Congestive Heart Failure

Heart failure is a syndrome, not a disease.

Incidence in USA: About 5.1 million, with more than 650,000 new cases diagnosed annually. Primary discharge diagnosis made in more than 1 million pts.

1-y and 5-y survival rates are 57% and 25% in men and 64% and 38% in women. Median survival after onset is 1.7 y in men and 3.2 y in women.

Heart failure occurs in 1–6% of pts after major surgery, and between 6% and 25%, in pts with existing cardiac conditions.

EF <35% associated with increased operative risk.

Single greatest risk factor for cardiac surgery. Use congestive heart failure score (CASS): Hx of CHF = 1; Rx digitalis = 1; Rales = 1; overt symptoms after treatment = 1; total 0–4. If score = 4, operative risk is 8× greater.

Ventricular dysfunction preop, which is associated with increased operative mortality.

Pt with diastolic dysfunction may be asymptomatic at rest but sensitive to increases in heart rate, which may result in flash pulm edema.

Dysrhythmias due to cardiac ischemia (sudden cardiac death).

Associated acute or chronic mitral insufficiency.

Volume status.

Prolonged effect of ACE inhibitors.

Different types of failure (left vs. right; acute vs. chronic; systolic vs. diastolic; low output vs. high output)

Reduced contractility, decreased stroke volume, increased heart rate, and hypertrophy and ventricular dilatation

Acute ischemia, which can lead to global diastolic dysfunction and CHF

Papillary muscle ischemia, which may lead to severe mitral regurgitation and pulm congestion

New York Heart Association classification: I, no limitation; II, slight limitation; III, marked limitation; IV, inability to carry out any physical activity; overall 1-year mortality for classes III and IV: 34–58%

Acquired, acute or chronic: CHD and MI; cardiomyopathy (idiopathic, hypertrophic, hypertrophic obstructive, congestive, and alcoholic). Valvular heart disease: Arrhythmias and severe hypertension.

Congenital: Congenital heart disease, left-to-right shunts; intracardiac (ASD, VSD, and AV canal), and extracardiac (PDA and anomalous pulm venous connection). Obstructive (coarctation of the aorta and aortic stenosis). Complex (Ebstein anomaly).

Multiple precipitating causes: Noncompliance with medications (digitalis and diuretics), excessive Na ⁺ ; excessive IV fluids; drugs (doxorubicin, corticosteroids, disopyramide, nortriptyline, NSAIDs, thiazolidinediones, metformin, cilostazol, PDE-5 inhibitors [sildenafil, vardenafil] androgens, and estrogens). Pulm embolism: High-output states (pregnancy, fever, hyperthyroidism, sepsis, AV fistula, and anemia).