Defining the Type of Heart Failure Table 2 ó New York Heart Association Functional Classification Class I : No limitation of activity Ordinary activity does not cause undue fatigue, palpita tion, dyspnea, or anginal pain.
Using this multifaceted approach, most patients with HF can be diagnosed appropriately; however, the primary care physician then needs to proceed one step further and define the type of HF. This allows the physician to outline physiologic goals of treatment and individualize pharmaceutic therapy. Measuring LVEF by echocardiography or radionuclide ventriculography helps to determine whether the cardiac mechanism for HF is primarily systolic or diastolic dysfunction.
Patients with an LVEF < 40% generally are considered to have systolic dysfunction.
The finding of normal systolic function in a patient with HF may be explained by a number of underlying factors. Clinical and echocardiographic findings help the clinician differentiate the cause of HF with normal systolic function. Patients with LVEF greater than 40%, no significant valvular disease, and concentric LV hypertrophy are likely to have isolated diastolic dysfunction as the basis for their HF syndrome.
Doppler flow measures also can help confirm a "stiff" ventrical with impaired diastolic function.
Assessment of the Patientís Volume Status, Renal Function, Symptom Severity, and Prognosis.
To formulate an appropriate dietary and pharmacologic management plan the primary care physician needs to assess the patientís volume status and corresponding renal function. Volume status is indicated by a patientís weight compared to their baseline or a previous dry weight and the presence of peripheral edema, pulmonary congestion, and/or elevated jugular venous pressure. The physician should assess a patientís volume in the context of renal function because therapeutic decisions such as salt restricted diets, changes in diuretic doses, or addition of ACE inhibitors or beta-blockers are influenced by this information.
The degree of functional impairment experienced by the patient is an important parameter to assess initially and follow longitudinally for all HF patients. The level of physical impairment from HF is a strong prognostic marker, allowing the physician to monitor the effects of treatment and determining whether patients will benefit from certain therapies. The New York Heart Association (NYHA)
Functional Classification is the simplest and most widely used tool for assessing physical functioning and prognosis (Table 2) .
Choosing Appropriate Pharmacologic Treatments to Treat Volume Overload and to Delay Disease Progression
Pharmacologic treatments address four specific management goals: optimize treatment of etiologic condition(s) or conditions that have an impact on HF treatment, treat fluid retention symptoms related to hemodynamic abnormalities, prevent progression of disease, and delay mortality. The management of HF depends on its cause and clinical course, and this mandates an individualized approach to treatment.
Class II : Slight limitations of physical activity. Patient is comfortable at rest. Ordinary activity results in fatigue, palpitation, dyspnea, or anginal pain.
Class III : Marked limitation of physical activity. Patient is comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
Class IV: Inability to carry out physical activity without symptoms. Symptoms of heart failure often present at rest. Increased symptoms or discomfort with even minor physical activity.
Table 2 ó New York Heart Association Functional Classification
Class I : No limitation of activity Ordinary activity does not cause undue fatigue, palpita tion, dyspnea, or anginal pain.
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