د. حسين محمد جمعه
اختصاصي الامراض الباطنةالبورد العربي
كلية طب الموصل
2011
Heart failure: an update on management
About 4% of men and 3% of women over the age of 65 years have heart failure. The prevalence of asymptomatic left ventricular dysfunction is 3% in people of all ages.And the mortality from heart failure is high. Studies describe a five year mortality ranging from 26% to 75%. So it is vital that doctors have a good grasp of how to treat patients with this condition.
"Most doctors have a good understanding of how to treat heart failure. In particular, the message about the benefits of angiotensin-converting enzyme inhibitors (ACE inhibitors) has largely got through. But many doctors want an update on the more recent advances in the management of heart failure.
They want advice about the roles of ECG, echocardiography, and B-type natriuretic peptides in the diagnosis of heart failure. They also want practical tips on when and how to start beta blockers and spironolactone. A growing body of evidence points to an increasing role for implantable cardiac defibrillators, so patients and doctors will also need to know about these.
The chances of someone with heart failure having a raised B-type natriuretic peptide level are greater than 90%. This is the same as the sensitivity. However if the ECG and the B-type natriuretic peptide level are both normal then heart failure is very unlikely and you should consider an alternative diagnosis.
If the ECG and B-type natriuretic peptide are both normal then the chances of heart failure are <5%. You should make the diagnosis of heart failure on the basis of symptoms and signs and tests. Raised jugular venous pressure has a high predicitve value in the diagnosis of heart failure.
The most common cause of death in patients with heart failure is ventricular arrhythmias, accounting for 25% to 50% of all deaths.
Amiodarone is effective against ventricular arrhythmias but it does not prolong life.
Amiodarone can cause side effects such as thyroid dysfunction and lung fibrosis. It also interacts with other drugs, for example it increases the plasma levels of digoxin. This can result in digoxin toxicity (nausea, headache, yellowing of vision).
Implantable cardioverter defibrillators prolong life in patients with left ventricular dysfunction and a history of sustained ventricular arrhythmias.
Flecainide is contraindicated in patients with cardiac failure.
By how much do beta blockers reduce the mortality in heart failure over one year (the figures given are absolute risk reductions)? Beta blockers result in an absolute risk reduction in mortality of 3%-7%. About 25% of patients with heart failure get worse while they are starting or increasing the dose of beta blockers.
