Getting A Medical Exam
Left Ventricular Mass Index And Relative Wall Thickness
Increased LV diastolic wall thickness in a non-dilated heart implies that the patient has LVH. It develops first in the basal segments of the ventricular septum, and a wall thickness 12mm at that site is common in elderly people. Localized septal hypertrophy may be a consequence of abnormal ventriculararterial coupling but it is not sufficient to indicate that there is significant global LV remodelling or hypertrophy.
Left ventricular geometry is often classified using relative wall thickness , calculated as twice the LV posterior wall thickness divided by the LV internal diameter at enddiastole , and using left ventricular mass index normalized to body surface area or height. Four patterns are described: normal , concentric remodelling , concentric hypertrophy , and eccentric hypertrophy .,, In patients with HFpEF, both concentric LVH and concentric remodelling can be observed.
The absence of LVH on echocardiography does not exclude HFpEF. We therefore recommend the finding of concentric hypertrophy as a major criterion, or any one of a lesser degree of LVH, RWT, and LV end-diastolic wall thickness as a minor criterion.,,
How Is Heart Failure Treated
The goal of heart failure treatment is to improve quality of life by addressing the underlying causes, reducing symptoms and managing overall health. Education plays a crucial role. Patients and their families who learn to recognize and respond to small changes, such as swelling or weight gain, can help slow the progression of heart failure.
These medications have been shown to prolong life in heart failure patients:
angiotensin converting enzyme inhibitors: This medication decreases the pressure inside the blood vessels and reduces the resistance against which the heart pumps.
angiotensin receptor blockers : This is an alternative medication for reducing the workload on the heart if ACE inhibitors are not tolerated. An ACE inhibitor or ARB blocker will often be recommended, but not both.
beta blockers: These reduce the heart’s tendency to beat faster and reduce its workload by blocking specific receptors on heart cells.
aldosterone blockers: This medication blocks the effects of the hormone aldosterone, which causes sodium and water retention.
angiotensin receptor-neprilysin inhibitors : This is a relatively new class of medication that for some people has been shown to be a better alternative than ACE inhibitors or ARB blockers.
These medications have been shown to reduce symptoms:
diuretics: These reduce the amount of fluid in the body.
vasodilators: These dilate the blood vessels and reduce workload on the heart.
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Clinical Recognition Can Be Challenging
Clinical recognition of HF can be challenging, especially for primary care providers.2 The diagnostic criteria for evaluating heart failure are based on parameters established by clinical experts. There are guidelines established to facilitate the decision making of providers in their routine practice. The guidelines provide up to date clinical information that can help in the diagnosis and treatment of patients with heart failure. Ultimately, decisions on individual patient care are made by the patient and their provider.1
Since the 1970s, multiple sets of diagnostic criteria have been developed with varying sensitivities. The Framingham, Duke, Gothenburg, ESC, and Boston criteria were established before noninvasive techniques for assessing systolic and diastolic dysfunction became widely available. The criteria were designed to assist in the diagnosis of heart failure. All of these criteria have proven helpful in guiding healthcare providers, particularly in diagnosing advanced or severe heart failure.4 Today, the Boston criteria are considered preferable when making a diagnosis of heart failure.5
Getting The Diagnosis Of Heart Failure
Receiving a diagnosis of heart failure will always be difficult. Choosing the best time to give the diagnosis is also hard because doctors need to know results of tests and have to take account of each person’s needs. Some people want detailed information about heart failure straightaway, others need reassurance that something can be done to help them. Those we talked to expressed a range of different attitudes to getting a diagnosis and some were still unsure what heart failure meant .
Some people had been given the diagnosis by a GP and liked talking to someone they knew about their problems one man described how he was seen by two GPs from the same practice, one of whom has a special interest in heart failure. Several appreciated straight talking, one man said that he had received a very clear picture of his heart failure from a hospital doctor and that he imagined his heart as a ‘withered hand’. but balancing the diagnosis with reassurance was imprtant for others: being told something could be done reduced the shock of the diagnosis for one woman. Several people said they found it difficult to visualise what was happening inside their own body despite having been shown diagrams, ECG print outs and angiograms by doctors.
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Utilization And Medical Coding
In addition to having the knowledge of the pathophysiology of the HF and its management with the help of established and novel therapies, it is important for a physician to understand how to document the therapy so as to satisfy the reimbursement requirements. The utilization process ensures the appropriateness of the incurred healthcare costs by reviewing inpatient and outpatient services and comparing them against medical necessity guidelines. Usually the clinical documentation improvement team facilitates the appropriate coding of the disease according to the guidelines and documents the codes in the International Classification of Diseases, Clinical Modification Version 10 mode. ICD-10 contains codes for human diseases, signs and symptoms, abnormal findings, social scenarios, external causes of injury or diseases and diagnostic and procedure codes associated with inpatient, outpatient and physician office utilization in the United States . Some of the ICD-10-CM for HF include I50heart failure, I50.1left ventricular failure, I50.2systolic heart failure, I50.3diastolic heart failure, I50.4combined systolic and diastolic heart failure and I50.9heart failure, unspecified .
Diagnostic Tests And Procedures
This animation discusses some of the tests used to diagnose heart failure. These tests may include an electrocardiogram to look at your hearts electrical activity, an echocardiogram to measure how well your heart is working and look at the structure, and a chest X-ray to see if your heart is enlarged or there is fluid in your lungs. Other tests may include blood tests and an exercise, or stress test. .
Your doctor may order blood tests to check the levels of certain molecules, such as brain natriuretic peptide . These levels rise during heart failure. Blood tests can also show how well your liver and your kidneys are working.
Tests to measure your ejection fraction
Your doctor may order an echocardiography or other imaging tests to measure your ejection fraction. Your ejection fraction is the percent of the blood in the lower left chamber of your heart that is pumped out of your heart with each heartbeat. Ejection fraction tells your doctor how well your heart pumps. This helps your doctor diagnose the type of heart failure you have and guide your treatment.
- If 40% or less of the blood in your left ventricle is pumped out in one beat, you have heart failure with reduced ejection fraction.
- If 50% or more of the blood in your left ventricle is pumped out in one beat, you have heart failure with preserved ejection fraction.
If your ejection fraction is somewhere in between , you may be diagnosed with heart failure with borderline ejection fraction.
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Usefulness Of Natriuretic Peptides
In general, NP levels are higher in patients presenting with acute shortness of breath for cardiac reason or in acute HF, than in patients who have chronic HF., Of note, our recommendations target stable symptomatic HFpEF, and natriuretic peptide levels can be normal in these patients even with invasively confirmed HFpEF. In consequence, normal NP levels do not exclude HFpEF, especially in the presence of obesity., Interpretation depends also on whether the patient is in sinus rhythm or has AF, which itself is associated with increased NP levels even in the absence of HF.,
Besides obesity, sex, age, and renal function affect NP levels,, but using stratified cut-points only marginally improves diagnostic accuracy , at the expense of less everyday utility. The variability of repeated measurements in individual patients is up to 100%, so a rise or fall of 100% may not necessarily indicate recovery or progression of disease.,
Small Changes Can Make A Big Difference
Following recommendations about diet, exercise and other habits can help alleviate heart failure symptoms, slow your diseases progression and improve your everyday life. In fact, people with mild to moderate heart failure often can lead nearly normal lives as a result.Important lifestyle changes may include:
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What Happens In Congestive Heart Failure
The heart has four chambers, a left atrium and right atrium and a left ventricle and right ventricle. Normally, blood:
But in heart failure, the heart cant pump the way it should. The blood and oxygen dont get to the organs. And blood backs up in the heart.
Tracking Your Daily Fluid Intake
If you have heart failure, its common for your body to retain fluid. So your healthcare team may recommend limiting your liquid intake.
Many people are prescribed diuretics to help them get rid of extra water and sodium to reduce their hearts workload.
Talk with your doctor about how much liquid to drink every day.
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Role Of Cardiac Rejuvenation Therapy In The Management Of Hf
Current medical management for heart failure only alleviates symptoms, delays deterioration and prolongs life modestly. As the science has progressed by leaps and bounds, the idea of rejuvenation of the failing myocardium has begun to seem feasible when the accumulating evidence from preclinical studies demonstrated that rejuvenating the myocardium at the molecular and cellular level can be achieved by gene therapy and stem cell transplantation .
Stem cells are the population of cells that have self-renewal properties and the potential to generate daughter cells capable of differentiating into specific cell lineages . Stem cells have shown promise to treat several human diseases due to their regenerative properties, and the idea of regeneration of myocardial damage or replacement of lost or damaged myocardial tissue by implanting stem cells has revolutionized the prospects in medicine. As far as heart failure is concerned, stem cells from both autologous and non-autologous sources are seen as feasible and efficient potential therapeutic agents. Several clinical trials using both autologous and allogenic stem cells have proven beneficial to patients of ischemic and non-ischemic heart failure in various clinical trials . Stem cells can be isolated from various sources viz. human-derived myoblast, cardiosphere, mesenchymal, embryonic and menstrual blood.
Women And Heart Failure
Women are just as likely as men to develop heart failure, but there are some differences:
- Women tend to develop heart failure later in life compared with men.
- Women tend to have heart failure caused by high blood pressure and have a normal EF .
- Women may have more shortness of breath than men do. There are no differences in treatment for men and women with heart failure.
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Stress Ekg Or Echocardiogram
Stress tests are performed to see how the heart performs under physical stress. The heart can be stressed with exercise on a treadmill or in a few instances, a bicycle. If a person cannot exercise on a treadmill or bicycle, medications can be used to cause the heart rate to increase, simulating normal reactions of the heart to exercise.
During the stress test, you will wear EKG leads and wires while exercising so that the electrical signals of your heart can be recorded at the same time. Your blood pressure is monitored throughout the test. The stress test can be performed together with the echocardiogram, described above.
What Medications Should I Avoid If I Have Heart Failure
There are several different types of medications that are best avoided in those with heart failure including:
- Nonsteroidal anti-inflammatory medications such as Motrin or Aleve. For relief of aches, pains, or fever take Tylenol instead.
- Most calcium channel blockers
- Some nutritional supplements, such as salt substitutes, and growth hormone therapies
- Antacids that contain sodium
If youâre taking any of these drugs, discuss them with your doctor.
Itâs important to know the names of your medications, what theyâre used for, and how often and at what times you take them. Keep a list of your medications and bring them with you to each of your doctor visits. Never stop taking your medications without discussing it with your doctor. Even if you have no symptoms, your medications decrease the work of your heart so that it can pump more effectively.
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How Heart Failure Is Diagnosed
Symptoms of heart failure can mimic those of other health issues. It’s important to bring such concerns to your healthcare provider’s attention, so they can determine whether heart failure or another condition is the cause.
A heart failure diagnosis is usually made based on your medical history, a physical examination, and heart function tests, primarily electrocardiogram and echocardiogram . Brain natriuretic peptide measurement has gained attention because it can be done using a blood test. It can be used with an EKG and an echo to piece together a diagnosis of heart failure.
What Do The Numbers Mean
Ejection Fraction 55% to 70%
- Pumping Ability of the Heart: Normal.
- Level of Heart Failure/Effect on Pumping: Heart function may be normal or you may have heart failure with preserved EF .
Ejection Fraction 40% to 54%
- Pumping Ability of the Heart: Slightly below normal.
- Level of Heart Failure/Effect on Pumping: Less blood is available so less blood is ejected from the ventricles. There is a lower-than-normal amount of oxygen-rich blood available to the rest of the body. You may not have symptoms.
Ejection Fraction 35% to 39%
- Pumping Ability of the Heart: Moderately below normal.
- Level of Heart Failure/Effect on Pumping: Mild heart failure with reduced EF .
Ejection Fraction Less than 35%
- Pumping Ability of the Heart: Severely below normal.
- Level of Heart Failure/Effect on Pumping: Moderate-to-severe HF-rEF. Severe HF-rEF increases risk of life-threatening heartbeats and cardiac dyssynchrony/desynchronization .
Normal Heart. A normal left ventricular ejection fraction ranges from 55% to 70%. An LVEF of 65%, for example means that 65% of total amount of blood in the left ventricle is pumped out with each heartbeat. Your EF can go up and down, based on your heart condition and how well your treatment works.
HF-pEF. If you have HF-pEF, your EF is in the normal range because your left ventricle is still pumping properly. Your doctor will measure your EF and may check your heart valves and muscle stiffness to see how severe your heart failure is.
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History And Physical Examination
Patients with heart failure can have decreased exercise tolerance with dyspnea, fatigue, generalized weakness, and fluid retention, with peripheral or abdominal swelling and possibly orthopnea.3 Patient history and physical examination are useful to evaluate for alternative or reversible causes .3,4,8 Nearly all patients with heart failure have dyspnea on exertion. However, heart failure accounts for only 30 percent of the causes of dyspnea in the primary care setting.24 The absence of dyspnea on exertion only slightly decreases the probability of systolic heart failure, and the presence of orthopnea or paroxysmal nocturnal dyspnea has a small effect in increasing the probability of heart failure .21,23
The presence of a third heart sound is an indication of increased left ventricular end-diastolic pressure and a decreased LVEF. Despite being relatively uncommon findings, a third heart sound and displaced cardiac apex are good predictors of left ventricular dysfunction and effectively rule in the diagnosis of systolic heart failure .21,23
Lab And Imaging Tests Are Important In Diagnosing Heart Failure
Your doctor may suspect heart failure after talking with you and examining you. If so, the doctor may want you to have some diagnostic tests. There are many options. These five are the most common tests:
EKG . This will show whether your heart beats at a normal rhythm. It can also show whether the walls of your heart are thicker than normal.
Chest X-ray. This can show whether your heart is enlarged, which is a sign of heart failure. The heart enlarges to compensate for reduced ability to pump blood. The X-ray also will show any fluid that’s in your lungs.
BNP blood test. This checks the level of a specific hormonebrain natriuretic peptidein your blood. Despite its name, your heart makes this peptide. The level is greater in people with some types of heart failure.
Echocardiogram. The test creates a moving picture of your heart. Like a chest X-ray, it shows whether your heart is enlarged. It also will show whether your heart is pumping blood like it should be.
Exercise stress test. This checks how your heart works when it’s under stress. That means it has to beat fast. You’ll probably do some sort of exercise for this test, such as running on a treadmill. People who can’t exercise may take a drug to make their heart beat fast during the test.
It’s important to find out if you have heart failure. There’s no cure for heart failure, but treatment can slow down its progression. You can get symptoms under control and lead a healthy, more active life.