Heart Failure: Epidemiology and Etiology

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Questions and Answers

What percentage of the adult population in developed countries is affected by heart failure?

15-20%

25-30%

5-10%

1-2% (correct)

Which condition is NOT typically considered a common cause of heart failure?

Arrhythmias

Coronary artery disease

Hypertension

Chronic lung disease (correct)

What is the estimated yearly mortality rate for patients with stable heart failure?

6-7% (correct)

50%

25%

1-2%

Among the listed conditions, which is NOT considered a factor contributing to diseased myocardium?

Carnitine deficiency Signup and view all the answers

Patients admitted to the hospital with acute heart failure face what approximate mortality rate per year?

25% or more Signup and view all the answers

Which of the following is classified under abnormal loading conditions that can lead to heart failure?

Hypertension Signup and view all the answers

What is a common infectious cause of myocarditis that can lead to heart failure?

Viral myocarditis Signup and view all the answers

In which demographic does the prevalence of heart failure significantly increase?

Adults aged 60 years and up Signup and view all the answers

Which congenital defect is characterized by a reversed arrangement of the great arteries?

Congenitally corrected transposition of great arteries Signup and view all the answers

What initial diagnostic test is used to measure natriuretic peptides in suspected heart failure patients?

Plasma concentration of BNP or NT-proBNP Signup and view all the answers

Which investigation is NOT essential for the diagnosis of chronic heart failure?

Genetic testing Signup and view all the answers

Which of the following is a type of arrhythmia characterized by rapid electrical impulses in the atria?

Atrial tachyarrhythmia Signup and view all the answers

In the context of heart failure, what role do neurohormonal mechanisms play?

They serve as compensatory mechanisms. Signup and view all the answers

Which of the following signs is an indicator of potential heart failure?

Persistent fatigue Signup and view all the answers

What is the purpose of echocardiography in the context of heart failure?

To evaluate myocardial structure and function Signup and view all the answers

Which type of heart failure is characterized by preserved ejection fraction?

HFpEF Signup and view all the answers

What is the primary purpose of using mineralocorticoid receptor antagonists (MRAs) in patients with HFrEF?

To reduce mortality and the risk of HF hospitalization Signup and view all the answers

When using MRAs, what should be monitored closely in patients?

Serum potassium levels Signup and view all the answers

What is sacubitril's mechanism of action as part of the ARNI?

It inhibits neprilysin Signup and view all the answers

Which class of medication is recommended to enhance natriuresis in patients with HFrEF?

Sodium-glucose co-transporter 2 inhibitors Signup and view all the answers

What is the goal of diuretic therapy in the management of HFrEF?

To achieve and maintain euvolemia Signup and view all the answers

In which situation are angiotensin II type 1 receptor blockers (ARBs) recommended?

For patients intolerant to ACE-I or ARNI due to side effects Signup and view all the answers

How do loop diuretics differ from thiazide diuretics in their action?

They provide a more intense and shorter diuresis Signup and view all the answers

Why might SGLT2 inhibitors reduce the need for loop diuretics in HFrEF treatment?

They enhance diuresis and natriuresis. Signup and view all the answers

What is the purpose of short-term mechanical circulatory support (MCS)?

To bridge to decision, recovery, or transplantation. Signup and view all the answers

Which of the following conditions is NOT a trigger for acute heart failure?

Advanced heart failure managed appropriately. Signup and view all the answers

What is a primary recommendation for patients being considered for long-term MCS?

They must demonstrate good medical compliance. Signup and view all the answers

Which surgical treatment is appropriate for aortic stenosis?

Transcatheter aortic valve replacement (TAVI). Signup and view all the answers

In patients with advanced heart failure, what is a significant condition that may prevent cardiac transplantation?

The existence of absolute contraindications. Signup and view all the answers

Which of the following substances can exacerbate acute heart failure?

Recreational drugs. Signup and view all the answers

What defines acute heart failure (AHF)?

A rapid or gradual onset of symptoms severe enough for urgent medical attention. Signup and view all the answers

Which of the following factors is associated with the increased risk of acute heart failure due to metabolic/hormonal derangements?

Thyroid dysfunction. Signup and view all the answers

What is the primary indication for Ivabradine in heart failure patients?

To reduce hospitalizations and cardiovascular death in specific symptomatic patients Signup and view all the answers

In which patients is the combination of hydralazine and isosorbide dinitrate indicated?

Self-identified black patients with HFrEF in NYHA Class III–IV Signup and view all the answers

Which of the following treatments is not recommended for symptomatic patients with HFrEF?

The addition of an ARB to ACE-I and MRA therapy Signup and view all the answers

Which criterion must be met for a patient to be eligible for cardiac resynchronization therapy (CRT)?

Symptomatic heart failure in sinus rhythm with LVEF ≤35% Signup and view all the answers

What role does digoxin play in the treatment of heart failure?

To reduce hospitalization risk in symptomatic patients Signup and view all the answers

What is the purpose of the implantable cardioverter-defibrillator (ICD) in heart failure management?

To prevent heart rhythm abnormalities Signup and view all the answers

Which of the following is a common contraindication for using Ivabradine?

A resting heart rate below 70 bpm Signup and view all the answers

What is the primary benefit of short-term mechanical circulatory support (MCS)?

To reverse critical end-organ hypoperfusion and hypoxia Signup and view all the answers

Study Notes

Heart Failure Epidemiology and Prognosis

Heart failure (HF) affects approximately 1-2% of the adult population in developed countries.
Prevalence increases with age, reaching around 10% for individuals aged 70 years or older.
HF carries a poor prognosis with high rates of hospitalization and mortality.
Mortality rates range from 6-7% per year for patients with stable HF to 25% or more per year for those hospitalized with acute HF.

Heart Failure Etiology

Diseased Myocardium:
- Coronary artery disease (CAD) is a primary cause.
- Cardiomyopathy:
  - Dilated
  - Hypertrophic
  - Restrictive
  - Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
  - Peripartum
  - Takotsubo
  - Toxin-induced (alcohol, cocaine, iron, copper)
- Endomyocardial Disease:
  - Endomyocardial fibrosis/eosinophilia
  - Radiotherapy
  - Carcinoid
- Drug-Induced:
  - Anthracyclines
  - Trastuzumab
  - Vascular endothelial growth factor inhibitors
  - Proteasome inhibitors
  - Antidepressants
  - Antiarrhythmics
  - Non-steroidal anti-inflammatory drugs (NSAIDs)
  - Anesthetics
- Infectious:
  - Viral myocarditis
  - Bacterial infections
  - Spirochetes
  - Fungi
  - Protozoa
  - Parasites (Chagas disease)
  - Rickettsiae
- Noninfectious:
  - Giant cell myocarditis
  - Autoimmune diseases (e.g., Graves' disease, rheumatoid arthritis, connective tissue disorders, systemic lupus erythematosus)
  - Hypersensitivity and eosinophilic myocarditis
- Infiltration:
  - Malignancy
  - Amyloidosis
  - Sarcoidosis
- Storage Diseases:
  - Glycogen storage diseases
  - Hemochromatosis
  - Fabry disease
- Endocrine Disorders:
  - Thyroid disease
  - Parathyroid disease
  - Acromegaly
  - Hypercalcemia
  - Addison's disease
  - Diabetes
  - Metabolic Syndrome
  - Phaeochromocytoma
- Nutritional Disease:
  - Thiamine, vitamin B1, and selenium deficiencies
- Neuromuscular Disease:
  - Friedreich's ataxia
  - Muscular dystrophy
Abnormal Loading Conditions:
- Hypertension
- Valvular Diseases:
  - Primary valve disease
  - Secondary valve disease
  - Congenital valve disease
- Congenital Defects:
  - Shunt defects
  - Congenitally corrected/repaired transposition of great arteries
  - Repaired tetralogy of Fallot
  - Ebstein's anomaly
- Pericardial Disease:
  - Pericardial effusion
  - Constrictive pericarditis
  - Infiltrative pericarditis
Arrhythmias:
- Atrial tachyarrhythmia
- Ventricular tachyarrhythmia

Heart Failure Pathophysiology

Compensatory mechanisms attempt to maintain adequate cardiac function.
Important adaptations include the Neurohormonal derangement, as shown in Figure 1.

Chronic Heart Failure Diagnosis

Presence of symptoms and/or signs of HF
Essential Initial Investigations:
- Laboratory Tests:
  - Serum urea, electrolytes, creatinine, full blood count, liver and thyroid function tests, transferrin saturation, and ferritin levels.
  - Natriuretic Peptides (NPs): BNP and NT-proBNP can be used for initial diagnosis, especially when echocardiography is not immediately available.
- 12-lead Electrocardiogram (ECG): Used to assess heart rhythm, heart rate, QRS morphology, and duration, as well as other abnormalities.
- Chest Radiography (X-ray): Useful for detecting alternative pulmonary or other diseases contributing to dyspnea, identifying pulmonary congestion/edema, and aiding in diagnosis of acute HF particularly.
- Echocardiography: Used to assess myocardial structure and function, aiding in diagnosis of:
  - Heart failure with reduced ejection fraction (HFrEF)
  - Heart failure with mildly reduced ejection fraction (HFmrEF)
  - Heart failure with preserved ejection fraction (HFpEF)
Investigations to Determine the Underlying Etiology of Chronic Heart Failure

Chronic Heart Failure Treatment

Mineralocorticoid Receptor Antagonists (MRA): Spironolactone or eplerenone are recommended with an ACE-I and beta-blocker in patients with HFrEF to reduce mortality and hospitalization risk.
- Caution: MRAs should be used with caution in patients with impaired renal function and potassium levels ˃5.0 mmol/L.
Angiotensin Receptor-Neprilysin Inhibitor(ARNI): Sacubitril/valsartan fixed-dose combination is recommended as a replacement for ACE-I. This combination further reduces HF hospitalization and death risk in patients with symptomatic HFrEF despite optimal treatment with ACE-I, ARB, beta-blocker, and MRA.
- Mechanism: Sacubitril (neprilysin inhibitor) slows degradation of NPs, bradykinin, and other peptides.
Sodium-Glucose Co-transporter 2 Inhibitors (SGLT2 Inhibitor): Dapagliflozin or empagliflozin are recommended for patients with HFrEF to reduce hospitalization and death risk.
- Mechanism: SGLT2 inhibitors enhance natriuresis and stimulate osmotic diuresis by inhibiting SGLT2 in the kidney's proximal tubule.

Other Treatments Recommended in Selected Symtpomatic Patients with HFrEF

Diuretics: Aim is to achieve and maintain euvolemia with the lowest possible dose.
- Loop diuretics: More intense and shorter diuresis than thiazides.
- Combination of loop and thiazide diuretics: Can be used for resistant edema.
Angiotensin II Type 1 Receptor Blockers (ARBs): Recommended for patients who cannot tolerate ACE-I or ARNI due to side effects.
If-Channel Inhibitor: Ivabradine is considered to reduce HF hospitalization and cardiovascular death in symptomatic patients with LVEF ≤35%, in sinus rhythm, resting heart rate 70 bpm despite optimal beta-blocker treatment, or those who cannot tolerate or have contraindications for beta-blockers.
- Mechanism: Ivabradine slows heart rate by inhibiting the If channel in the sinus node and should only be used in patients with sinus rhythm.
Combination of Hydralazine and Isosorbide Dinitrate: Fixed-dose combination given to self-identified black patients with HFrEF and NYHA Class III-IV despite optimal treatment with ACE-I, beta-blocker, and MRA to reduce HF hospitalization and death risk.
Digoxin: May be considered in symptomatic patients in sinus rhythm despite optimal treatment with ACE-I (or ARB), beta-blocker, and MRA to reduce hospitalization risk.
- May also be helpful in patients with symptomatic HF and atrial fibrillation (AF).

Treatments Not Recommended in Symptomatic Patients with HFrEF

Thiazolidinediones (glitazones)
NSAIDs or COX-2 inhibitors
Non-dihydropyridine calcium channel blockers (e.g., diltiazem or verapamil)
Addition of an ARB to the combination of an ACE-I and an MRA.

Device Treatment in Patients with HFrEF

Implantable Cardioverter-Defibrillator (ICD): Recommended to reduce sudden death risk in patients who have recovered from a ventricular arrhythmia causing hemodynamic instability.
Cardiac Resynchronization Therapy (CRT): Recommended for symptomatic patients with HF in sinus rhythm, QRS duration 130 msec, LBBB QRS morphology, and LVEF ≤35% despite optimal medical therapy.
Short-Term Mechanical Circulatory Support (MCS): Indicated to reverse critical end-organ hypoperfusion and hypoxia during cardiogenic shock.
- Used as a bridge to decision (BTD), bridge to recovery (BTR), or bridge to bridge (BTB) for either long-term MCS or urgent heart transplantation.
Long-Term MCS: Recommended for patients with advanced HF despite optimal medical or device therapy. Patients must have good compliance, appropriate capacity for device handling, and psychosocial support.

Surgical Treatment in Patients with HFrEF

Aortic valve replacement: Surgical (SAVR) or transcatheter (TAVI) for aortic stenosis.
TEE mitral valve repair: For mitral regurgitation.
Coronary artery bypass graft (CABG): For coronary artery disease.
Cardiac transplantation: Recommended for patients with advanced HF refractory to medical or device therapy and without absolute contraindications.

Acute Heart Failure (AHF)

AHF refers to rapid or gradual onset of symptoms and/or signs of HF, severe enough to require urgent medical attention.
Triggers for AHF:
- Acute coronary syndrome (ACS)
- Excessive rise in blood pressure.
- Infection (e.g., pneumonia, infective endocarditis, sepsis).
- Tachyarrhythmias (atrial fibrillation, ventricular tachycardia).
- Non-adherence to diet/drug therapy.
- Toxic substances (alcohol, recreational drugs).
- Drugs (e.g., NSAIDs, corticosteroids, negative inotropic substances, cardiotoxic chemotherapeutics).
- Exacerbation of chronic obstructive pulmonary disease (COPD).
- Pulmonary embolism (PE).
- Surgery and perioperative complications.
- Increased sympathetic drive, stress-related cardiomyopathy.
- Metabolic/hormonal derangements (e.g., thyroid dysfunction, diabetic ketoacidosis, adrenal dysfunction, pregnancy and peripartum related abnormalities).
- Cerebrovascular insult.
- Acute mechanical cause:
  - Myocardial rupture complicating ACS (free wall rupture, ventricular septal defect, acute mitral regurgitation).
  - Chest trauma or cardiac intervention.
  - Acute native or prosthetic valve incompetence secondary to endocarditis.
  - Aortic dissection or thrombosis.

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Explore the critical aspects of heart failure, including its prevalence, age-related risks, and poor prognosis. Understand the various causes of heart failure, ranging from coronary artery disease to drug-induced factors among others. This quiz covers essential information for anyone studying cardiac health.