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Congestive heart failure
ICD-10 code:	I50.0
ICD-9 code:	428.0

Congestive heart failure (CHF) (also called congestive cardiac failure and heart failure) is the inability of the heart to pump a sufficient amount of blood throughout the body, or requiring elevated filling pressures in order to pump effectively.

CHF is an abnormal cardiac condition that reflects impaired cardiac pumping and blood flow. The pooling of blood leads to congestion in body tissue.

The term heart failure is frequently misused, especially when given as cause of death: it is not synonymous with "cessation of heartbeat" – for which see cardiac arrest.

Because not all patients have volume overload at the time of initial or subsequent evaluation, the term "heart failure" is preferred over the older term "congestive heart failure".

Contents 1 Classification 2 Symptoms and signs 3 Treatment 3.1 Medication 3.2 Devices and surgery 4 References 5 See also

Classification

There are many different ways to categorize heart failure, including:

• the side of the heart involved, (left heart failure versus right heart failure)
• whether the abnormality is due to contraction or relaxation of the heart (systolic heart failure vs. diastolic heart failure)

The NYHA functional class is a commonly used way to gauge the progression of CHF in a particular patient. This classification is used to determine how much CHF limits their lifestyle, and does not apply to a particular decompensated episode.

Symptoms and signs

Signs of decompensated heart failure include pulmonary edema (fluid accumulation in the lungs), peripheral edema (fluid build-up in dependent portions of the body). Other physical examination findings include rales heard on chest auscultation, an enlarged or pulsatile liver, and jugular venous distension.

Symptoms of decompensated heart failure include dyspnea (shortness of breath) on exertion, orthopnea (dyspnea that increases upon lying down), fatigue and paroxysmal nocturnal dyspnea ("cardiac asthma", shortness of breath that occurs hours or minutes after lying down).

Treatment

Individuals with heart failure are sensitive to small shifts in their intravascular volume status (the amount of fluid in their circulatory system). Increasing the volume in their circulatory system can cause symptoms and signs of decompensated heart failure, while decreasing the volume in the circulatory system can cause hypotension.

The treatment of CHF focuses on treating the symptoms and signs of CHF and preventing the progression of disease. If there is a reversible cause of the heart failure (e.g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, or hypertension), that should be addressed as well.

Medication

Treating the signs and symptoms of CHF involves maintaining a euvolemic state (normal fluid level in the circulatory system). This is done with the judicious use of diuretic agents, vasodilator agents, and positive inotropes.

Delaying the progression of heart failure involves the use of ACE inhibitors, beta blockers, and aldosterone inhibitors. These agents have been proven to improve survival in individuals with CHF. While the mechanism of improving is not entirely clear, it appears that these agents prevent remodelling of the heart and therefore prevent progression of dilatation of the left ventricle.

Devices and surgery

Patients with NYHA class III or IV, LVEF of 35% or less and a QRS interval of 120ms or more may benefit from bi-ventricular pacemaker (CRT) placement or surgical remodelling of the heart. These treatment modalities may make the patient symptomatically better, improving quality of life and in some trials have been proven to reduce mortality. In the recently completed COMPANION trial, cardiac resynchronization therapy (pacing the left ventricle as well as the right ventricle) has been shown to improve survival in individuals with NYHA class III or IV heart failure with a widened QRS complex on EKG.² The CARE-HF trial, showed that patients receiving a Medtronic bi-ventricular pacemaker (CRT) and optimal medical therapy benefit from a 36% reduction in all cause mortality, and a reduction in cardiovascular related hospitalization.³

Additionally, patients with NYHA class II, III or IV, LVEF of 35% (without a QRS requirement) may benefit from an Implantable Converter Defibrillator (ICD), a device that is proven to reduce all cause mortality (death) by 23% compared to placebo. This mortality benefit was observed in patients who were already optimally managed on drug therapy.⁴

Another current treatment involves the use of left ventricular assist devices (LVADs). LVADs are battery-operated mechanical pump-type devices that are surgically implanted on the upper part of the abdomen. They take blood from the left ventricle and pump it through the aorta. LVADs are becoming more common and are often used by patients who have to wait for heart transplants. Acorn Cardiovascular, based in St. Paul, Minnesota, recently created the CorCap Cardiac Support Device (CSD), also known as the "heart sock." It is a dacron mesh that is placed around the heart. The elastic CSD works by mechanically restoring the contractility of the expanded heart. The CorCap CSD recently failed to be approved by the FDA.

The ultimate treatment is cardiac transplant surgery (heart transplant) or implantation of an artificial heart.

References

1. ACC / AHA guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult (PDF Copy)

2. Bristow MR, Saxon LA, Boehmer J, et al for the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350:2140-2150.

3. Cleland JGF, Daubert J-C, Erdmann E, et al; the Cardiac Resynchronization -- Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005 March 7 N Engl J Med 2005; 10.1056/NEJMoa050496

4. Bardy GH, Lee KL, Mark DB, et al for the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352:225-237

5. Donatelle, Rebecca J. Health: The Basics. 6th ed. San Francisco: Pearson Education, Inc. 2005.

See also

• Killip class

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