heart failure

definition
abnormal cardiac structure or function, which leads to signs (edema, rale) and symptoms (fatigue, dyspnea )

etiology:
75% due to CAD and HTN in developed country

pathogenesis
1. index events
2. compensatory mechanism
    a. RAA system
    b. adrenergic nerve system
    c. increased myocardial contratility

basic mechanism
1. systolic dysfunction
2. diastolic dysfunction
3. LV remodeling

Clinical menifestation
1. fatigue and dyspnea
2. orthopnea and nocturnal cough
3. Paroxysmal nocturnal dyspnea
4. Cheyne-Stoke respiration
5. Acute lung edema
6. Anorexia, nausea
7. Nocturia

Physical examination
1. reduced BP and pulse pressure
2. cool extremities
3. Jugular vein engorgement
4. rales and crackles (may be absent in chronic HF due to increased lymphatic drainage)
5. pleural effusion (drain to systemic and pulmonary vein, means bi-ventricular failure)
6. displaced the point of maximal impulse (PMI), usually displaced below the fifth intercostal space and/or lateral to the midclavicular line
7. S3, S4, MR and TR murmur in advaned cases
8. hepatomegaly, ascites
9. peripheral edema

Diagnosis
1. Clinical symptoms/ signs
2. routine lab
3. ECG
4. CXR
5. cardiac echo/ MRI
6. cardiac enzyme

Treatment
1. stage:   A: high risk patients without structural abnormality or symptoms
                B: structural abnormality without symptoms
                C: structural heart disease with symptoms
                D: refractory heart failure
2. factors may precipitate acute decompensation in chronic heart failure patient
    a. dietary
    b. discontinue treatment
    c. MI
    d. arrhythmia
    e. infection
    f. anemia
    g. medication:
        NSAID, CCB, Beta-blocker, Class I anti-arrhythmic drugs
    h. alcohol
    i. pregnancy
    j. worsing hypertension
    k: acute valvular disease
3. Diet
    sodium: 2~3 g/ day
    fluid restriction (< 2 L/ day) is not generally necessary

4. Diuretics
5. ACEI
6. Beta-blocker

7. Aldactone
8. Hydralazine/ Ismo-20
9. Digoxin

Acute heart failure

Theraputic goal
1. stablize hymodynamic
2. treat reversible factors
3. reestablish an effective outpatient medical regimen

LV filling pressure: elevated: wet             normal: dry
Cardiac output:      decreased: cold         normal: warm

Pharmacological management
1. Diuretics
2. Vasodilators
3. Inotropic agents

Mechanical management:
1. IABP
2. ECMO
3. LV assist device
4. heart transplant