Causes of heart failure | |
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The most common causes (80-90% of cases) | Alone or in different combinations
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More rare causes | Cardiac or circulatory faults
Metabolic cause
Infectious
Infiltrating
Associated with chemotherapy
Toxic
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Diagnostic criteria | Signs and symptoms |
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1. Patient has symptoms typical to HF or he/she is known to have a heart disease that predisposes to HF such as hypertension, coronary heart disease, sequelae of myocardial infarction, valvular disease. |
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2. Patient has clinical findings specific to HF |
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3. Imaging studies show structural and/or functional impairment of the heart (echocardiography, radionuclide ventriculography, left ventricular angiography, cardiac MRI) |
Diagnosis of HF | Other diseases and conditions to consider | |
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is supported by | is opposed by | |
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NYHA class | Symptoms |
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NYHA I | No significant limitation of physical activity. Activities of daily living do not cause symptoms even though left ventricular dysfunction can be noted with echocardiography. |
NYHA II | Limitation of physical activity. Strenuous physical activity results in dyspnoea or abnormal fatigue. |
NYHA III | Marked limitation of physical activity. Less than ordinary physical activity results in dyspnoea or fatigue. |
NYHA IV | All physical activity causes symptoms. Symptoms may also occur at rest. |
BNP and proBNP concentration | Interpretation |
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| HF is unlikely; look for other causes of the symptoms. |
| Further investigations necessary ** See abnormal and slightly elevated concentrations below. |
BNP/proBNP abnormal or slightly elevated (within the grey area) | |
| Uncertain diagnosis; findings should be related to clinical symptoms and sex- and age-specific reference values taken into account. However, further investigations are often necessary **. |
| Chronic HF likely * Further investigations necessary ** |
* The reference values are according to the 2021 ESC recommendations; pg/ml = ng/l. Interpretation should also take into account the method, age and sex specific reference values supplied by the laboratory. ** Echocardiography indicated | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Spirometry
Imaging studiesChest x-ray
Echocardiography
Indication for specialist consultation and investigations
Treatment of systolic HFNon-pharmacological treatment Exercise-Based Rehabilitation for Heart Failure, Disease Management Interventions for Heart Failure
Pharmaceutical therapy to improve prognosisDrugs affecting the renin-angiotensin-aldosterone (RAA) system The Effect on ACE Inhibitors on Mortality and Morbidity in Patients with Heart Failure, Angiotensin Receptor Blockers for Heart Failure, Aldosterone Receptor Antagonists Spironolactone and Eplerenone for Congestive Heart Failure
Drugs affecting the sympathetic nervous system Beta-Blockers for Heart Failure
Sodium-glucose cotransporter-2 (SGLT2) inhibitors
Symptomatic drug treatment Digitalis for Congestive Heart Failure in Patients in Sinus Rhythm, Optimal Serum Digoxin Concentration in Heart Failure, Nitrates for Acute Heart Failure Syndromes, Ivabradine as Adjuvant Treatment for Chronic Heart Failure
Diastolic HF
Treatment Drugs for Chronic Heart Failure with Preserved Ejection Fraction
Drug choice and use in HF
ACE inhibitors (ACEIs) and ARBs The Effect on ACE Inhibitors on Mortality and Morbidity in Patients with Heart Failure, Angiotensin Receptor Blockers for Heart Failure
Dosage of ACE inhibitors, ARBs and the combination of ARB and neprilysin inhibitor (ARNI) (mg/day)
Combination of an ARB and a neprilysin inhibitor
Beta-blockers Beta-Blockers for Heart Failure
Dosage of beta-blockers (mg/day)
SGLT2 inhibitors
Ivabradine Ivabradine as Adjuvant Treatment for Chronic Heart Failure
Diuretics and spironolactone Aldosterone Receptor Antagonists Spironolactone and Eplerenone for Congestive Heart Failure
Starting and maintenance doses of diuretics (mg/day)
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* Dose when used with an ACE inhibitor/ARB (** dose if an ACE inhibitor/ARB is not in use) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The maximum hydrochlorothiazide dose is 50 mg and it should normally not be exceeded. If a higher dose is needed, furosemide should be prescribed as it is more effective in renal failure (if creatinine > 180-200 µmol/l or creatinine clearance [GFR] < 30 ml/min). | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
A thiazide and furosemide can be combined in severe fluid retention, if necessary. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Spironolactone (or eplerenone) may also be added to the regimen if the patient has severe symptoms (NYHA III-IV) despite maximal treatment with an ACE inhibitor and beta-blocker.
Digoxin Optimal Serum Digoxin Concentration in Heart Failure, Digitalis for Congestive Heart Failure in Patients in Sinus Rhythm
Anticoagulants and aspirin Anticoagulation for Heart Failure in Sinus Rhythm
Drugs to be avoided in HF
Treatment of AF in HF
Pacemaker therapy
Treatment of HF in the elderly
Management of worsening HF or treatment-resistant HF
Patient education and self-care
Follow-up Structured Telephone Support or Telemonitoring for Chronic Heart Failure, Disease Management Interventions for Heart Failure, Allopurinol for Chronic Gout, B-Type Natriuretic Peptide-Guided Treatment for Heart Failure
End-of-life treatment
References
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