Heart failure (HF) is a clinical syndrome characterised by inadequate systemic perfusion to meet the body's metabolic demands as a result of impaired cardiac pump function. It is one of the leading cardiovascular health problems in Europe, and its incidence, particularly in the elderly, continues to increase despite an intensive effort to increase education and delivery of healthcare to affected patients. Decompensated HF is characterised by an increase in symptoms such as breathlessness, fatigue, and fluid retention. It remains a lethal diagnosis with morbidity and mortality rates that often exceed neoplastic or infectious diseases. Decompensated HF is a complex entity and multiple strategies usually need to be implemented simultaneously.
Dr Veli-Pekka Harjola from the Division of Emergency Care, Department of Medicine, Helsinki University Hospital talks to European Cardiovascular Disease 2006 about the treatment and diagnosis of decompensated HF.
Q: Which drugs would you use to treat decompensated HF?
A: First-line drugs for acute HF are nitrates and intravenous furosemide and also, if the patient has pulmonary oedema, continuous positive airway pressure (CPAP) mask ventilation is an essential part of the treatment. If the patient does not improve with this first-line therapy, the second line would then be intravenous infusion of levosimendan.
Q: When would you diagnose them?
A: First, an echocardiography should be performed as soon as possible if there are no recent data on cardiac function. The physician then needs to ascertain whether there is systolic dysfunction or a diastolic dysfunction. The inotropic drugs as well as the levosimendan have been used for systolic dysfunction and most often for those patients who have left ventricle ejection fraction less than 30-35%. The physician will then look for the predisposing factor or the underlying disease, since acute HF is just a syndrome with specific symptoms and signs.
It is imperative to discover this underlying disease and the most common of these is ischaemic heart disease. The important elements to identify are signs of acute coronary syndrome. If these are present the aim would then be to perform a coronary angiogram and a percutaneous coronary intervention if needed. While the patient will initially need treatment for symptoms and support for circulation and ventilation, the physician will also need to look for causative factors and direct specific therapy to them.
Clinical judgement is also a very important part of diagnosis. From a chest X-ray it is possible to see whether there is any congestion, any signs of fluid extravasation or pulmonary oedema. In such cases beneficial treatments would include the use of inodilators, vasodilators and diuretics. Clinical signs should also be taken into account, and can include:
- Evaluation of congestion:
- auscultation of pulmonary rates
- estimation of central venous pressure from the jugular veins;
- liver size;
- occurrence of peripheral oedema;
- Evaluation of organ perfusion:
- whether the perfusion of the organ is sufficient;
- the occurrence of diuresis;
- the peripheral temperature of the skin;
- the consciousness of the patient; and
- the presence of any other signs of hypoperfusion.
If these signs of hypoperfusion are present, then a drug like levosimendan, or inotropic drugs, would be required to treat the HF.
Q: What is the future of HF drug treatment?
A: In the future physicians need to conduct comprehensive clinical diagnoses of patients. For example, new European guidelines have described different classes of acute HF patients and have made a particular point of highlighting the heterogeneity of patients, reinforcing the message that acute HF is not a single disease but a heterogeneous group of different manifestations and different underlying diseases. Therefore, the primary goal in the future is how to shorten the length of stay of patients in hospital.
To achieve this goal, one has to be more active in evaluating the response to initial therapy. If the patient does not get relief from this initial therapy, the physician has to be proactive, and be willing to start the second-line therapies. Of these second-line therapies, currently levosimendan is the most promising and we have had very good experiences of this drug in our healthcare system. However, it can happen that the patient receives the initial treatment regimen for several days and physicians do not want to take the step to offer the next level of treatment as quickly as would be beneficial for the patient
Q: What are the main issues regarding prevention of HF?
A: The treatment of coronary heart disease (CHD) has taken huge steps during the last few years, and the treatment of chronic stable CHD as well as the treatment of acute coronary syndromes has also improved. As such the number of patients with severe cardiac dysfunction after coronary artery disease (CAD) may be lowering. On the other hand, patients are surviving for longer periods and, as these patients start getting elderly, diastolic dysfunction becomes more common and for diastolic dysfunction, the treatment of hypertension is essential. Thus, if you manage to treat hypertension and CAD well enough that is the best way to get some kind of prophylaxis of HF.
However, if the patient already has diagnosed chronic HF, patient education is essential. Well-trained nurses who are an integral part of the HF team will usually co-ordinate this education, and in some cases assist with the follow-up care. This care involves some kind of individual treatment based on daily monitoring of weight and flexible use of diuretics - treatment that prevents chronic HF cases developing into acute cases.