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KEY POINTS
The incidence of heart failure (HF) is increasing significantly due to the aging population, improved drug, and device therapies for myocardial infarction as well as heart failure.
Categorizing HF patients based on volume status (“wet/dry”) and perfusion status (“cold/warm”) can guide treatment as well as risk stratify patients.
Routine use of inotropic agents in HF patients without a definitive low output state and end organ failure is generally not indicated, since these medications can increase myocardial oxygen demand and can promote arrhythmias, and outcomes data from randomized trials and registry data typically demonstrate worse outcomes with inotropic therapy compared to vasodilator therapy.
Pulmonary artery catheterization is typically reserved for HF patients with respiratory distress or evidence of hypoperfusion in whom intracardiac filling pressures cannot be determined from bedside assessment as well as patient who are doing poorly with empiric treatment based on clinical assessment.
Mechanical circulatory support (intra-aortic balloon pump, Impella device, tandem heart, and extracorporeal membrane oxygenation) can be extremely effective therapy in select patients.
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HEART FAILURE SYNDROME
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Heart failure (HF) is a global clinical syndrome which occurs when the metabolic demands of the body are not met by the circulation due to impairment of cardiac structure and function. Patients typically present with symptoms of progressive dyspnea, decreased exercise tolerance, and may or may not have signs of volume overload and congestion. The final diagnosis of HF must be made by a comprehensive clinical assessment and is not determined by a solitary laboratory value or radiological test.1,2,3,4,5
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HF WITH REDUCED OR PRESERVED LEFT VENTRICULAR EJECTION FRACTION
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HF may occur with or without the presence of left ventricular (LV) systolic dysfunction and thus it is widely categorized into 2 separate entities, namely, HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Though different investigators and societies have used different definition of HFrEF and HFpEF, the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Heart Failure Guidelines define HFrEF as patients with an LV ejection fraction of 40% or lower; these patients often have varying degrees of diastolic dysfunction as well. Oral HF therapies (beta-blockers, angiotensin converting enzyme inhibitors, mineralocorticoid receptor antagonists, hydralazine, and nitrates) have been extensively validated to provide a quality of life and mortality benefit by many randomized-control trials in patients with chronic HFrEF.
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HFpEF includes patients with a left ventricular ejection fraction (LVEF) of 50% or higher and such patients may comprise up to 50% of the entire HF population. HFpEF is described by clinical signs of volume overload, preserved or normal LVEF, and diastolic dysfunction, typically demonstrated by Doppler echocardiography or cardiac catheterization. Patients with HFpEF tend to be older women with hypertension, and other prevalent comorbidities in this group include coronary artery disease, obesity, diabetes mellitus, and atrial fibrillation. To date, no oral ...