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    • Importance of heart failure Acute decompensated heart failur

    2019-04-18

    Importance of myeloperoxidase failure Acute decompensated heart failure (ADHF) refers to a clinical condition of worsening HF with dyspnea, often with evidence of fluid overload [1]. This is generally triggered by 1 of the 4 main factors: atrial fibrillation, anemia, hypertension, and medication/dietary indiscretion. About 5 million Americans suffer from HF [2]. In the 1991–1994 Connecticut Medicare beneficiaries review [3], ADHF necessitating hospitalization was found to be associated with an in-hospital mortality of 8%. Importantly, of the 17,448 survivors, 44% were readmitted once, with 18% of these patients being admitted due to recurrent HF. Overall, 24% died within 6 months of the first clinical manifestation of ADHF, and 53% either died or were readmitted during the study period. Thus, prevention of ADHF can have significant prognostic value for the patient, in addition to reducing the cost of HF management.
    Limitations of symptoms, signs, and investigations While dyspnea is the commonest presenting symptom for hospitalization in ADHF, it occurs relatively late in association with hemodynamic and fluid status changes. Adamson et al. [4] implanted a right ventricular (RV) sensor to measure RV systolic and diastolic pressure during HF exacerbation in 32 patients. At a mean of 4±2 days before admission, RV systolic pressure started increasing in the case of 9/12 HF events. Overall, there was an increase in the RV systolic pressure by 25±4% and in the heart rate, by 11±2% during ADHF. These findings suggested that pressure changes are the mechanisms responsible for initiating HF exacerbation. Similarly, a study using an implantable intrathoracic impedance sensor to assess pulmonary fluid revealed that fluid overloading occurs at 18.3±10.1 days before dyspnea occurred [5]. Thus, dyspnea is a late event and does not allow time for the clinician to start or for the patient to seek appropriate intervention and thereby avert hospitalization. The cardinal physical signs of congestive HF are as follows: a third heart sound, pulmonary crackles, raised jugular venous pressure, and pedal edema. However, these signs have poor sensitivity in detecting HF. In a study [6] of 50 patients with raised pulmonary arterial wedge pressure (PAWP; ≥22mmHg), lung crackles were identified in only 19% of the patients, while a raised jugular venous pressure and peripheral edema were present in 50% and 20% of patients, respectively. While a third heart sound was heard in most cases, it was also detected in those with a low PAWP. The combination of these signs has a sensitivity of 58% and specificity of 100% for diagnosing congestive HF. However, physical examination of jugular pressure is reported to be both difficult and inaccurate [7]. In a recent study [8], 134 patients with ADHF were compared with a case-matched group of non-hospitalized patients. Body weight gain 1 week before hospitalization was associated with an increased risk of hospitalization. However, while daily body weight measurement is recommended in most HF guidelines, body weight is a non-specific parameter and may be influenced by the amount of intake and several other factors. Radiological evidence of ADHF tends to appear late. HF management is reported to be facilitated by a brain natriuretic peptide (BNP)-guided approach; in a study on HF therapy guided by the levels of N-terminal BNP (TIME-CHF) [9], 499 patients who were aged ≥60 years and had systolic HF were randomized. Titration to achieve an N-terminal BNP level of ≤2 times the upper limit was compared to conventional management without BNP guidance. There was no difference in the survival rates between BNP-guided therapy and conventional therapy (41% versus 40%), and both groups had a similar degree of improvement in the quality of life (QOL). However, the secondary endpoint of HF-related hospitalization was significantly reduced (72% versus 62%), and the outcomes were better in the 60- to 75-year-old patients than in those aged ≥75 years.