HEART FAILURE

CONTEMPORARY CARDIOLOGY

CHRISTOPHER P. CANNON, MD SERIES EDITOR

Heart Failure: A Clinician's Guide to Ambulatory Diagnosis and Treatment, edited by Mariell L. Jessup, MD, FACC, FAHA, and Evan Loh, MD, FACC, FAHA, 2003

Cardiac Repolarization: Bridging Basic and Clinical Science, edited by Ihor Gussak, MD, PhD, Charles Antzelevitch, PhD, Stephen C. Hammill, MD, co-edited by Win-Kuong Shen, MD, and Preben Bjerregaard, MD, DMSC, 2003

Cardiovascular Health Care Economics, edited by William S. Weintraub, MD, 2003

Nuclear Cardiology Basics: How to Set Up and Maintain a Laboratory, edited by Frans J. Th. Wackers, MD, Wendy Bruni, CNMT, and Barry L. Zaret, MD, 2003

Essentials of Bedside Cardiology: With a Complete Course in Heart Sounds and Murmurs on CD, Second Edition, by Jules Constant, MD, FACC, 2003

Minimally Invasive Cardiac Sur­gery, Second Edition, edited by Mehmet C. OZ, MD and Daniel J. Goldstein, MD, 2003

Platelet Glycoprotein IIblIIIa Inhibitors in Cardiovascular Disease, Second Edition, edited by A. Michael Lincoff, MD, 2003

Management of Acute Coronary Syndromes, Second Edition, edited by Christopher P. Cannon,MD,2003

Aging, Heart Disease, and Its Management, Facts and Controversies, edited by Niloo M. Edwards, MD, Mathew S. Maurer, MD, and Rachel B. Wellner, MPH, 2003

Peripheral Arterial Disease: Diag­nosis and Treatment, edited by Jay D. Coffman, MD and Robert T. Eberhardt, MD, 2003

Primary Angioplasty in Acute Myo­cardial Infarction, edited by James E. Tcheng, MD, 2002

Cardiogenic Shock: Diagnosis and Treatment, edited by David Hasdai, MD, Peter B. Berger, MD, Alexander Battler, MD, and David R. Holmes, Jr., MD, 2002

Management of Cardiac Arrhythmias, edited by Leonard I. Ganz, MD, 2002

Diabetes and Cardiovascular Dis­ease, edited by Michael T. Johnstone and Aristidis Veves, MD, DSC, 2001

Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics, edited by Will­iam B. White, MD, 2001

Vascular Disease and Injury: Pre­clinical Research, edited by Daniel I. Simon, MD, and Campbell Rogers, MD 2001

HEART FAILURE A Clinician s Guide to Ambulatory Diagnosis and Treatment

Edited by

MARl ELL L. JESSUP, MD, FACC, FAHA Heart Failure/Transplant Program University of Pennsylvania Health System, Philadelphia, PA

EVAN LOH, MD, FACC, FAHA

University of Pennsylvania Health System, Philadelphia, PA

Foreword Robert O. Bonow, MD

President, American Heart Association

HUMANA PRESS TOTOWA, NEW JERSEY

ISBN 978-1-4684-9759-5 ISBN 978-1-59259-347-7 (eBook) DOI 10.1007/978-1-59259-347-7 © 2003 Humana Press Inc. 999 Riverview Orive. Suite 208 Totowa. New Jersey 07512 Softcover reprint ofthe hardcover lst edition 2003

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Oue diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the informatian published and ta describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selectians and dosages set forth in this text are accurate and in accord with the standards accepted at the time ofpublication. Notwithstanding, as new research, changes in government regu­lations, and knowledge from clinical experience relating ta drug therapy and drug reactions constantly occurs, the reader is advised ta check the product information provided by the manufacturer of each drug for any change in dosages Of fOf additional warnings and contraindications. This is of utmost importance when the recol11-

mended drug herein is a new ar infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors ar omissions or for any consequences from the application ofthe information presented in this book and make no warranty, express or implied, with respect ta the contents in this publication.

Produc ti an Editor: Robin B. Weisberg. Cover Illustration: From Fig. 9 in Chapter 8, "Evaluation ofVentricular Function" by Craig H. Scott and Victor A. Ferrari. Cover design by Patricia F. Cleary.

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Library of Congress Cataloging-in-Publication Data Heart failure a clinician's guide ta ambulatroy diagnosis and treatment / edited by Mariell

L. Jessup, Evan Loh. p. cm. -- (Contemporary cardiology)

Includes bibliographical references and index.

1. Heart failure. 2. Ambulatory medical care. 1. Jessup, Mariell L. II. Loh. Evan. III. Contemporary cardiology (Totowa, N.J : unnumbered)

RC685.C53H4252003 616.1 '29--dc21 2002191939

FOREWORD

During the past few decades, significant progress has been made in the prevention and treatment of cardiovascular disease in the United States. Despite these advances, national statistics indicate that the inci­dence and prevalence of chronic heart failure have been increasing in recent years. In fact, heart failure is the only category of cardiovascular disease in which the prevalence, incidence, and mortality have increased steadily in the past 25 years. These worrisome trends are paralleled by steady increases in the hospitalization rates and health care costs related to heart failure. The heart failure epidemic is fueled by several factors. Heart failure is age related, with a prevalence of 1 % between the ages of 50 and 59. This rate increases to roughly lO% above the age of75. With the aging of the population, a greater number of patients with chronic heart failure will undoubtedly occur. Additionally, improvement in the treatment of acute myocardial infarction translates into more patients surviving with left-ventricular dysfunction, which translates into more patients developing clinical heart failure over the course of subsequent decades. Finally, better management of heart failure itself, with the po­tential for improved survival through advances in medical therapy and implantable devices, could result in the paradoxical situation in which enhanced survival might be achieved at the expense of more patients alive with heart failure symptoms. The combination of an aging popu­lation and decline in mortality from other forms of cardiovascular dis­eases indicates that heart failure will continue to increase in public health importance. Hence, more and more patients will be diagnosed, treated, and followed in the primary outpatient setting.

Heart Failure: A Clinician's Guide to Ambulatory Diagnosis and Treatment, edited by Drs. Jessup and Loh, provides an in-depth, hands­on approach to the office-based evaluation and management of the patient with heart failure. Extensive coverage is provided regarding the presenting signs and symptoms of heart failure, as well as the tools with which to evaluate left-ventricular function, hemodynamics, and exer­cise performance. The chapters on treatment recommendations are up-to-date and evidence-based, consistent with current peer-reviewed practice guidelines. Appropriate attention is placed on treatment options for the patient with advanced heart failure, including alternative thera­pies, emerging therapeutic alternatives, and surgical approaches and devices. A highly commendable feature of the book is the considerable

v

VI Foreword

emphasis on patient education and disease management, and the many related references to web-based resources will be of great practical value. Heart Failure: A Clinician's Guide to Ambulatory Diagnosis and Treat­ment will prove an indispensable resource to physicians and nurses on the primary care team in the daily management of their patients with heart failure.

Robert O. Bonow, MD

Division of Cardiology Northwestern University Feinberg School of Medicine,

Chicago,IL

PREFACE

Heart failure is a complex clinical syndrome manifested by dyspnea, fatigue, fluid retention, and decreased exercise tolerance. Heart failure may result from disorders of the pericardium, the myocardium, the endocardium, valvular structures, and the great vessels of the heart or from rhythm disturbances. Nearly 5 million Americans have heart failure today, an incidence approaching 10 per 1000 population after the age of 65 years. Heart failure is the reason for at least 20% of all hospital admis­sions in persons above age 65; hospitalizations for heart failure have increased by 159%. The prevalence of patients with heart failure has grown markedly as a result of the aging population and the number of patients who have survived heart attacks, heart valve surgery, and other cardiac procedures as a result of improvements in adjunctive medical therapies and surgical techniques. Thus, almost any practicing clinician will encounter a patient with the heart failure syndrome on a regular basis.

Heart Failure: A Clinician's Guide to Ambulatory Diagnosis and Treatment reviews all aspects of heart failure diagnosis and manage­ment, with a particular emphasis on office-based/ambulatory care. The volume discusses diagnostic and therapeutic options for clinicians in evaluating patients with dyspnea, fatigue, or edema. The recommenda­tions contained herein are specific and directed at targeted symptoms. The many diagnostic-imaging modalities discussed focus on the practi­cal utility of the tests. Heart Failure: A Clinician's Guide to Ambulatory Diagnosis and Treatment reviews the state-of-the-art pharmacologic, device, and surgical options for heart failure management, with care algorithms that are usually supervised by a nurse or nurse specialist.

Heart Failure: A Clinician's Guide to Ambulatory Diagnosis and Treatment is intended for generalists and internists, nurse practitioners, physician assistants, and general cardiologists who practice in the com­munity setting. The epidemic of heart failure that faces our country necessitates a coordinated effort at prevention and optimal treatment of the disease. Unfortunately, all of the solutions to this enormous problem have yet to be elucidated, but additional efforts to educate and inform our busy clinicians will be important to keep up to date with the evolu­tions in heart failure care available today. We hope Heart Failure: A Clinician's Guide to Ambulatory Diagnosis and Treatment will serve as a platform for a systematic approach to the care of patients with heart failure for all clinicians.

VII

V111 Preface

We are very grateful for the excellent contributions from our authors, all of whom practice or trained at the University of Pennsylvania Health System. This work represents our approach to the plague of heart failure, a northeastern United States approach certainly, but a concerted and devoted one nevertheless.

Mariell L. Jessup, MD, FACC, FAHA

Evan Loh, MD, FACC, FAHA

CONTENTS

Foreword .............................................................................................. v

Preface ............................................................................................... vii

Contributors ....................................... , ................................................ xi

1 Heart Failure: The Economic Burden of a Deadly Disease .................................................................... 1

Daniela Pini

2 Taking a History in a Patient with Heart Failure ........... 17 Irving M. Herling

3 Evaluation of Dyspnea ................................................... 25 David M. McCarthy

4 Heart Failure and Fatigue ............................................... 37 Eric D. Popjes

5 Evaluation of Edema ...................................................... 55 Srihari S. Naidu and Ross Zimmer

6 Evaluation of Palpitations .............................................. 69 Henry H. Hsia

7 Examination of the Patient Suspected to Have Heart Failure ......................................................... 87

Susan C. Brozena

8 Evaluation of Ventricular Function ............................. 103 Craig H. Scott and Victor A. Ferrari

9 Coronary Artery Disease and Congestive Heart Failure ....................................................... 131

Robert L. Wilensky and Bruce D. Klugherz

10 Hemodynamic Evaluation of Patients with Heart Failure ...... '" ...................................... 149

Ruchira Glaser and Daniel M. Kolansky

11 Exercise Performance Evaluation in Patients with Heart Failure ............................................... 163

Andrew Kao

ix

x Contents

12 Understanding the Syndrome of Heart Failure ............ 209 Mariell L. Jessup

13 Education and Management of the Whole Patient ...... 223 Kathleen M. McCauley

14 Pharmacologic Therapy for Symptomatic Congestive Heart Failure .................................... 237

Evan Loh 15 Evaluation and Treatment of Arrhythmias

in Heart Failure ................................................... 253 David J. Callans

16 Emerging Therapies in Heart Failure ........................... 271 David Zeltsman and Michael A. Acker

17 Current Concepts of Biventricular Pacing in Heart Failure ................................................... 279

Robert W. Rho, Vickas V. Patel, and Dusan Z. Kocovic

18 Alternate Therapies for Congestive Heart Failure ...... 297 Shashank Desai

19 Established Therapies for Advanced Heart Failure ..... 307 Lee R. Goldberg

20 Diastolic Heart Failure: A Clinician's Approach to Diagnosis and Management ........................... 321

Martin G. Keane 21 Disease Management and Practice Guidelines

for Heart Failure: A Practical Approach ........... 339 Jerry Johnson

Index ................................................................................................. 349

CONTRIBUTORS

MICHAEL A. ACKER, MD, Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA

SUSAN C. BROZENA, MD, FACC, FAHA, Heart FailurelTransplant Program, University of Pennsylvania Health System, Philadelphia, PA

DAVID J. CALLANS, MD, Electrophysiology Program of the Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

SHASHANK DESAI, MD, Heart FailurelTransplant Program, University of Pennsylvania Health System, Philadelphia, PA

VICTOR A. FERRARI, MD, Noninvasive Imaging Program of the Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

RUCHIRA GLASER, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

LEE R. GOLDBERG, MD, MPH, FACC, Heart FailurelTransplant Program, University of Pennsylvania Health System, Philadelphia, PA

IRVING M. HERLING, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

HENRY H. HSIA, MD, FACC, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

MARl ELL L. JESSUP, MD, FACC, FAHA, Heart FailurelTransplant Program, University of Pennsylvania Health System, Philadelphia, PA

JERRY JOHNSON, MD, Division of Geriatric Medicine, University of Pennsylvania Health System, Philadelphia, PA

ANDREW KAo, MD, FACC, Heart FailurelTransplant Program, University of Pennsylvania Health System, Philadelphia, PA

MARTIN G. KEANE, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

BRUCE D. KLUGHERZ, MD, Cardiac Catheterization Laboratory, Philadelphia Veterans Affairs Hospital, University of Pennsylvania Health System, Philadelphia, PA

DUSAN Z. KOCOVIC, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

DANIEL M. KOLANSKY, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

Xl

Xli Contributors

EVAN LOH, MD, FACC, FAHA, University of Pennsylvania Health System, Philadelphia, PA

DAVID M. MCCARTHY, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

KATHLEEN M. MCCAULEY, PhD, RN, CS, FAAN, School of Nursing, University of Pennsylvania Health System, Philadelphia, PA

SRIHARI S. NAIDU, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

VICKAS V. PATEL, MD, PhD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

DANIELA PINI, MD, Heart Failurefl'ransplant Program, University of Pennsylvania Health System, Philadelphia, PA

ERIC D. POPJES, MD, Penn State Milton S. Hershey Medical Center, Hershey, PA

ROBERT W. RHO, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

CRAIG H. SCOTT, MD, Noninvasive Imaging Program of the Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

ROBERT L. WILENSKY, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, PA

DAVID ZELTSMAN, Division of Cardiothoracic Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ

Ross ZIMMER, MD, Division of Cardiovascular Medicine, University of Pennsylvania Health System Philadelphia, PA