Heart Failure Management
Prevention of Heart Failure by Treating the Conditions that Cause Myocardial Injury. Many patients have one or more concomitant conditions that contribute to the development of HF. Once the patient has HF, these same conditions can hasten the progression of the HF syndrome. The primary care physician must adequately control these conditions to help prevent the development and progression of HF.
Chronic hypertension that leads to left ventricular hypertrophy (LVH) is a common pathway in the development of HF. Appropriate treatment of hypertension by the primary care physician may limit the development of LVH and significantly reduce the risk of HF. Coronary Artery Disease
Coronary artery disease (CAD) and myocardial ischemia are common causes of LV systolic dysfunction. These conditions are present in about two thirds of patients with HF. Measurable decreases in systolic function may be present for months or years before overt HF symptoms develop. Acute myocardial ischemia and myocardial infarction can result in sudden changes in systolic and diastolic ventricular function and acute HF with systemic congestion.
Smoking cessation and controlling dyslipidemia prevents CAD events that are precursors to the development of HF. Patients who have experienced a myocardial infarction benefit from the introduction of a beta-blocker or an ACE inhibitor to prevent reinfarction. The administration of an ACE inhibitor to postmyocardial infarction patients with LV systolic dysfunction with or without HF symptoms decreases the risk of developing HF by 20% to 30%. In patients with known angina who are asymptomatic for HF evaluation for revascularization may be an important preventive maneuver to prevent progression to HF. Other Causes of Cardiomyopathy
Many diseases, infections, and toxins can cause ventricular dysfunction through a direct deleterious effect on the myocardium. Viral infections, diabetes mellitus, and excessive alcohol intake are associated with cardiomyopathy and ventricular dysfunction. Controlling diabetes and reducing alcohol intake would be expected to reduce the risk of progression to HF.
Significant valvular stenosis and/or regurgitation, particularly in the mitral or aortic valves, are well-documented factors that contribute to ventricular dysfunction. Surgical valve replacement or repair improves cardiac function. Such surgery should be performed when indicated.
Obesity causes an increased hemodynamic load on the heart and is a frequent cause of dyspnea secondary to deconditioning. Sleep apnea may be a complicating factor in the obese patient. Reducing weight to closer to the patientís ideal body weight often leads to symptomatic improvement. Cardiovascular changes that occur with normal aging help explain why HF incidence and prevalence increase with age. Arterial stiffening with increased afterload and peripheral resistance occurs with advancing age even in normotensive individuals and may worsen the effects of ventricular systolic dysfunction. An increase in LV mass that often occurs with aging may lead to impaired ventricular diastolic filling and heart failure owing to diastolic dysfunction in the elderly.
The aforementioned conditions are the common etiologic factors leading to HF. Recognizing them is important in confirming the patient does in fact have HF. If these conditions are not present before the diagnosis of the HF syndrome, then the physician should begin to question the diagnosis and look for uncommon causes of HF.
Establishing Heart Failure as the Patientís Diagnosis and Determine the Type of Heart Failure.
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