Coronary Artery Disease
- The most common disease that leads to heart failure.
- Stepwise evaluation includes history, physical exam, stress test (ECG), stress/pharmacological radionuclide or echocardiographic test, coronary angiographic study.
- Treatment strategies are:
- Interventional revascularization.
- Surgical revascularization.
- In regards to any of the above treatments, patients should also receive ASA, beta blocker, and ACE inhibitor.
- Risk modification is essential.
Hypertensive Heart Disease
- One of the most common conditions that leads to heart failure, both systolic and diastolic dysfunction.
- JNC VII blood pressure goal:
- <140/90 in patient without risk factors
- <130/80 in patient with heart failure, renal failure and diabetes
- Monitor home or out of hospital/clinic BP record.
- Prescribe medications that helps decrease LVH.
- Non-pharmacologic treatment is also important, such as low salt intake, exercise, weight reduction.
- Patient with dilated cardiomyopathy should be evaluated for the etiologies which require specific treatment.
- Idiopathic - Usually by exclusion, thought to be viral related.
- Alcoholic - Diagnosed by history. Alcohol abstinence is essential.
- Myocarditis - Diagnosis confirmed by endocardial-myocardial biopsy. In the early phase, steroid and immunosuppresive therapy have been tried.
- Others: Drugs-toxin induced, peripartum, blunt chest trauma, hemochromatosis, etc.
- With or without dynamic outflow tract obstruction.
- Usually cause left ventricular diastolic dysfunction.
- Echocardiogram is essential for diagnosis.
- Management includes control of BP, negative inotropic drugs, avoid dehydration in outflow tract obstruction case. If the patient has a clinical picture of heart failure, be careful when using diuretic or vasodilators.
- Dual chamber pacing with short AV interval may improve symptomatic outflow tract obstruction in some patients.
- In severe outflow tract obstruction, treatment may include interventional alcoholic induces septal infarction, surgical septal myectomy.
- Patient with sudden death or cardiac arrest history in the family requires further evaluation (include family members) for possible ICD implantation.
Valvular Heart Disease
- Needs echocardiogram and/or cardiac catheterization to confirm the severity.
- Systolic dysfunction caused by aortic stenosis usually improves after valvular surgery.
- Systolic dysfunction caused by aortic regurgitation and particularly mitral regurgitation may deteriorate after valvular surgery.
- Significant mitral regurgitation secondary to dilated cardiomyopathy needs maximum afterload reduction therapy.
- Diagnosed by history, physical examination, ECG, cardiac monitoring (Holter monitoring vs arrhythmia monitor depends on frequency of the event), electrophysiologic study.
- Sustained tachycardia can cause left ventricular systolic dysfunction which should improve or resolve when the tachycardia has been controlled or eliminated.
- Asymptomatic PAC, PVC or nonsustained tachycardia should not receive pharmacological therapy.
- Symptomatic PAC, PVC should be treated with education and reassurance first.
- Most antiarrhythmic medicines have deleterious effects in heart failure patients with systolic dysfunction except for amiodarone, beta blockers (some) and dofetilide.
- Pacemaker therapy is indicated in appropriate, symptomatic or drug (that is necessary for heart failure treatment program) induced bradycardia.