HEART FAILURE/PRACTICE CHANGES
From the 2007 Scientific Assembly of the American Academy of Family Physicians, October 3-6, 2007, Chicago, IL
| HEART FAILURE —Daniel B. Friedman, MD, Cardiologist, Presbyterian Heart Group, Albuquerque, NM
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| Heart failure (HF): caused by cardiac dysfunction, generally resulting from myocardial muscle dysfunction or loss;
characterized by ventricular dilatation or hypertrophy, leading to fluid retention, shortness of breath, and fatigue; progressive
and often fatal, but patients can be stabilized; causes high cardiac filling pressure and inadequate O2 delivery; HF
with reduced ejection fraction (EF)—HF with dilated left ventricle (LV); commonly associated with large cardiac
chamber; HF with preserved EF—HF with nondilated LV; may result from valvular or ischemic heart disease; becoming
more common in, eg, aging population with hypertension and diastolic dysfunction
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| Myocardial remodeling: once it begins to fail, heart changes shape and function; pathologic myocardial hypertrophy
or dilation in response to increased myocardial stress; many therapies designed to stop remodeling
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| Hypertension: normal blood pressure (BP) <140/90 mm Hg; consider maintaining BP at 125/72 mm Hg in patients at risk
(eg, patients with renal insufficiency or proteinuria); controlling BP can lower incidence of HF significantly; restriction of
sodium intake mainstay of therapy; angiotensin-converting enzyme (ACE) inhibitors—recommended for patients at
high risk (eg, patients with coronary artery disease [CAD], peripheral vascular disease, stroke), patients with diabetes or
other major risk factors, and patients with microalbuminuria; β-blockers—recommended for patients with history of myocardial
infarction (MI); may prevent progression of atherosclerotic disease
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| Evaluation for ventricular dysfunction and HF: history, physical examination, chest x-ray, and electrocardiography
(ECG) recommended for patients with hypertension, diabetes, obesity, CAD, peripheral arterial disease, valvular
heart disease, positive family history of cardiomyopathy in first-degree relative, history of exposure to cardiac toxins, or
sleep disorder; look for abnormal ECG (eg, arrhythmias, left bundle-branch block, pathologic Q waves) and cardiomegaly
on chest x-ray; echocardiography recommended for patients with suspected LV dysfunction and risk factors; risk factors—
CAD; valvular heart disease; positive family history for cardiomyopathy; atrial fibrillation or flutter; abnormal ECG; complex
arrhythmias; cardiomegaly; S3 gallop; concerning murmur
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| Symptoms of HF: dyspnea; orthopnea; paroxysmal nocturnal dyspnea; reduced exercise capacity; edema (ascites or scrotal
edema common); less specific symptoms—early satiety; in many young patients, gastrointestinal symptoms (eg,
edema in bowel) more common than lung or peripheral symptoms; wheezing; coughing; unexplained fatigue; confusion or
delirium
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| Physical examination: elevated jugular venous pressure (JVP) and hepatojugular reflux; S3 gallop; rales; laterally displaced
apical impulse in enlarged heart; murmur suggesting valvular heart disease; jugular venous distention (JVD) or
hepatojugular reflux—look at neck vein or press abdomen while patient lying at 45º; check pulsation of neck vein;
good sensitivity and specificity (80%); only 3 in 15 with low wedge pressure had high JVP; 30 in 37 with high wedge
pressure had high JVP; measure distance between right atrium to angle of Louis (≈5 cm) and look at top of water column
of jugular pulsation; 5 to 7 cm normal; abdominal jugular reflux should be negative; eliminate edema
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| Brain natriuretic peptide (BNP) or N-terminal prohormone BNP (NT-proBNP): assess in patients suspected
of having HF when diagnosis not certain; BNP higher in patients with HF; high BNP associated with risky outcome
(eg, death, hospitalization)
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| Testing: laboratory testing—electrolytes; serum urea nitrogen and creatinine; glucose; calcium; lipid profile; complete
blood cell count; serum albumin; liver function tests; urinalysis; thyroid function tests; exercise testing—not recommended
in all persons with HF; recommended when ischemic heart disease suspected; if suspicion high, consider angiography
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| Treatment of HF with LV dysfunction: ACE inhibitors—recommended for routine administration to symptomatic
or asymptomatic patients with EF ≤40%; should be titrated to doses used in clinical trials (highest dose possible
while uptitrating β-blocker); β-blockers—effective in patients with EF ≤40%; recommended for patients with recent
decompensated HF after optimization of volume status and discontinuation of intravenous (IV) diuretics, vasoactive
drugs, or inotropic support; beneficial to start drugs in hospital; start with low doses and uptitrate every 2 wk; doses found
effective in clinical trials tend to be higher and achieved in 1 to 3 mo; patients with worsening HF symptoms during titration
may require dose adjustment; some patients may need long interval between steps in uptitration; discuss dizziness
and shortness of breath; recommended that therapy be continued in most patients, even with symptomatic exacerbations;
dose may need to be reduced or discontinued during hospitalization (reinitiate therapy before patient discharged); angiotensin-receptor
blockers (ARBs)—recommended for routine use in patients with symptomatic and asymptomatic HF
who are intolerant to ACE inhibitors for reasons other than hyperkalemia and kidney disease; routine use as adjunct to
ACE inhibitors or β-blockers not recommended; can be used in patients with ACE inhibitor-induced angioedema; combination
of hydralazine and oral nitrates can be used; bid or tid dosing effective; aldosterone antagonists—recommended
for patients already receiving standard therapy who are classified as New York Heart Association Class IV or Class III
that was previously class IV HF; not recommended when creatinine >2.5 mg/dL or serum potassium >5.0 mmol/L; avoid
use with other potassium-sparing diuretics (eg, triamterene); start drug cautiously in patients with persistent hypokalemia;
diuretics—recommended for restoring appropriate volume status in patients with evidence of fluid overload; patients
with congestive symptoms (eg, orthopnea, edema, shortness of breath) or signs of elevated filling pressure (eg,
hepatojugular reflux, JVD, pulsatile hepatomegaly) should be started on loop diuretics (eg, furosemide [Lasix], bumetanide
[Bumex]); diuretics decrease renal absorption of sodium; can result in hypomagnesemia, hyponatremia, neurohormonal
activation, need for more β-blockade, prerenal azotemia, renal dysfunction, hyperuricemia, gout, kidney stones,
and hypokalemia; once stabilized, gradually decrease dose to maintain patient on lowest dose possible; with education on
sodium restriction and other therapy, many patients with HF can be maintained without significant amounts of diuretics;
chlorothiazides or metolazone may be added to Lasix once or twice weekly (electrolyte shifts significant with combination
therapy; potential for hypokalemia); volume status and electrolytes must be monitored closely when multiple diuretics
used; digoxin—should be considered in patients with systolic dysfunction and signs and symptoms of HF despite
major care; no outcome data supporting mortality benefits; 0.125 mg daily; aim for digoxin level <1.0 ng/mL to avoid
toxicity; aspirin—not recommended for routine use in patients with cardiomyopathy unrelated to ischemic heart disease;
aspirin and ACE inhibitors can be used together if both indicated; aspirin should be used at lowest dose possible; 81
mg/day; incidence of renal dysfunction low
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| Diastolic HF: predictive value of clinical signs (eg, LV hypertrophy on ECG, S4 , normal apical pulse) low; echocardiography
helps rule out systolic dysfunction; good BP control may result in improved incidence of HF, but not mortality
outcomes; prognosis similar to that for systolic HF; pressure-volume curve steep (start low in older patients and uptitrate
gradually); evaluate for possibility of ischemic heart disease and valvular heart disease; in patients treated for ischemic
heart disease, incidence of diastolic dysfunction may improve greatly
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| Treatment of diastolic HF: diuretics initially; ARBs; ACE inhibitors; calcium channel blockers; β-blockers; most trials
show greater effect with BP control than with specific drug; restore sinus rhythm in patients with atrial fibrillation or
flutter who are symptomatic; prevention of hospitalizations important; ≈2% of patients return to hospital 2 days after discharge,
20% within 1 mo, and 50% within 6 mo; hospitalization recommended with evidence of decompensated HF,
including hypotension, worsening renal failure, altered mentation, dyspnea at rest (particularly resting tachypnea; decreased
O2 saturation less common), hemodynamically significant arrhythmia (including atrial fibrillation), and acute
coronary syndrome
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| Electrical devices: Centers for Medicare & Medicaid Services (CMS) implantable cardioverter defibrillator (ICD)
coverage—depends on whether patient has ischemic heart disease; if patient has history of MI, EF <30%, cardiogenic
shock, coronary artery bypass graft, angioplasty, irreversible brain damage, is candidate for revascularization, or has
other disease associated with <1 yr survival, give defibrillator; if EF <35%, consider functional class; EF determined by
echocardiography (quantitated EF not perfect measurement and must be adequate enough to see endocardiac borders);
nonischemic cardiomyopathy for 3 to 9 mo; if EF <35%, patient must have had ventricular tachycardia or significant HF;
threshold for defibrillation greater in nonischemic than in ischemic patient; ischemic HF patients have less favorable
prognosis; guidelines based on clinical trials; cardiac resynchronization therapy (CRT)—for patients with LV dysfunction
and wide QRS; changing sequence of activation by 3-lead pacemaker has profound effect; patient must have
QRS duration >120 ms and significantly reduced functional class; candidates for defibrillation receive CRT with defibrillator;
enhanced external counterpulsation (EECP)—indicated for refractory CAD and angina; beneficial in HF, but
not indicated; similar to intra-aortic balloon counterpulsation; cuffs on leg; 1-hr sessions for 35 days; profound benefit in
refractory angina; impedance cardiography—4 dual sensors with 8 lead wires placed on neck and chest; current transmitted
through electrodes and blood-filled aorta; measures baseline impedance; helps determine change in water content,
cardiac output, and volume overload; reports HR, cardiac output, stroke volume, and systemic vascular resistance
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| THINGS THAT CHANGED MY PRACTICE THIS YEAR —Frank J. Domino, MD, Associate Professor of Family Medicine,
University of Massachusetts School of Medicine, Worcester
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| Gun violence: in United States each year, ≈200 children abducted, 2300 children die from motor vehicle accidents, and
≈3000 children die from gun violence (≈8 deaths per day); most cases of gun violence involve suicide by teenagers (especially
in predominantly white communities); other cases involve homicide (incidence higher than suicide in minority
communities); small percentage of cases accidental; discuss gun violence and gun accessibility in home with parents; talk
to children about use of seat belts, exercise, and gun safety
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| Diet and heart disease: randomized trial compared American Heart Association low-fat diet to Mediterranean diet;
study found consuming 1 L olive oil per week or 30 g nuts daily for 3 mo led to decreased systolic BP, decreased fasting
blood glucose, and decreased lipid ratio; weight loss same in both groups
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| Vitamin D: vitamin E increases mortality rates in some populations; vitamin D associated with lowered rates of colon,
breast, and prostate cancer; meta-analysis suggests 30% to 50% of US adult population vitamin D-deficient; if serum 25-
hydroxyvitamin D level insufficient (ie, below acceptable limit, but not deficient), give vitamin D3 1000 U/day; if patient
deficient, give ergocalciferol, 50,000 U once weekly for 8 to 12 wk, then switch to 1000 to 2000 IU/day; 2006 data show
decreased rates of cancer, falls, and hip fracture, and improvement in muscle function, but no improvement in mood; low
sun exposure or low vitamin D leads to elevated parathyroid hormone (increases osteoclast activity and risk for type 2 diabetes
and heart disease); vitamin D deficiency increases risk for bad outcomes; study found vitamin D replacement decreased
rates of HF exacerbations in women; study showed improved statin efficiency in vitamin D-sufficient patients;
meta-analysis saw decrease in all-cause mortality with maintenance of adequate vitamin D level
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| Cold sores: treat with penciclovir (Denavir) 5 times daily; study found taking famciclovir (Famvir; 1500 mg or 750 mg
bid) within 1 hr of onset of symptoms decreased healing time by 2 days ≈33% of time and decreased duration of pain by
1 day or 25%
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| Unnecessary blood testing: study found providing quarterly report on appropriate use of testing or providing brief educational
reminders about test results decreased overuse of testing by ≈10% (20% when both provided); in white patients
with anemia, risk for iron deficiency nearly 0% (confirming with ferritin test unnecessary); screening for hemochromatosis
not endorsed by United States Preventive Services Task Force because treatment not shown to improve outcomes;
CA-125 and carcinoembryonic antigen testing should not be used for screening (tumor markers should be used only for
managing treatment of cancer); serum IgE levels for determining allergies highly inaccurate; in patients with documented
gastrointestinal bleeding, repeating Helicobacter pylori levels has no benefit because antibodies stay positive for extended
period; checking follicle-stimulating hormone level helpful for diagnosing menopause; thyroid disease and vitamin
B12 deficiency—screening not found useful; problems with unnecessary testing—false-positive results require
further testing, which may induce morbidity and mortality; consider pretest probability (“only order test if you feel like
it’s going to help with decision-making”); if pretest probability of patient having certain condition low, chance for false-
positive result greater than chance for true-positive result
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| Side effects of statins: rhabdomyolysis—risk of creatine kinase (CPK) becoming 10 times baseline value, 1 in 10,000
patients; risk for kidney failure, 15 in 100 million (risk greater in patients with renal disease); check CPK before and after
starting statin; hepatitis—risk of tripling alanine aminotransferase, 1% to 2%; no reported cases of liver failure and
death from statin use
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| Sexually transmitted diseases (STDs): Chlamydia—azithromycin (1 g) safe in pregnancy; doxycycline for 7 days
drug of choice for nonpregnant women and patients with no compliance issues; metronidazole—approved for use during
first to third trimester for treatment of Trichomonas; can be teratogenic, but no reported cases; quinolones no longer appropriate
for gonorrhea due to increasing resistance
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| Type 2 diabetes: BP control best intervention (produces best outcomes); maintenance of BP <120/80 mm Hg reduces
relative risk for death by 32%, stroke by 44%, and retinopathy by 33%; as mean systolic BP increases, incidence of adverse
outcomes increases; Australian study found glycemic control not associated with frequency of blood glucose monitoring;
counsel patients about BP control, exercise, and checking hemoglobin A1C at least twice yearly; metformin—>1
g/day increases risk of developing vitamin B12 deficiency (risk triples for each gram of metformin); theorized that metformin
blocks calcium-dependent pathway associated with vitamin B12 absorption; treat with calcium supplementation
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| Human papillomavirus (HPV) vaccine and risk analogies: some parents assume that providing prevention
leads to risky behavior; risk for hepatitis B in unit of blood, 1 in 250,000 (HIV, 1 in 8 million; hepatitis C, 1 in 30 million);
risk of teenage girl having sex with >1 partner during high school decreased from ≈50% to 43% since 1990s (for
boys, decreased to ≈50%); 68% of twelfth graders sexually active in 1991, 61% in 2001; use of drugs and alcohol increased
from 21% to 25%; remind parents prevention does not promote promiscuity; herpes zoster—lifetime prevalence
≈30%; with use of vaccine, relative risk reduction for shingles ≈51%, ≈67% for postherpetic neuralgia; to prevent
one case of shingles, number needed to treat (NNT) 59, but to prevent postherpetic neuralgia, NNT 360
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Suggested Reading
Batok GR et al: Gun control: a simple answer to the wrong question. Am J Emerg Med 11:678, 1993; Campos-Outcalt
D: Practice alert: CDC no longer recommends quinolones for treatment of gonorrhea. J Fam Pract 56:554, 2007;
Gullestad L et al: The role of statins in heart failure. Fundam Clin Pharmacol 21:35, 2007; Holick MF: Vitamin D:
important for prevention of osteoporosis, cardiovascular heart disease, type 1 diabetes, autoimmune diseases, and some cancers.
South Med J 98:1024, 2005; Koilpillai C et al: Relation of ventricular size and function to heart failure status and
ventricular dysrhythmia in patients with severe left ventricular dysfunction. Am J Cardiol 77:606, 1996; Lam SK et al:
Combined resynchronisation and implantable defibrillator therapy in left ventricular dysfunction: Bayesian network meta-
analysis of randomised controlled trials. BMJ 335:925, 2007; Epub 2007 Oct 11. Mottram PM et al: Is 'diastolic heart
failure' a diagnosis of exclusion? Echocardiographic parameters of diastolic dysfunction in patients with heart failure and
normal systolic function. Heart Lung Circ 12:127, 2003; Phelps MA et al: Pretest probability estimates: a pitfall to the
clinical utility of evidence-based medicine? Acad Emerg Med 11:692, 2004; Phillips CO et al: Adverse effects of combination
angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a
quantitative review of data from randomized clinical trials. Arch Intern Med 167:1930, 2007; Spinarová L et al: Right
ventricular dysfunction in chronic heart failure patients. Eur J Heart Fail 7:485, 2005; Vijan S et al: Treatment of hypertension
in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern
Med 138:593, 2003; Wilkins CH et al: Vitamin D deficiency is associated with low mood and worse cognitive
performance in older adults. Am J Geriatr Psychiatry 14:1032, 2006.
Educational Objectives
| The goal of this program is to improve the management of heart failure (HF) and to review useful practice pearls. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Describe medication options for HF.
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| 2. Discuss benefits of electrical devices for patients with heart disease.
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| 3. Counsel parents and patients about gun safety, diet modification, and vitamin D supplementation.
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| 4. Order laboratory testing judiciously, based on pretest probability.
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| 5. Advise patients with type 2 diabetes about interventions for improved outcomes.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to
ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following
has been disclosed: Dr. Friedman is on the Speakers’ Bureau for Bristol-Myers Squibb, Novartis, and Sanofi-aventis. Dr. Domino is President
and Software Developer for RxPalm, Inc, and Editor for Wolters Kluwer. The planning committee reported nothing to disclose.
Acknowledgements
Drs. Friedman and Domino spoke in Chicago, IL, at the 2007 Scientific Assembly of the American Academy of Family Physicians
, presented October 3-6, 2007. The Audio-Digest Foundation thanks the speakers and the American Academy of Family Physicians (AAFP)
for their cooperation in the production of this program.
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