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1、Relationship between cardiac dysfunction, HF and HF rendered asymptomatic,NORMAL,CARDIAC DYSFUNCTION CORRECTED OR RESOLVED,CARDIAC DYSFUNCTION,SYMPTOMS,HEART FAILURE,THERAPY,Therapy CAN be withdrawn without recurrence of symptoms,Symptoms relieved,Therapy CANNOT be withdrawn without recurrence of sy
2、mptoms,Transient Heart Failure,No symptoms,Asymptomatic cardiac dysfunction,Systolic dysfunction,Symptoms persist,Diagnosis,According to the Working Group in Heart Failure, Heart Failure is a syndrome where the diagnosis has the following essential components: A combination of: Symptoms, typically b
3、reathlessness or fatigue Cardiac dysfunction documented at rest The diagnosis is supported by: Response to treatment directed towards heart failure,Assessments in all cases Necessary Supports Opposes History with symptoms + If absent Objective evidence + If absent Response to treatment +,Establish d
4、iagnosis,Test Necessary Supports Opposes Electrocardiogram + If normal Echocardiography + If normal Chest x-ray If congestion If normal Blood count If normal Blood chemistry If normal,Tests for Diagnosis,Additional Tests for Diagnosis,Test Necessary Supports Opposes Exercise test If normal Natriuret
5、ic peptide If elevated If normal Cardiac cath. If normal,Test to Exclude Alternatives,Chest x-ray (Lung disease) Pulmonary function Blood chemistry (Renal and hepatic disease) Blood count (Anaemia) Exercise tolerance (if impaired),Electrocardiography,A normal ECG suggests that the diagnosis of heart
6、 failure should be carefully reviewed. The predictive value of a normal ECG to exclude LV systolic dysfunction exceeds 90%,Chest X-ray,A high predictive value of X-ray findings is only achieved by interpreting them in the context of clinical findings and ECG anomalies. It is useful to detect cardiac
7、 enlargement and pulmonary congestion In chronic heart failure, increased cardiac size and pulmonary venous congestion are useful indicators of abnormal cardiac function with decreased ejection fraction and/or increased LV filling pressure However, cardiomegaly is frequently absent in acute heart fa
8、ilure and in cases with diastolic dysfunction,Pulmonary function tests,Measurements of lung function are of little value in diagnosing chronic heart failure. However, they are useful in excluding respiratory causes of breathlessness,Exercise testing,In clinical practice exercise testing is of limite
9、d value for the diagnosis of heart failure. However, a normal maximal exercise test, in a patient not receiving heart failure treatment, excludes heart failure as a diagnosis,Invasive investigation,Invasive investigation is generally not required to establish the presence of chronic heart failure, b
10、ut may be important in elucidating the cause or to obtain prognostic information,Echocardiography,As objective evidence of cardiac dysfunction at rest is mandatory for the diagnosis of heart failure, echocardiography is the preferred method for this documentation The most important parameter for ide
11、ntifying patients with systolic cardiac dysfunction and those with preserved systolic function is the LV ejection fraction When the diagnosis of heart failure is confirmed, echocardiography is also helpful in determining its aetiology,Natriuretic Peptides,These peptides may be most useful clinically
12、 as a “rule out” test due to a consistent and very high negative predictive values Especially in primary care patients suspected of having heart failure can be selected for further investigation by echocardiography or other tests of cardiac function on the basis of having an elevated plasma concentr
13、ation of a natriuretic peptide In those in whom the concentrations are normal, other causes of dyspnoea and associated symptoms should be considered The added value of natriuretic peptides in this situation has yet to be determined,Natriuretic Peptides,High levels of natriuretic peptides identify th
14、ose at greatest risk of future serious cardiovascular events including death There is also recent evidence that adjusting heart failure therapy in order to reduce natriuretic peptides levels in individual patients may improve outcome,Other neuroendocrine evaluations,Other tests of neuroendocrine eva
15、luation are not recommended for diagnostic or prognostic purposes,Suspected Heart Failure because of symptoms and signs,Tests abnormal,Tests abnormal,Assess presence of cardiac disease by ECG, X-Ray or Natriuretic peptides (where available),Normal Heart Failure unlikely,Imaging by Echocardiography (
16、Nuclear angiography or MRI where available),Normal Heart Failure unlikely,Algorithm for Diagnosis of Chronic HF,Additional diagnostic tests where appropriate (e.g. coronary angiography),Management Outline,Establish that patient has heart failure,Identify presenting symptom,Assess severity of limitation,Determine etiology,Exclude or confirm concomitant diseases,Predict prognosis,Choose therapy,Monitor progress,Guidelines Treatment - Contents,General advice and measures Exercise and exe
