Académique Documents
Professionnel Documents
Culture Documents
Section Editors
Christine Laine, MD, MPH
David Goldmann, MD
Science Writer
Jennifer F. Wilson
Diagnosis
page ITC12-2
Treatment
page ITC12-6
Practice Improvement
page ITC12-14
Patient Information
page ITC12-15
CME Questions
page ITC12-16
The content of In the Clinic is drawn from the clinical information and
education resources of the American College of Physicians (ACP), including
PIER (Physicians Information and Education Resource) and MKSAP (Medical
Knowledge and Self-Assessment Program). Annals of Internal Medicine
editors develop In the Clinic from these primary sources in collaboration with
the ACPs Medical Education and Publishing Division and with the assistance
of science writers and physician writers. Editorial consultants from PIER and
MKSAP provide expert review of the content. Readers who are interested in these
primary resources for more detail can consult http://pier.acponline.org and other
resources referenced in each issue of In the Clinic.
The information contained herein should never be used as a substitute for clinical
judgment.
2007 American College of Physicians
in the clinic
in the clinic
A
Diagnosis
1. Finn P. American
Heart Association
scientific sessions
2005. 13-16 November 2005, Dallas, TX,
USA. IDrugs.
2006;9:13-5.
[PMID: 16374724]
2. Kannel WB. Current
status of the epidemiology of heart
failure. Curr Cardiol
Rep. 1999;1:11-9.
[PMID: 10980814]
3. Centers for Disease
Control and Prevention (CDC). Mortality
from congestive
heart failureUnited
States, 1980-1990.
MMWR Morb Mortal
Wkly Rep. 1994;43:7781. [PMID: 8295629]
4. He J, Ogden LG, Bazzano LA, et al. Risk
factors for congestive
heart failure in US
men and women:
NHANES I epidemiologic follow-up study.
Arch Intern Med.
2001;161:996-1002.
[PMID: 11295963]
5. The sixth report of
the Joint National
Committee on prevention, detection,
evaluation, and treatment of high blood
pressure. Arch Intern
Med. 1997;157:241346. [PMID: 9385294]
6. HOPE Investigators.
Effects of ramipril on
coronary events in
high-risk persons: results of the Heart
Outcomes Prevention
Evaluation Study. Circulation.
2001;104:522-6.
[PMID: 11479247]
Diabetes
among patients at least 55
Caucasians in the same
Cardiotoxic substance use
years of age with either
age range (3). Men
Hyperlipidemia
atherosclerosis or diabetes
have a higher rate of
Thyroid disorders
and at least 1 other risk
heart failure than
Tachycardia
factor but without a history
women, although this
Coronary artery disease
of heart failure, the
difference narrows as
angiotensin-converting
women get older.
enzyme (ACE) inhibitor
Certain conditions and behaviors
also increase the risk for heart failure, and these conditions should
be treated to reduce the risk (see
Box). In addition to these, epidemiologic study has linked increased risk for heart failure to
physical inactivity, obesity, and
lower levels of education (4).
ramipril reduced the risk for stroke, myocardial infarction (MI), and death from
cardiovascular disease by 22% while also
significantly reducing heart failure (6).
Longstanding untreated hypertension is associated with the development of both systolic and diastolic
heart failure as well as an independent risk for coronary artery
disease (CAD). Clinical trials have
shown that a reduction in systolic
ITC12-2
Hypertension
In the Clinic
4 December 2007
Hyperlipidemia
Hyperlipidemia is strongly associated with CAD, which may ultimately lead to heart failure. Largescale clinical trials have shown the
benefit of lipid lowering for primary and secondary prevention of
cardiovascular events.
The CARE (Cholesterol and Recurrent
Events) trial found that pravastatin treatment significantly reduced mortality as well
as subsequent cardiovascular events and
reduced the incidence of heart failure (7).
Thyroid Disorders
Studies have shown that rapid prolonged ventricular rates can lead to
cardiomyopathy. Restoration of
normal rhythm or rate control in
patients with poorly controlled
atrial fibrillation and other
supraventricular tachycardias can
improve function and potentially
prevent left ventricular dysfunction
(1012).
Coronary Artery Disease
4 December 2007
The American College of Cardiology (ACC)/American Heart Association (AHA) recommends electrocardiography (ECG) in any
patient at risk for or with a history
of cardiac disease, including newonset or exacerbated heart failure.
If possible, the tracing should be
compared with a previous baseline
tracing. Results can help document
the presence of ventricular hypertrophy, atrial abnormality, arrhythmias, conduction abnormalities,
prior MI, and evidence of active ischemia.
Echocardiography
Two-dimensional echocardiography
with Doppler should be performed
In the Clinic
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4 December 2007
Characteristics
Dilated cardiomyopathies
Ischemic heart disease
Occurs in people with a history of MI, presence of infarction pattern on ECG, or risk factors for
coronary disease.
Hypertension
Presents in people with a history of poorly controlled blood pressure, presence of an S4 on physical
examination, or left ventricular hypertrophy on echocardiogram or ECG. Hypertension can also cause
hypertrophic as well as dilated caridomyopathy.
Mitral regurgitation: ejection murmur at apex, dyspnea on exertion, atrial fibrillation. Aortic stenosis:
dyspnea with exertion, ejection murmur at base that radiates to carotid arteries, decreased carotid
upstroke, syncope, angina.
Bacterial myocarditis
Fever, exposure to known agent, or positive blood cultures. Includes Borrelia burgdorferi (Lyme
disease), diphtheria, rickettsia, streptococci, and staphylococci.
Parasitic myocarditis
Travel history to endemic areas, fever, or peripheral stigmata of infection. Rare in United States.
Includes Trypanosoma cruzi (Chagas disease), leishmaniasis, and toxoplasmosis.
Toxic cardiomyopathies
History, positive serology results, or other stigmata of a collagen vascular disease, including systemic
lupus erythematosus, polyarteritis nodosa, scleroderma, or dermatomyositis.
Atrial and ventricular arrhythmias that are difficult to control, rapidly progressive left
ventricular dysfunction, heart block.
Peripartum cardiomyopathy
Heart failure symptoms with left ventricular dysfunction within 6 months of a pregnancy.
Neuromuscular disorders
Clinical history of Becker muscular dystrophy, myotonic dystrophy, Friedreich ataxia, limb-girdle
muscular dystrophy, or Duchenne muscular dystrophy. Physical examination findings depend on the
underlying disease.
Hypertrophic cardiomyopathies
Hypertrophic obstructive
cardiomyopathy
Restrictive cardiomyopathies
Infiltrative diseases affecting
the myocardium
4 December 2007
In the Clinic
ITC12-5
Diagnosis... Be alert for the development of heart failure in older persons; African
Americans; men; and in patients with hypertension, hyperlipidemia and diabetes,
and those who smoke, drink alcohol, or use illicit drugs. Dyspnea and fatigue are
the primary symptoms of heart failure. In addition to history and physical examination, use 2-dimensional Doppler echocardiography to assess left ventricular
function along with ECG and additional studies to determine the cause of the
heart failure and to identify exacerbating factors.
Treatment
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4 December 2007
4 December 2007
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Evidence from the randomized, placebocontrolled CHARM-Alternative (Candesartan Cilexitil [Atacand] in Heart Failure Assessment of Reduction Mortality and
Morbidity) trial showed that the ARB candesartan decreased a combined end point
of death from cardiovascular causes or
hospitalization due to heart failure when
compared with placebo in patients with
left ventricular dysfunction intolerant of
ACE inhibitors (28).
There have been some studies suggesting that combining ACE inhibitors and ARBs may be beneficial in reducing left ventricular
size and decreasing hospitalizations, with an equivocal effect on
mortality (29).
Hydralazine and Nitrates
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4 December 2007
4 December 2007
In the Clinic
ITC12-9
It is important to ensure that electrolytes and renal function are stable before starting digoxin, and
serum levels should be monitored,
especially if renal function is
changing. Some controversy exists
over the appropriate serum level of
digoxin. A recent study suggested
that lower serum levels of digoxin
were as efficacious as therapeutic
levels, with a lower risk for side
effects (44). In fact, in a post hoc
subgroup analysis of 1 recent study,
mortality rate was increased among
women on digoxin compared with
men, which may have been due to
higher serum digoxin levels (45).
What drug therapy is appropriate
for patients with diastolic
dysfunction?
The goals of treatment of diastolic
heart failure are: 1) to control heart
rate to allow for adequate filling of
the ventricle; 2) to maintain normal
sinus rhythm, if possible; 3) to control volume status to decrease diastolic pressures; 4) to control blood
pressure or other stimuli to left
ventricular hypertrophy; and 5) to
minimize myocardial ischemia in
the setting of left ventricular hypertrophy, even in the absence of epicardial coronary disease.
In the MADIT II (Multicenter Automatic Defibrillator Implantation Trial II), 1232 patients with a previous MI and an ejection
fraction < 30% were randomly assigned (in
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4 December 2007
4 December 2007
In the Clinic
ITC12-11
Mechanism of Action
Benefits
Side Effects
Notes
Improves patient
exercise tolerance,
hemodynamic status,
survival; may halt
progression and cause
regression of HF
Cough, angioedema,
renal insufficiency,
hyperkalemia
ACE inhibitors
Enalapril, 520 mg PO bid
Inhibits angiotensin-converting
enzyme; results in decreased
Captopril, 12.550.0 mg PO tid conversion of angiotensin I to
angiotensin II and decreased
Lisinopril, 540 mg PO qd
metabolism of bradykinin. The
or 520 mg PO bid
latter produces prostaglandins
and nitric oxide
Angiotensin-receptor antagonists
Losartan, 25100 mg PO qd
Improves hemodynamic
status, LVEF, survival;
may halt progression
and cause regression
of HF
Improves survival in
patients with NYHA
stages III to IV HF.
Improves survival after
MI with LV dysfunction.
Hyperkalemia,
gynecomastia
Palliative in patients
with congestive
symptoms. No survival
benefit.
Improves exercise
tolerance, reduces
hospitalizations. Slows
heart rate. No survival
benefit.
Arrhythmias, bradycardia
(exacerbated by
hypokalemia); visual
changes. Low therapeutic
index
Improves hemodynamics;
arrhythmogenic
Arrhythmogenic; no
survival benefit
Valsartan, 80320 mg PO qd
Candesartan, 1632 mg PO qd
-blockers
Carvedilol, 3.12525.0 mg
PO bid (50 mg PO bid
for patients weighing
>85 kg)
Bradycardia, depression,
hypotension, diabetes,
exacerbation of asthma
or COPD
Aldosterone antagonists
Spironolactone, 12.550.0
mg PO qd
Eplerenone, 2550 mg
PO qd
Loop diuretics
Furosemide, 10160 mg PO
qd bid
Torsemide, 1040 mg PO qd
bid
Bumetanide, 14 mg PO
qd bid
Ethacrynic acid, 25100 mg
PO qd bid
Digitalis glycoside
Digoxin, 0.1250.25 mg PO
qd
* ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; bid = twice daily; BUN = blood urea nitrogen; HF = heart failure; COPD = chronic obstructive
pulmonary disease; IV = intravenous; LV = left ventricular; LVEF = left ventricular ejection fraction; PO = oral; qid = four times daily; qd = once daily; tid = three times daily.
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In the Clinic
4 December 2007
4 December 2007
In the Clinic
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in the clinic
Tool Kit
Heart Failure
What do professional
organizations recommend with
regard to the care of patients
with heart failure?
The ACC/AHA published guidelines for the Evaluation and Management of Chronic Heart Failure in
the Adult in 2001 (54), and these
were updated in 2005 (55). The
guidelines contain extensive information on the characterization of
heart failure as a clinical syndrome,
initial and serial clinical assessment
of patients, drug and device therapy
for patients with heart failure at various stages of the disease, treatment
of special populations, managing
patients with heart failure and concomitant disorders, end-of-life considerations, and issues involved in
implementation of the guidelines.
The updated guidelines stress the
importance of early diagnosis to stop
or slow disease progression and
changes in drug therapy based on
several pivotal clinical trials.
pharmacologic management of
chronic heart failure (57).
PIER Modules
www.pier.acponline.org
Heart failure and percutaneous coronary intervention modules with updated information
on current diagnosis and treatment of heart failure, designed for rapid access at the point
of care.
Patient Information
www.annals.org/intheclinic
Download copies of the Patient Information sheet that appears on the following page for
duplication and distribution to your patients.
ITC12-14
In the Clinic
in the clinic
Practice
Improvement
4 December 2007
In the Clinic
Annals of Internal Medicine
Heart failure, sometimes called congestive heart failure, is a condition in which the
heart cant pump as well as it should. Because the heart has a hard time getting blood
to the rest of the body, patients with heart failure can feel weak and tired.
In some patients with heart failure, fluid (edema) builds up in the lungs and parts of
the body, making it hard to breathe and causing swelling in the legs.
Treating heart failure means working together with your doctor to control salt in your
diet, watching your weight, and taking all your medications every day. Its important
to keep your regular doctor appointments.
Heart failure affects nearly 5 million adults, and 550 000 new cases are diagnosed
each year. It is more common in older people but can occur at any age. Although
there is no cure yet, heart failure is very treatable and millions of Americans lead a
full life by managing their condition through medications and by making healthy
changes in their lifestyles.
Patient Information
Heart failure can result from many different conditions that directly or indirectly affect the heart. People with high blood pressure, diabetes, high cholesterol, and coronary artery disease can develop heart failure. Treating these conditions may prevent
heart failure.
CME Questions
1. A 48-year-old woman with a history of
Medications include ramipril, carvedilol,
Which of the following is most likely to
furosemide, aspirin, digoxin, and spironoan ischemic cardiomyopathy and New
be exacerbating the heart failure in this
lactone. His condition is classified as
York Heart Association class II heart failpatient?
New York Heart Association functional
ure symptoms is seeking advice about her
A. Alendronate
class III.
medical therapy. She has no inducible
B. Glipizide
ischemia on stress testing and her last
On physical examination, heart rate is
C. Ibuprofen
ejection fraction by echocardiography
62/min and blood pressure is 96/60 mm Hg.
D. Thyroxin
was estimated to be 35%. She was last
He has bibasilar crackles and jugular
E. Estrogen
hospitalized for an exacerbation of heart
venous distention. A summation gallop
failure 1 year ago. She takes extendedand a 3/6 holosystolic murmur at the
3. A 35-year-old man with a 2-year history
release metoprolol, aspirin, lisinopril,
apex and radiating to the axilla are presof dilated, nonischemic cardiomyopathy
digoxin, and furosemide. On physical
ent. Electrocardiogram shows left bundle
and New York Heart Association funcexamination, her heart rate is 62/min and
branch block and first-degree atrial ventional class III symptoms is admitted to
blood pressure is 104/78 mm Hg. There is
tricular block.
the hospital with worsening shortness of
no jugular venous distention, and her
breath for the third time in 6 months. He
Which of the following is the most
chest is clear on auscultation. She has a
has normal coronary arteries and an ejecappropriate next step in the management
regular rhythm without gallop or murmur.
tion fraction of 25%. His current medicaof this patient?
Her complete blood count and serum
tions include extended-release metoproelectrolytes are normal.
A. Coronary artery bypass graft
lol, lisinopril, furosemide, digoxin, and
surgery.
Which one of the following changes in
spironolactone. On physical examination,
B.
Left ventricular aneurysmectomy.
her medications should be made at this
his blood pressure is 96/70 mm Hg, his
C.
Implantation of a cardiodefibrillator/
time?
pulse rate is 84/min, and his respiration
atrioventricular sequential
rate
is
22/min.
He
has
crackles
halfway
A. Add an angiotensin-receptor
biventricular pacemaker.
up
his
lung
fields
bilaterally,
a
displaced
blocker.
D. Mitral valve repair.
cardiac apex, and an S3 gallop. His electro
B. Add nitroglycerin and hydralazine.
E. Transmyocardial laser
cardiogram shows sinus rhythm with a
C. Add spironolactone.
left bundle branch block and a QRS
revascularization.
D. Discontinue metoprolol.
duration of 170 msec.
E. No changes at this time.
5. A 72-year-old woman with a 2-year hisWhich of the following outcomes can
tory of ischemic heart disease and NYHA
this patient expect from a cardiac
2. A 56-year-old woman who is new to your
stage I heart failure seeks advice about
resynchronization procedure?
practice is evaluated for recent exacerbaimplantable defibrillators. One year ago, a
tion of dyspnea and fatigue. She has
A. Decreased risk for all-cause
cardiac catheterization demonstrated
idiopathic dilated cardiomyopathy and
mortality
nonobstructive coronary artery disease
receives a stable heart failure regimen,
B. Decreased risk for cardiac death
and an ejection fraction of 55%. Her
including lisinopril, 20 mg/d; digoxin, 125
electrocardiogram shows sinus rhythm at
C. Decreased risk for sudden cardiac
mg/d; furosemide, 40 mg/d; and meto76/min with normal perfusion rate, quandeath
prolol XL, 50 mg/d. She also takes alentitative radioscintigraphy, and cardiac
D. Improved heart failure symptoms
dronate, hormone replacement therapy,
output intervals.
and
exercise
tolerance
glipizide, folic acid, and ibuprofen beE.
No
benefit
Which of the following outcomes can
cause of rheumatoid arthritis. Thyroid
reasonably be expected with the use of
hormone therapy with thyroxin was initi4. A 65-year-old man who had an acute
an implantable cardiac defibrillator in
ated because of the finding of an elevatmyocardial infarction 10 years ago is
this patient?
ed serum thyroid-stimulating hormone
reevaluated. Despite diet and exercise
level 4 months earlier. The thyroidA. Fewer hospital admissions for heart
therapy, he has had recurrent ischemic
stimulating hormone level returned to
failure.
events, and over the past 2 years, he has
normal after therapy.
B.
Decreased risk for acute coronary
been hospitalized several times for exacersyndrome.
On physical examination, blood pressure
bations of heart failure. Six months ago,
is 110/72 mm Hg, and heart rate is
C. Decreased risk for sudden cardiac
a dipyridamole thallium scan showed no
82/min. Jugular venous pressure is estideath.
ischemia and echocardiogram showed
mated at 10 cm H2O. The lungs are clear.
D. Decreased risk for cardiac death.
anterior akinesia, global hypokinesia,
Cardiac examination shows an S3 gallop
and moderate to severe mitral regurgitaE. No benefit.
and 2+ pitting edema.
tion, with an ejection fraction of 28%.
Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/
to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.
ITC12-16
In the Clinic
4 December 2007