis of heart failure.