In his classic 1933 text, Diseases of the Heart,1 Sir Thomas Lewis identified the diagnosis and management of chronic heart failure as the cardinal problem in clinical cardiology. This observation is relevant today, as heart failure represents one of the most rapidly growing and costly forms of cardiovascular disease. As discussed in Chap. 27 both the incidence and prevalence of heart failure are substantial and rising, because heart failure remains a principal complication of virtually every form of heart disease. Moreover, heart failure is associated with high rates of morbidity, mortality, and economic cost. For example, it is estimated that at any time 30% to 40% of heart failure patients are determined to be in New York Heart Association (NYHA) functional class III or class IV, indicating an advanced degree of disability.2 Readmission rates for heart failure remain high, and 5-year mortality ranges from 15% for those with asymptomatic disease to more than 50% in patients with advanced heart failure.3-6 Fortunately, a sound understanding of the pathophysiology of the disease (see Chap. 26) and a systematic approach to heart failure evaluation and management as reviewed in this chapter results in improved patient outcomes.
In general, the current evaluation and management of patients with chronic systolic heart failure has been well-studied. Recommendations for its treatment are supported by numerous randomized controlled trials or by substantial clinical/observational experience. This evidence base has led to the publication and update of national and international guidelines directing the evaluation and management of chronic systolic heart failure in adults.7-10 In contrast, the treatment of diastolic heart failure remains largely empirical and is directed toward controlling symptoms by reducing ventricular filling pressures without reducing cardiac output. Likewise, the treatment of acutely decompensated heart failure has been inadequately studied. While published guidelines address the management of decompensated heart failure, recommendations are generally based on consensus expert opinion rather than randomized controlled trials.7-11
Preferably, heart failure should be prevented through the early treatment of risk factors and, when present, asymptomatic left ventricular dysfunction. The first revision to the 1995 American College of Cardiology/American Heart Association Guideline for the Evaluation and Management of Heart Failure developed a framework for heart failure prevention.12 The guideline, published in November 200112 and updated in September 2005,7 views heart failure as a continuum beginning with risk factors and culminating in end-stage or refractory disease. According to the guideline, there are known risk factors and structural prerequisites leading to the development of left ventricular systolic and/or diastolic dysfunction and the clinical syndrome of heart failure.
The guideline outlines four stages describing the progression of heart failure (Table 28–1).7Stage A describes those patients who exhibit one or more risk factors for the development of heart failure. If inadequately treated, the risk factors, such as hypertension, diabetes, and coronary artery disease frequently lead to the development of a structural abnormality of ...