Congestive Heart Failure

In your diagnosis of peripheral arterial disease, you will start by getting an anklebrachial index, which is a blood pressure evaluation of the ankle and brachial arteries, dividing these two numbers. If the level is less than 0.9, the diagnosis is that of peripheral vascular disease. If further evaluation is further indicated, a Doppler ultrasound will help detect blood flow through the arteries in a noninvasive way. The gold standard is angiography or a dye study, used to detect specific areas of occlusion or narrowing, particularly before surgical intervention, if this is indicated.

The treatment of all patients requires risk factor modification to include smoking cessation, dyslipidemia treatment, management of diabetes, exercise, management of hypertension, and improved diet. Statin drugs, aspirin, and ACE inhibitors are required to slow progression. Walking is a good form of exercise so this should be undertaken. Preventive foot inspections and foot care are also essential.

Drug therapy should include aspirin or other antiplatelet drugs like dipyridamole, clopidogrel, or ticlopidine. The claudication itself can be treated with pentoxifylline or cilostazol. If these fail to help, percutaneous transluminal angioplasty is indicated using a stent to keep the vessel open or to prevent gangrene. This works best for short or just a few lesions. If the disease is extensive, then surgical interventions, like bypass grafting or revascularization is indicated. A thromboendarterectomy can be done to remove existing clots and a sympathectomy is done to remove the sympathetic nervous system’s impact on the leg vessels. An amputation is done as a last resort if there is gangrene that cannot be fixed with other surgery.

CONGESTIVE HEART FAILURE

Congestive heart failure involves some type of left ventricular or right ventricular dysfunction, leading to a backup of fluid into the lungs or peripheral tissues. It is a common disease, affecting more than six million patients in the US. There are two types of heart failure, including heart failure with preserved ejection fraction and heart failure with reduced ejection fraction.

Heart failure with preserved ejection fraction is called diastolic heart failure with an increase in end-diastolic pressure at rest or with exertion and an essentially normal

ejection fraction. Common causes include constrictive pericarditis, valvular disease, and high levels of ventricular stiffness. It is common in older adults and is seen in hypertrophic cardiomyopathy, amyloidosis, hypertension, and aortic stenosis. Heart failure with reduced ejection fraction involves output or systolic heart failure so that the output of the heart is reduced.

If left heart failure is seen, the fluid backs up into the lungs. There is worsened symptoms with lying down and major symptoms of dyspnea that is worse at night and with exertion. The worst case scenario is pulmonary edema, which is often lifethreatening. Some patients will die of acute respiratory failure.

Right ventricular failure involves backup of fluid into the systemic venous system, leading to hepatomegaly, ascites, and peripheral edema. The stomach and intestines become congested so absorption of nutrients is poor. The patient will have diarrhea from malabsorption and protein-losing enteropathy, which worsens their outcome.

Heart failure is different from cardiomyopathy, even though cardiomyopathy can lead to heart failure. Cardiomyopathy is a disease of the myocardial cells, which are damaged for many reasons, including inflammatory diseases, ischemic heart disease, hypertension, and hypertrophy of the myocardium. It is also possible to have what’s called high-output heart failure, which is caused by things like thyrotoxicosis, beriberi, end-stage liver disease, severe anemia, prolonged tachycardia, arteriovenous fistulae, and advanced Paget disease.

The diagnosis of asthma is made by getting a clinical history and a chest x-ray to rule out lung disease and to see if there is cardiomegaly. An ECG can show if there has been a myocardial infarction or evidence of ischemia. To assess whether or not there are issues with reduced ejection fraction, an echocardiogram, MRI of the heart, or radionuclide scan of the heart can be done. The main blood test for heart failure is the BNP or brain natriuretic peptide level. An alternative is the N-terminal-pro-BNP level, which will essentially assess the same thing. It is a sensitive test but a normal BNP level does not exclude the diagnosis of heart failure. A coronary angiography or CT coronary angiography is only indicated when the probable cause is coronary artery disease.

In treating the heart failure patient, the approach is multifactorial. Inpatient management is recommended for the patient who has severe symptoms or worsened heart failure over a brief period of time. The short-term goals are to relieve symptoms without worsening hypokalemia, hypotension, or renal dysfunction. Over the long term, the underlying cause is addressed, such as correction of hypertension, improving cardiac function, and maximizing quality of life.

Most patients need extensive education about their disease and instruction on how to avoid eating excessive amounts of salt. Sodium restriction is necessary in most cases as are lifestyle measures, such as weight loss, improved diet, and initiation of exercise. Underlying conditions, such as hypertension, diabetes, dyslipidemia, and smoking need to be addressed.

Many patients will need some drug therapy. This includes digoxin, nitrates, and diuretics to improve symptoms acutely. Long-term management involves chronic use of ACE inhibitors, beta blockers, angiotensin II receptor blockers, aldosterone antagonists, among others. Arrhythmias are treated according to their underlying cause. This might involve normalizing electrolytes, controlling the heart rate, and using antiarrhythmic drugs. Atrial fibrillation should be managed, especially if the heart rate is too high.

The rare patient might need an implantable cardioverter-defibrillator or ICD or possibly a cardiac resynchronization therapy or CRT. The ICD will restart the heart spontaneously if the person develops an unsustainable rhythm, while CRT is another implantable device that also has an ICD component. These are expensive devices but will improve heart function and reduce death rates due to heart failure complications. LV assist devices are also implantable but will help augment the left ventricular output as a bridge to receiving a heart transplant if this is necessary.

The main surgical options include coronary artery bypass grafting if ischemia underlies the problem. If the person has valvular disease as a cause of their heart failure, the valve needs to be replaced or repaired. The end-stage treatment for those under sixty years with severe heart failure is to recommend a heart transplant, which will prolong life for up to 10 or more years.