Heart failure: It is inability of the heart to pump enough blood to the body tissues.
Signs and symptoms
Signs and symptoms of heart failure include the following:
Exertional dyspnea and/or dyspnea at rest
Orthopnea
Acute pulmonary edema
Chest pain/pressure and palpitations
Tachycardia
Fatigue and weakness
Nocturia and oliguria
Anorexia, weight loss, nausea
Exophthalmos and/or visible pulsation of eyes
Distention of neck veins
Weak, rapid, and thready pulse
Rales, wheezing
S 3 gallop and/or pulsus alternans
Increased intensity of P 2 heart sound
Hepatojugular reflux
Ascites, hepatomegaly, and/or anasarca
Central or peripheral cyanosis, pallor
Causes of Heart failure:
1. Hypertension
2. Coronary heart diseases
3. Valvular heart diseases
4. Cardiomyopathy
Diagnosis
Major criteria include the following:
Paroxysmal nocturnal dyspnea
Weight loss of 4.5 kg in 5 days in response to treatment
Neck vein distention
Rales
Acute pulmonary edema
Hepatojugular reflux
Central venous pressure greater than 16 cm water
Circulation time of 25 seconds
Radiographic cardiomegaly
Pulmonary edema, visceral congestion, or cardiomegaly at autopsy
Minor criteria are as follows:
Nocturnal cough
Dyspnea on ordinary exertion
A decrease in vital capacity by one third the maximal value recorded
Pleural effusion
Tachycardia (rate of 120 bpm)
Bilateral ankle edema
The New York Heart Association (NYHA) classification system categorizes heart failure on a
scale of I to IV, as follows:
Class I: No limitation of physical activity
Class II: Slight limitation of physical activity
Class III: Marked limitation of physical activity
Class IV: Symptoms occur even at rest; discomfort with any physical activity
Testing
The following tests may be useful in the initial evaluation for suspected heart failure
Complete blood count (CBC)
Urinalysis
Electrolyte levels
Renal and liver function studies
Fasting blood glucose levels
Lipid profile
Thyroid stimulating hormone (TSH) levels
B-type natriuretic peptide levels
N-terminal pro-B-type natriuretic peptide
Electrocardiography
Chest radiography
2-dimensional (2-D) echocardiography
Nuclear imaging
Maximal exercise testing
Pulse oximetry or arterial blood gas
Management
Treatment includes the following:
Nonpharmacologic therapy: Oxygen and noninvasive positive pressure ventilation,
dietary sodium and fluid restriction, physical activity as appropriate, and attention to
weight gain
Pharmacotherapy: Diuretics, vasodilators, inotropic agents, anticoagulants, beta
blockers, and digoxin
Surgical options
Hypertension
Signs and symptoms
Hypertension is defined as a systolic blood pressure (SBP) of 140 mm Hg or more, or a
diastolic blood pressure (DBP) of 90 mm Hg or more.
The classification of BP for adults aged 18 years or older has been as follows:
Normal: Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg
Prehypertension: Systolic 120-139 mm Hg, diastolic 80-89 mm Hg
Stage 1: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg
Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater
Hypertension may be primary, which may develop as a result of environmental or genetic
causes, or secondary, which has multiple etiologies, including renal, vascular, and endocrine
causes. Primary or essential hypertension accounts for 90-95% of adult cases, and secondary
hypertension accounts for 2-10% of cases.
Diagnosis
The evaluation of hypertension involves accurately measuring the patient’s blood pressure,
performing a focused medical history and physical examination, and obtaining results of
routine laboratory studies. A 12-lead electrocardiogram should also be obtained. These steps
can help determine the following:
Presence of end-organ disease
Possible causes of hypertension
Cardiovascular risk factors
Baseline values for judging biochemical effects of therapy
Other studies may be obtained on the basis of clinical findings or in individuals with
suspected secondary hypertension and/or evidence of target-organ disease, such as CBC,
chest radiograph, uric acid, and urine microalbumin.
Management
The lifestyle modification as the first step in managing hypertension.
Lifestyle modifications:
Weight loss (range of approximate systolic BP reduction [SBP], 5-20 mm Hg per 10
kg)
Limit alcohol intake.
Reduce sodium intake
Maintain adequate intake of dietary potassium
Maintain adequate intake of dietary calcium and magnesium for general health
Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall
cardiovascular health
Engage in aerobic exercise at least 30 minutes daily for most days (range of
approximate SBP reduction, 4-9 mm Hg)
Pharmacologic therapy
If lifestyle modifications are insufficient to achieve the goal BP, there are several drug
options for treating and managing hypertension. Thiazide diuretics are the preferred agents in
the absence of compelling indications.
Heart failure: Diuretic, beta-blocker, ACE inhibitor, ARB, aldosterone antagonist
Postmyocardial infarction: Beta-blocker, ACE inhibitor, aldosterone antagonist
High coronary disease risk: Diuretic, beta-blocker, ACE inhibitor, CCB
Diabetes: Diuretic, beta-blocker, ACE inhibitor, ARB, CCB
Chronic kidney disease: ACE inhibitor, ARB
