Showing papers on "Management of heart failure published in 1994"

Diagnosis and management of heart failure.

Abstract: #### Summary points Doctors diagnose heart failure when patients whom they suspect of having heart disease develop fatigue, dyspnoea, or oedema. By these standards, this is a terminal condition because in severe cases its annual mortality may exceed 60 %1 Even in so called mild cases detected in community screening programmes such as the Framingham study the five year mortality approached 50 %.2 These survival rates are worse than for many of the common forms of cancer, emphasising that heart failure is indeed a malignant condition. Heart failure also imposes a heavy burden of symptoms. In studies of the major chronic illnesses such as diabetes, arthritis, and hypertension, heart failure had the greatest negative impact on quality of life, and not just slightly so.3,4 The high morbidity is also reflected in the number of hospital admissions for heart failure, about 120 000 cases each year in the United Kingdom.5,6 These represent 5% of all adult medical and geriatric admissions and are about the same as the number of admissions for acute myocardial infarction.7 Heart failure is a serious public health problem, with a prevalence in the United Kingdom, Scandinavia, and the …

Management of heart failure. III. The role of revascularization in the treatment of patients with moderate or severe left ventricular systolic dysfunction.

Abstract: Objective. —This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. Data Sources. —Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure ; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty . Study Selection. —All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed. Data Extraction and Synthesis. —Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws. Conclusion. —Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting. ( JAMA . 1994;272:1528-1534)

Management of Heart Failure: II. Counseling, Education, and Lifestyle Modifications

Abstract: Objective. —This article reviews the role of counseling, education, dietary modifications, and exercise for patients with heart failure due to left ventricular systolic dysfunction. Data Sources. —We reviewed studies published in English between 1966 and 1993 and referenced in MEDLINE or EMBASE. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure ; and dilated cardiomyopathy in conjunction with terms for the specific areas of interest. Where data were lacking, we relied on opinions of panel members and peer reviewers. Study Selection and Data Synthesis. —Studies were reviewed to determine whether patients had heart failure due to systolic dysfunction (left ventricular ejection fraction, Conclusion. —Counseling and education can improve patient outcomes and decrease unnecessary hospitalizations. Patients with mild to moderate heart failure should be restricted to 3 g/d of sodium initially. Those who are unresponsive to this dosage or who have more severe disease should be advised to consume 2 g/d or less. Patients should be strongly advised to drink no more than 30 mL/d of alcohol or, preferably, to abstain completely. Exercise training is safe and can improve exercise duration and symptoms. Adherence to the treatment plan should be stressed and monitored at each visit. Clinicians should inform patients of the seriousness of their disease and their prognosis, but they should emphasize that patients can continue to remain active and enjoy a reasonable quality of life. ( JAMA . 1994;272:1442-1446)

Management of Heart Failure: IV. Anticoagulation for Patients With Heart Failure Due to Left Ventricular Systolic Dysfunction

Abstract: Objective. —This article reviews the incidence of arterial thromboembolism in patients with heart failure who are not receiving anticoagulants. We also examine whether more severe ventricular dysfunction increases this incidence and the efficacy and risks of anticoagulation for patients in sinus rhythm. Data Sources. —English-language studies referenced in MEDLINE or EMBASE (January 1966 to September 1993) were reviewed. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure ; and dilated cardiomyopathy in conjunction with the terms anticoagulation, cerebrovascular disorders, stroke , and thromboembolism . Study Selection. —All studies with separate data for patients with chronic heart failure not receiving anticoagulants were included. Articles addressing valvular heart disease or heart failure secondary to acute myocardial infarction or Chagas' disease were excluded. Studies of the occurrence of left ventricular mural thrombi were also reviewed. Data Extraction and Synthesis. —Inclusion and exclusion criteria, prevalence of atrial fibrillation, mean follow-up, and the occurrence of arterial thromboembolic events were extracted. If the incidence was not given, this was estimated using the proportion of patients with events divided by the mean follow-up. Conclusion. —The incidence of arterial thromboembolism ranged from 0.9 to 5.5 events per 100 patient-years, with the largest studies reporting incidence of 2.0% and 2.4%. Findings regarding the relationship between ventricular function and thromboembolic events are contradictory. No controlled trial has assessed the efficacy or risks of anticoagulation for patients with heart failure and sinus rhythm, and reported efficacy in case series ranged from 0% to 100%. Until adequate studies are performed, anticoagulation should be discouraged for patients with heart failure who are in sinus rhythm. ( JAMA . 1994;272:1614-1618)

Management of Heart Failure: I. Pharmacologic Treatment

Abstract: Objective. —This review of the pharmacologic treatment of heart failure due to left ventricular systolic dysfunction summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. It provides specific advice to help guide practitioners through clinical decision making. Data Sources. —Data were obtained from English-language studies and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search termsheart failure, congestive; congestive heart failure; heart failure; cardiac failure; anddilated cardiomyopathyin conjunction with terms for the specific treatments. Where data were lacking, we relied on opinions of panel members and peer reviewers. Study Selection. —Only large prospective trials were used to estimate treatment efficacy. Smaller trials, case series, and case reports were reviewed for the incidence of adverse effects. Data Extraction and Synthesis. —Randomized clinical trials were reviewed for inclusion and exclusion criteria, patient outcomes, adverse effects, and eight categories of study quality using a defined list of study flaws. Conclusion. —Angiotensin-converting enzyme (ACE) inhibitors should be given to all patients unless specific contraindications exist. Diuretics should be used judiciously early in treatment to prevent excessive diuresis that could prevent titration of ACE inhibitors to target doses. Digoxin has not been shown to affect the natural history of heart failure and should be reserved for patients who remain symptomatic after treatment with ACE inhibitors and diuretics. Isosorbide dinitrate and hydralazine hydrochloride should be tried in patients who cannot tolerate ACE inhibitors or who have refractory symptoms. (JAMA. 1994;272:1361-1366)

Has the problem of heart failure been solved

Abstract: Emphasis on the management of heart failure has shifted from attempts to alter hemodynamics and symptoms to attempts to interfere with the natural history of the disease. This shift in emphasis has been stimulated by the recognition that heart failure progresses despite therapy and that shortened life expectancy makes the disease as lethal as most cancers. Most recent trials have therefore focused on mortality and have evaluated therapies designed to impact on progression of the syndrome. In this article the results of several recent trials are discussed, as well as the future of effective therapy.

Post infarct heart failure: what to do in addition to ACE inhibition.

Abstract: ACE (angiotensin converting enzyme) inhibitors are revolutionizing the management of heart failure and are now earning themselves a place in the early treatment of post myocardial infarction (MI) patients who have evidence of left ventricular (LV) dysfunction or, more modestly, evidence of infarct expansion. The aims of ACE inhibitor therapy are to control symptoms, if any, and to improve prognosis. For these indications, they are impressive. Nonetheless, they are not a panacea. Post MI patients face a variety of threats, not least from progression of their underlying ischemic disease, and they should not be denied prognostically advantageous interventions, such as beta-blockers and aspirin. Moreover, ACE inhibitor monotherapy may not be the best management for heart failure itself. The role of other additive agents should not be dismissed.

The Management of Heart Failure in the Age of Reperfusion

Abstract: It has been established over the past several decades that infarct size is the prime determinant of mortality in the period following acute myocardial infarction (MI)(1). It has also been recognized that the presence of congestive heart failure in the post-infarction period—whether determined clinically (2) or hemodynamically (3), and whether occurring early (3) or late (4)—reflects both infarct size and the likelihood of death.