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CHAPTER SUMMARY AND CENTRAL ILLUSTRATION

Chapter Summary

This chapter discusses the diagnosis and treatment of heart failure with reduced ejection fraction (HFrEF), mid-range EF (HFmrEF) and recovered EF (HFrecEF), clinical syndromes that involve a complex interplay between myocardial, vascular, hemodynamic neurohormonal, and comorbid factors (see Fuster and Hurst’s Central Illustration). Early diagnosis and treatment of heart failure can improve quality of life and reduce rates of hospitalization and death. Cardinal manifestations of heart failure include dyspnea, which may limit exercise tolerance, and fluid retention, which may lead to pulmonary, splanchnic and peripheral edema. Foundational pharmacological therapies for chronic heart failure include diuretics, beta blockers, angiotensin receptor-neprilysin inhibitors, aldosterone receptor antagonists, and sodium glucose co-transporter 2 inhibitors. Certain heart failure patients may benefit from device-based therapies such as implantable cardioverter defibrillators and cardiac resynchronization therapy. Considering the high morbidity and mortality associated with heart failure, it is essential to appropriately diagnose and employ guideline directed medical therapy.

eFig 48-01 Chapter 48: Diagnosis and Management of Chronic Heart Failure

INTRODUCTION

The syndrome of heart failure has existed since humans first began to document disease. Clinical texts attributable to Hippocrates describe patients with shortness of breath, edema, and anasarca, in a manner not too varied from contemporary accounts.1 It has also long been realized that heart failure is not caused by a single disease; rather, it is an amalgamate of several diseases that have unique etiologies, natural histories, and treatments.2 The shared feature of this cluster of illnesses is damage to the cardiac issue. Initially, the heart compensates in various manners to a loss in reserve; however, once there is a critical degree of impairment in its structure and function, a final common pathway emerges that shares similarities in symptoms and findings.

Over the last several decades, dramatic improvements in management of valvular and ischemic heart disease have decreased mortality from these illnesses and consequently led to an increase in the incidence and prevalence of heart failure. Coupled with the aging of the global population, there has been a growth of the heart failure prevalence to epidemic proportions. Currently, heart failure affects more than 60 million people globally.3 Heart failure is a difficult disease to manage and is associated with high rates of morbidity and mortality, and costs associated with it, both in terms of direct financial costs as well as indirect cost of patient and caregiver burden.4 Therefore, it is imperative to recognize and manage the syndrome using the best currently available information, and to make concerted efforts to find novel ways to further improve its management.

DEFINING HEART FAILURE

According to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) heart failure guidelines, “Heart failure is a complex clinical syndrome that results from any structural or functional ...

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