heart author" faq

Congestive heart failure is a condition in which the cardiac muscle does not pump blood efficiently through the various valves of the heart and the remainder of the circulatory system. Either the right or left ventricle or both and the atria may be involved in this condition. With failure of the left ventricular myocardium (heart muscle), the blood tends to backup in the lungs with elevated pressure causing shortness of breath (dyspnea), orthopnea (having to sit to breathe) and paroxysmal nocturnal dyspnea, as well as the accumulation of fluid in the lower extremities (swelling of ankles and feet and even the abdomen).
Among the many causes severe coronary atherosclerosis (see figures 51a, 53, 54, 55, 56a) with ischemic myocardium often scarred by prior myocardial infarctions, chronic and acute valvular heart diseases (see figures 49, 48e, 48c, 48b, 48a, 46a, 44d, 44a) and various cardiomyopathies (see figures 43a, 43b) are prominent.

The prognosis of patients with heart failure is generally poor; and in several series 50% of the patients with severe symptoms died within 12 months. In less severe heart failure, mortality approaches 50% in 3 to 4 years.

The primary factor determining prognosis is the left ventricular function, as reflected in the left ventricular ejection fraction of blood being pumped out with each heat beat.
Other factors that have been shown to have prognostic value include functional classification; electrolyte abnormalities such as a low sodium in the blood; elevated levels of plasma catacholamines etc; poor exercise tolerance; presence of atrial fibrillation; and coronary artery disease as the etiology of the heart failure.

Many patients with heart failure, perhaps 30-40%, die suddenly, presumably from ventricular arrhythmias. Moreover, increasing heart failure is associated with an increased incidence of ventricular arrhythmias, which may be decreased by aggressive, successful therapy for heart failure or by the prevention of a low potassium or magnesium in the blood.
In patients surviving myocardial infarction, the prognosis is strongly related to the ventricular ejection fraction, in addition to the amount of heart tissue (myocardium) that becomes ischemic (lack of adequate oyxgen) during stress and the amount of ventricular ectopy.

Once patients with heart failure symptoms have moderate to severe left ventricular systolic dysfunction, the mortality is quite high, averaging more than 10% per year. Studies have shown that the administration of an ACE inhibitor (captopril or enalapril) was associated with a reduction of morbid events, an apparent slowing of the progression of left ventricular dysfunction, and a trend toward a reduction in mortality. Vasodilator therapy of mild heart failure is often appropriate in an elderly individual. The decrease in mortality with vasodilator therapy holds for the subgroup of heart failure patients over the age of 70 years.

The two beta-blockers bisoprolol and metropolol CR/XL have beneficial effects on total mortality, death due to progressive heart failure and sudden death when added to standard therapy with diuretics and angiotensin-converting enzyme(ACE) inhibitors even in patients with severe heart failure

Reference:Goldstein,S. and others: Metoprolol CR/XL in Patients with Severe Heart Failure,JACC,Vol.#8,No.4,2001,932-938.

A change from metoprolol to carvedilol and vice versa preserves the improvement in LVEF in patients with heart failure.

Reference:Maack,C. and others,Prospective Crossover Comparison of Carvedilol and Metoprolol in Patients with Chronic Heart Failure,JACC,Vol.38,No.4,2001939-946.