In US, incidence is 400 000/yr

Incr with hypertension, in 40% of men and 60% of women (Jama 1996;275:1557), systolic BP >160 just as significant as a diastolic >95; obesity (Nejm 2002;347:305); homocysteine levels (Jama 2003;289:1251)

Decr incidence by 1/2 in regular alcohol users, even heavy users ([Framingham] Ann IM 2002;136:181)

Sx:

Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, ankle edema, bowel bloating and sense of fullness pc, nocturia

NY Heart Association Classification:

• I: No dyspnea on moderate exertion
• II: Dyspnea w moderate exertion; 25% 4-yr mortality
• III: Dyspnea w mild exertion; 50% 4-yr mortality
• IV: Dsypnea at rest; 50%/yr mortality

Si:

JVD, S3 gallop (techniques—Nejm 2001;345:612) in systolic dysfn; both correlate w worse prognosis (Nejm 2001;345:574); S₄ in diastolic dysfn

Pulse >100 (pulse > dias BP = 53% sens, 80% specif—Bmj 2000;320:220); displaced point of maximal impulse, dullness in L 5th intercostal space 10.5 cm from sternum (Am J Med 1991;91:328); pleural effusions R > L (Nejm 1983;308:696).

Central apnea in 45%, especially Cheyne-Stokes respirations from increased sens to pCO₂ (Nejm 1999;341:949, 985), rx w theophylline 250 mg po bid (Nejm 1996;335:562)

Diastolic and systolic dysfunction CHF types have same poor prognosis: 16% 6-mo, 25% 1-yr, and 65% 5-yr mortality (Nejm 2006;355:251, 260, 308; Jama 2006;296:2209, 2259). Prognosis worse w lower (<120 mm Hg) admission systolic BP (Jama 2006;296:2217)

Sleep apnea (Ann IM 1995;122:487)

Lab:

Chem:Hyponatremia due to inappropriate ADH (Nejm 1981;305:263)

Ventricular type B natiuretic peptide >100 pgm/cc 90% sens 75% specif by rapid fluorescent immunoassay, so run stat can r/o CHF in acute SOB or if >500 pgm/cc (vs >1500 for proBNP) can rule in to allow rapid aggressive rx (Nejm 2004;350:647; 2002;347:161; ACP J Club 2002;136:68). More false positives in elderly w pBNP (33%) than BNP alone (14%) (Jags 2005;53:643), and in pts w Afib (J am coll cardiol 2006;46:838)

Cystatin C levels >10 mg % linearly predict CHF, better than creatinine, muscle mass independent (Ann IM 2005;142:497)

Hem:ESR low when acute and severe, correlates with fibrinogen levels (Nejm 1991;324:353)

Inv monitoring:Swan-Ganz monitoring now discouraged because of incr morb and mort (Jama 2001;286:309), use only when cardiac output and/or wedge data will change rx; in and out as quickly as possible (Ann IM 1985;103:445) since cmplc are pulmonary infarction, pulmonary artery rupture, knotting, endocardial thrombosis (50%), subsequent endocarditis (8%) (Nejm 1984;311:1152)

Urine:Proteinuria, why? (Nejm 1982;306:1031)

Echocardiogram: EF <50% in systolic dysfunction, >50% in diastolic dysfunction often seen in elderly

Xray:Chest shows redistribution of blood to apices on upright, perihilar "haze," Kerley B lines, increased heart size, pleural effusions R > L (Nejm 1983;308:696) possibly because thoracic duct provides a "pop-off valve" to L pulmonary vasculature, ie, better lymphatic drainage (J. Sutherland 6/95)

Rx:

(Nejm 1996;335:490, Ann IM 1994;121:363)

Acutely:

• O₂ at 2-3 L/min (Ann IM 1989;111:777) w CPAP (Nejm 1991;325:1825)
• Dobutamine iv acutely best choice immediately post-MI, better than dig or diuretics, no arrhythmias, short half-life (Nejm 1980;303:846)
• Nitrates, eg, nitroprusside iv or nitroglycerine iv drip; help even if severe aortic stenosis?? (Nejm 2003;348:1735, 1756)
• nesiritide iv (Jama 2002;287;1531, 1578; Nejm 2000;343:246) natriuretic peptide drip increases risk of renal failure and 1-mo mortality (Jama 2005;293:1900); initially promoted inappropriately despite this cmplc and great expense (Nejm 2005;353:113) but now use declining (Jama 2006;296:1877)

Chronically: (see medication section Anticoagulants for dosing) (Med Let 1999;41:12; Nejm 1998;339:1848). Generally use ACE inhibitors and other vasodilators, diuretics, + digitalis (Nejm 1993;329:1)

• Exercise training helps (Jama 2000;283:3095; Circ 1999;99:1173; Ann IM 1996;125:1051)
• Avoid NSAIDs, especially if hyponatremia (Nejm 1984;310:347), and calcium channel blockers (Nejm 1996;335:1107)
• ACE inhibitors alone increase survival from 50% to 73% at 6 mo (Jama 1995;273:1450; Med Let 1994;36:69); to doses of enalapril 20 mg qd, or lisinopril 30 mg qd, or captopril 150 mg qd; may need to decrease diuretic doses to avoid hypotension; less effective in blacks (Nejm 2001;344:1351). Or ARB (Circ 2004;110:2618; Jama 2005;294:1794; Nejm 2003;349:1893), like losartan (Cozaar) 12.5-50 mg po qd or valsartan 80 mg qd-160 bid if cough or angioedema prevent ACEI use, but combined use w ACEI no benefit, and ARBs are 5 × as expensive as ACEIs
• -blockers (Med Let 2000;42:54) to reduce sympathetic tone, improve survival even in severe CHF if can tolerate (Nejm 2001;344:1651, 1659, 1711; Jama 2003;289:712; 2000;283:1295; Lancet 1999;353:9)
• metoprolol 12.5-25 mg of CR/XL type or in tid doses titrated up to 100-200 mg po qd, or
• bisoprolol (Zebeta) 1.25-10 mg po qd, or
• carvedilol (Coreg) 3.125-25 mg po bid
• Spironolactone (Med Let 1999;41:81) 12.5-25 mg po qd, if creat <2.5 mg %, used w ACEI and digoxin improves survival and hospitalization by 30% (Nejm 1999;341:709, 753) but also quadruples the rate of hyperkalemia hospitalizations and deaths (Nejm 2004;351:543)
• Diuretics like thiazides, furosemide, and occasionally metolazone (Zaroxolyn), always use with ACEIs; beware decreased po absorption with increased CHF (Ann IM 1985;102:314); transient CHF worsening for 20 min via renin-angiotensin system (Ann IM 1985;103:1)
• Nitrates, eg, nitroprusside acutely, or TNG paste 1-5 in. q3-6h, or isosorbide up to 40 mg po tid-qid also clearly shown to prolong life
• Inotropes like digitalis glycosides, especially if S₃ gallop (Ann IM 1984;101:113; Nejm 1982;306:699) and/or EF <35% (Nejm 1993;329:1), decreases admission for CHF but doesn't decr mortality (Nejm 1997;336:525) and in fact incr mortality in women (Nejm 2002;347:1403) and a poor derivative study (Jama 2003;289:730) suggests levels in high therapeutic range may harm; amrinone ok acutely not useful chronically po (Lancet 1994;344:493 vs ACP J Club 1995;122(2):33)
• Vasodilators such as hydralazine especially w nitrates when ACEI intolerant, eg, questionable drug co. study of nitrates/hydralzine in blacks (Nejm 2004;351:2049)
• Experimental: coenzyme Q10 (Clin Investig 1993;71:S134) 50 mg po bid-tid, incr mitochondrial ATPase and decr CHF cmplc; vasopressin antagonists like tolvaptan (Jama 2004;291:1963, 2017)

if IVCD (QRS >0.12-0.15 sec), atrio-biventricular pacing improves sx and function (Jama 2003;289:730; Nejm 2005;352:1539; 2004;350:2140) but many being done w/o prolongation of life

of fatal Vtach: ICD shock-only, in pts w EF <35% improves mortality (NNT-5 = 14) (Jama 2006;295:809; Nejm 2005;352:225, 285)

of Cheyne-Stokes breathing: O₂ or CPAP improves survival (Nejm 1999;341:985), which also improves CHF in silent sleep apnea (Nejm 2003;348:1233)

Surgical: heart transplant, 3500/yr in US, 65% 5 yr survival (Jama 1998;280:1692)