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Chf Exacerbation

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Last Updated: 02 July 2021

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General | Latest Info

Most experienced practitioners are familiar with patients who present with shortness of breath from exacerbation of Congestive Heart Failure. However, options for management of these patients remain crude and limited. 1 2 Acute decompensated Heart Failure is a common and growing medical problem associated with major morbidity and mortality. 36 It is the leading reason for hospital admission among patients over age 65 and the most costly cardiovascular disorder in Western countries. 7 60 - day mortality following hospital admission because of exacerbation of Congestive Heart Failure is 8% 20%, depending on population study. 8 9 difficulties surrounding treatment begin with the lack of clear definitions. The term Acute decompensated Heart Failure broadly represents new or worsening symptoms or signs of dyspnea, fatigue or edema that lead to hospital admission or unscheduled Medical Care and that are consistent with underlying worsening of left ventricular function. 10 Acute Heart Failure is defined as an onset of symptoms or signs of Heart Failure in patients with no prior history of Heart Failure and previously normal function is an uncommon cause of Acute decompensated Heart Failure, particularly in patients without concomitant Acute coronary syndromes. Much more frequently, Acute decompensated Heart Failure occurs in patients with previously established myocardial Dysfunction who present with exacerbation of symptoms or signs after a period of relative stability. Acute decompensated Heart Failure represents a heterogeneous group of disorders with various causes, many of which are not yet well understood. 11 Recent large registries of patients with exacerbation of Congestive Heart Failure show that about 50% of them have preserved Systolic function. 12 Because patients with underlying chronic Diastolic Dysfunction seem to have a narrow window for optimal volume status, and because so few targeted therapies are available for Diastolic Dysfunction, Acute decompensated Heart Failure in this subset of patients presents a unique challenge to clinicians. With a handful of randomized trials over the past 5 years investigating new treatments for Acute decompensated Heart Failure, field has recently received increasing attention. Here, we attempt to briefly examine physiologic rationale for currently available treatments and summarize existing evidence for their efficacy, with the goal of informing providers of how to optimize their management of patients with Acute decompensated Heart Failure. Our review is meant to complement more comprehensive guidelines for diagnosis and treatment of Acute Heart Failure issued by the European Society of Cardiology 1 and Heart Failure Society of America.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Clinical course

The main goal of initial Inpatient treatment for Acute CHF exacerbation is reducing CHF symptoms, with secondary aims of improving quality of life and slowing progression of cardiac Failure to decrease mortality. In the majority of cases, CHF exacerbation has multiple causes. According to a large multicenter study, common factors implicated in worsening of CHF status include non - adherence to dietary restriction; infectious processes, notably pulmonary infections; and inappropriate reductions in CHF Therapy. Many of these factors are modifiable and avoidable, meaning that readmissions could be avert. Chf exacerbation is clinical diagnosis based on at least 1 of the following symptoms: exertional dyspnea, fatigue, paroxysmal nocturnal dyspnea, orthopnea, cough, early satiety, weight gain, and increasing abdominal girth. Physical exam findings may consist of S3 gallop, JVD, bibasilar crackles, abdominal distention, hepatomegaly, and peripheral edema. Initial workup should include CBC, CMP, BNP, 12 - lead ECG, and chest X - ray. While there is no consensus on the utility of obtaining serial BNP measurements, measurement of BNP or N - terminal Pro - Btype natriuretic peptide may be useful in diagnosis of acutely decompensated CHF, especially in setting of clinical uncertainty. Tte should be complete if there is no documentation of previous study. Tte may be repeated when there is change in clinical status. Decompensation of CHF is not an indication for repeat echocardiogram. According to 2013 guidelines from the American College of Cardiology Foundation / American Heart Association, all patients who are volume overload and classified as New York Heart Association class II - IV should be on IV loop diuretics during hospitalization. There is insufficient evidence to recommend bolus doses over continuous infusion of loop diuretic Therapy. However, if patients are already receiving loop diuretic Therapy, initial IV dose should equal or exceed their oral daily dose and be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be assessed serially. Diuretic doses should be titrated for relief of symptoms, to reduce volume excess, and to avoid hypotension. High doses should be avoided as they are linked with an increase in mortality. During CHF exacerbation, oxygen supplementation should also be provided for hypoxemia. Once acute symptoms of exacerbation have resolve, patients should be placed on both the ACE Inhibitor and beta - blocker. Ace inhibitors, beta - blockers, and aldosterone antagonists have been shown to reduce both mortality and hospitalizations. Ace inhibitors as class have show mortality benefit, and there is no single preferred ACE Inhibitor. In contrast, among beta - blockers, only 3 shown to provide mortality benefit are bisoprolol, Carvedilol, and Metoprolol succinate. Hydralazine and nitrates were shown to be particularly beneficial, as early as 1987, in reduction of mortality in younger white veterans with lower ejection fraction and those with a history of hypertension. In African - Americans with NYHA class III - IV HF who are persistently symptomatic, hydralazines and nitrates have been shown to reduce mortality as well.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Overview

The main goal of initial inpatient treatment for acute CHF exacerbation is reducing CHF symptoms, with secondary aims of improving quality of life and slowing progression of cardiac failure to decrease mortality. In the majority of cases, CHF exacerbation has multiple causes. According to a large multicenter study, common factors implicated in worsening of CHF status include non - adherence to dietary restriction; infectious processes, notably pulmonary infections; and inappropriate reductions in CHF therapy. Many of these factors are modifiable and avoidable, meaning that readmissions could be avert.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Clinical presentations

Table III.

Major CriteriaMinor CriteriaMajor or Minor Criteria
PND or orthopneaJVDRalesCardiomegalyAcute pulmonary edemaS 3 GallopIncreased venous pressure >16 cm H 2 OCirculation time > or equal to 25 secHepatojugular refluxAnkle edemaNight coughDyspnea on exertionHepatomegalyPleural effusionVital capacity decreased by one third from maximumTachycardia (rate > or equal to 120)Weight loss > or equal to 4.5 kg in 5 days in response to treatment

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Symptoms

Table

Symptoms you may notice firstSymptoms that indicate your condition has worsenedSymptoms that indicate a severe heart condition
fatigueirregular heartbeatchest pain that radiates through the upper body
swelling in your ankles, feet, and legsa cough that develops from congested lungsrapid breathing
weight gainwheezingskin that appears blue , which is due to lack of oxygen in your lungs
increased need to urinate , especially at nightshortness of breath, which may indicate pulmonary edemafainting

Congestive heart failure is a chronic progressive condition that affects the pumping power of your heart muscles. While often referred to simply as heart failure, CHF specifically refers to the stage in which fluid builds up around the heart and causes it to pump inefficiently. You have four heart chambers. The upper half of your heart has two atria, and the lower half of your heart has two ventricles. Ventricles pump blood to your body's organs and tissues, and atria receive blood from your body as it circulates back from the rest of your body. Chf develops when your ventricles ca pump enough blood volume into body. Eventually, blood and other fluids can back up inside your: lungs, abdomen, liver, lower body. Chf can be life - threatening. If you suspect you or someone near you has CHF, seek immediate medical treatment. Cardiomyopathy, or damage to heart muscle, can be the cause of heart failure, and genetics could play a role in some types of cardiomyopathy. However, most cases of congestive heart failure are not hereditary. Some risk factors for CHF, such as hypertension, diabetes, and coronary artery disease, can run in families. To reduce your risk of developing CHF, consider making lifestyle changes like eating a healthy diet and getting regular exercise.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Causes

Table

Type of heart failureDescription
Left-sided heart failureFluid may back up in your lungs, causing shortness of breath.
Right-sided heart failureFluid may back up into your abdomen, legs and feet, causing swelling.
Systolic heart failureThe left ventricle can't contract vigorously, indicating a pumping problem.
Diastolic heart failure (also called heart failure with preserved ejection fraction)The left ventricle can't relax or fill fully, indicating a filling problem.

You and your doctor may consider different treatments depending on your overall health and how far your condition has progress. There are several medications that can be used to treat CHF, including: angiotensin - converting enzyme inhibitors open up narrowed blood vessels to improve blood flow. Vasodilators are another option if you cannot tolerate ACE inhibitors. Benazepril captopril, enalapril fosinopril, lisinopril quinapril ramipril moexipril perindopril trandolapril ACE inhibitors shouldnt be taken with following medications without consulting with a doctor, because they may cause adverse reaction: thiazide diuretics can cause additional decrease in blood pressure. Potassium - sparing diuretics, such as triamterene, eplerenone, and spironolactone, can cause potassium buildup in the blood. This may lead to abnormal heart rhythms. Nonsteroidal anti - inflammatory drugs, such as ibuprofen, aspirin, and naproxen, can cause sodium and water retention. This may reduce ACE inhibitors ' effect on your blood pressure. This is an abbreviated list, so always speak with your doctor before taking any new medications. Beta - blockers can reduce blood pressure and slow rapid heart rhythm. Acebutolol atenolol bisoprolol carteolol esmolol metoprolol nadolol nebivolol propranolol beta - blockers should be taken with caution with following medications, as they may cause adverse reaction: antiarrhythmic medications, such as amiodarone, can increase cardiovascular effects, including reducing blood pressure and slowing heart rate. Antihypertensive medications, such as lisinopril, candesartan, and amlodipine, may also increase the likelihood of cardiovascular effects. Effects of albuterol on bronchodilation may be cancelled out by beta - blockers. Fentora may cause low blood pressure. Antipsychotics, such as thioridazine, may also cause low blood pressure. Clonidine may cause high blood pressure. Some medications may not be listed here. You should always consult your doctor before taking any new medications. Diuretics reduce your body's fluid content. Chf can cause your body to retain more fluid than it should. Thiazide diuretics. These cause blood vessels to widen and help the body remove any extra fluid. Examples include metolazone, indapamide, and hydrochlorothiazide. Loop diuretics. These cause the kidneys to produce more urine. This helps remove excess fluid from your body. Examples include furosemide, ethacrynic acid, and torsemide. Potassium - sparing diuretics. These help get rid of fluids and sodium while still retaining potassium. Examples include triamterene, eplerenone, and spironolactone. Diuretics should be taken with caution with following medications, as they may cause adverse reaction:s ACE inhibitors, such as lisinopril, benazepril, and captopril, can cause decreased blood pressure. Tricyclics, such as amitriptyline and desipramine, may cause low blood pressure. Anxiolytics, such as alprazolam, chlordiazepoxide, and diazepam, may cause low blood pressure. Hypnotics, such as zolpidem and triazolam, may cause low blood pressure. Beta - blockers, such as acebutolol and atenolol, may cause low blood pressure. Calcium channel blockers, such as amlodipine and diltiazem, may cause drop in blood pressure. Nitrates, such as nitroglycerin and isosorbide - dinitrate, may cause low blood pressure. Nsaids, such as ibuprofen, aspirin, and naproxen, may cause toxicity to the liver.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

Table2

Symptoms you may notice firstSymptoms that indicate your condition has worsenedSymptoms that indicate a severe heart condition
fatigueirregular heartbeatchest pain that radiates through the upper body
swelling in your ankles, feet, and legsa cough that develops from congested lungsrapid breathing
weight gainwheezingskin that appears blue , which is due to lack of oxygen in your lungs
increased need to urinate , especially at nightshortness of breath, which may indicate pulmonary edemafainting
* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Risk factors

Patients with heart failure often require costly emergency or hospital care. In United States, total annual annual health - care costs of 5. 3 million people with heart failure exceed 34. 8 billion. 1 These costs derive largely from exacerbations requiring expensive emergency visits and hospitalizations. In 2004, heart failure was the second most expensive disease bill for Medicare, involving 5. 8% of Medicare total hospital expenditures. 2 in 2005, it accounted for 59. 3% of estimated direct costs, largely from more than > 1 million hospital admissions. 1 Studies of factors associated with clinical exacerbation requiring urgent care services, such as emergency department visits and hospitalizations, have primarily examined either socioeconomic or biomedical constructs but not both in the same analysis. Socioeconomic Studies often include factors such as income, insurance status, marital status, and some measures of health - related quality of life. 3 4 Biomedical Studies often target clinical laboratory tests and cardiovascular - specific tests such as plasma brain natriuretic peptide concentration and assessment of left ventricular ejection fraction. 5 8 Demographic factors and the New York Heart Association class are often considered in each type of analysis. However, until recently, socioeconomic and biomedical factors have seldom been simultaneously assess. 9 10 in addition, assessments of treatment adherence and health literacy skills are rarely considered in any analysis, even though these patient abilities are essential for effective self - management of chronic illness and are important for improved health outcomes. 11 13 guide by framework that links health system and patient characteristics to self - care and health outcomes, 14 we measure a comprehensive set of variables in cohort of 192 participants nest within a randomized controlled trial to ascertain patient characteristics and risk factors associated with clinical deterioration requiring emergency department visits or hospitalization. Variables include demographic classification, socioeconomic status, cardiac performance, functional status, results of laboratory tests, and treatments. We also measure treatment adherence and health literacy skills. We then simultaneously assess the association of socioeconomic and biomedical factors, treatment adherence, and health literacy with incidence of emergency and hospital care. In doing so, we determine factors independently associated with clinical exacerbation of heart failure, as well as relative strengths of their associations. Factors amenable to intervention could be targeted to mitigate their impact on health outcomes.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Diagnosis

We have achieved great success in optimization of pharmacological therapy along with a relative increase in availability of better healthcare options. This has led to a reduction in mortality in comparison to one seen in the 1970s. On contrary, this has led to a rise in the prevalence of HF and a proportionate increase in burden on the healthcare system, especially when associated with extended and frequent readmissions. The long - term goal of treatment and management of HF is to avoid exacerbation of HF and to decrease hospital readmission rate. Achievement of this goal encompasses an interdisciplinary approach involving patients and their physicians, nurses, family and care takers. Various reports have discussed strategies to improve the overall quality of care of patients with HF. We have tried to summarize crucial ones below. Patient education: patient education about HF and strategies for its treatment. Dietary counseling about sodium and fluid restriction < 2 L / day is considered when fluid retention persists and when severe hyponatremia is present. Healthy lifestyle changes; especially, recent studies have advocated the importance of exercise training for HF patients via improvement in skeletal muscle O 2 delivery, while simultaneously correcting mitochondrial and contractile efficiency. Localized muscle training has been shown to improve convective and diffusive O 2 transport in HF and, hence, is useful for patients with minimal lung reserve capacity; several variables, such as exercise type, duration, frequency, intensity, etc., Need to be taken into consideration to best benefit from such training. Efforts to improve patients ' compliance with medical regimens and interventions, such as phone calls, reminders and home nurse, to help patients remember to take medications. Understand alarming signs and symptoms, such as shortness of breath, excessive fatigue, swelling of feet / ankle, etc. Weight monitoring. Arranging follow - up care: this includes assistance in scheduling first follow - up appointment post - hospitalization along with re - enforcement of the importance of other follow - up visits. It also includes documentation of date, time and location of follow - up visit on discharge plan, as well as sending reminders for subsequent appointments. One recent study has shown that it is possible to predict readmission based on the response of patients on an automated follow - up questionnaire. Home tele - monitoring: this is a unique approach where transmission of clinical parameters and symptoms of patients with HF at home to their healthcare provider, such as weight, blood pressure, heart rate, oxygen saturation, along with patients ' queries and questions regarding medications and symptoms and signs is conduct, thereby titrating therapy based on symptoms and signs. Few studies have shown that home tele - monitoring reduces mortality and hospitalizations, while in other studies, home tele - monitoring was found to be equivalent to telephone calls by nurse.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Treatment

Patients with Heart Failure can benefit from attention to exercise, diet, and nutrition. Restriction of activity promotes physical deconditioning, so physical activity should be encourage. However, limitation of activity is appropriate during Acute Heart Failure exacerbations and in patients with suspected myocarditis. Most patients should not participate in heavy labor or exhaustive sports. A 2012 meta - analysis shows that aerobic exercise training, particularly over the long term, can reverse left ventricular remodelling in clinically stable Heart Failure patients, whereas strength training had no effect on remodelling. Because nonadherence to diet and medication can have rapid and profound adverse effects on Patients clinical status, close observation and follow - up are important aspects of care. Patient education and close supervision, including surveillance by patient and family, can improve adherence. These measures also facilitate early detection of weight gain or slightly worsened symptoms, which often occur several days before major clinical episodes that require emergency care or hospitalization. Patients can then alert their clinicians, who may be able to prevent such episodes through prompt intervention. Dietary sodium restriction of 2 - 3 g / day is recommend. Fluid restriction to 2 L / day is recommended for patients with evidence of hyponatremia and for those whose fluid status is difficult to control despite sodium restriction and use of high - dose Diuretics. Caloric supplementation is recommended for patients with evidence of cardiac cachexia. Analysis of concentrations of plasma eicosapentaenoic acid, long - chain omega - 3 fatty acid, in Cardiovascular Health Study identify plasma phospholipid EPA concentration as being inversely related to incident Congestive Heart Failure. These results support additional studies on potential benefits of omega - 3 fatty acids for Primary Prevention of Heart Failure. The GISSI - HF trial, which included nearly 7000 patients with systolic Heart Failure who received either 1 g of omega - 3 polyunsaturated fatty acids or placebo daily, demonstrated that the PUFA regimen had small but significant reduction in both all - cause mortality and all - cause mortality / hospitalization for Cardiovascular causes.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Sources

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

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