Congestive Heart Failure / Сердечная недостаточность

http://en.wikipedia.org/wiki/Heart_failure 

Terminology

Heart failure is a global term for the physiological state in which cardiac output is insufficient in meeting the needs of the body and lungs.
This occurs most commonly when the cardiac output is low (often termed "congestive heart failure" or CHF, because the body becomes congested with fluid).^[11]
It may also occur when the body's requirements for oxygen and nutrients are increased and demand outstrips what the heart can provide, (termed "high output cardiac failure").^[12] This can occur from severe anemia, Gram negative septicaemia, beriberi (vitamin B₁/thiamine deficiency), thyrotoxicosis, Paget's disease, arteriovenous fistulae, or arteriovenous malformations.
Fluid overload is a common problem for people with heart failure but is not synonymous with it. Patients with treated heart failure will often be euvolaemic (a term for normal fluid status), or more rarely, dehydrated.
Medical professionals use the words "acute" to mean of rapid onset and "chronic" of long duration. Chronic heart failure is therefore a long term situation, usually with stable treated symptomatology.
Acute decompensated heart failure is a term used to describe exacerbated or decompensated heart failure, referring to episodes in which a patient can be characterized as having a change in heart failure signs and symptoms resulting in a need for urgent therapy or hospitalization.^[13]
There are several terms which are closely related to heart failure, and may be the cause of heart failure, but should not be confused with it:

• Cardiac arrest and asystole refer to situations in which there is no cardiac output at all. Without urgent treatment these result in sudden death.
• Myocardial infarction ("Heart attack") refers to heart muscle damage due to insufficient blood supply, usually as a result of a blocked coronary artery.
• Cardiomyopathy refers specifically to problems within the heart muscle, and these problems usually result in heart failure. Ischemic cardiomyopathy implies that the cause of muscle damage is coronary artery disease. Dilated cardiomyopathy implies that the muscle damage has resulted in enlargement of the heart. Hypertrophic cardiomyopathy involves enlargement and thickening of the heart muscle.

[edit] Classification

There are many different ways to categorize heart failure, including:

• the side of the heart involved, (left heart failure versus right heart failure) Left heart failure compromises aortic flow to the body and brain. Right heart failure compromises pulmonic flow to the lungs. Mixed presentations are common, especially when the cardiac septum is involved.
• whether the abnormality is due to insufficient contraction and/or relaxation of the heart (systolic dysfunction vs. diastolic dysfunction)
• whether the problem is primarily increased venous back pressure (behind) the heart Afterload, or failure to supply adequate arterial perfusion (in front of) the heart Preload (backward vs. forward failure)
• whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance (low-output heart failure vs. high-output heart failure)
• the degree of functional impairment conferred by the abnormality (as in the NYHA functional classification)
• the degree of coexisting illness: i.e. heart failure/systemic hypertension, heart failure/pulmonary hypertension, heart failure/diabetes, heart failure/renal failure, etc.

Functional classification generally relies on the New York Heart Association Functional Classification.^[14] The classes (I-IV) are:

• Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.
• Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
• Class III: marked limitation of any activity; the patient is comfortable only at rest.
• Class IV: any physical activity brings on discomfort and symptoms occur at rest.

This score documents severity of symptoms, and can be used to assess response to treatment. While its use is widespread, the NYHA score is not very reproducible and doesn't reliably predict the walking distance or exercise tolerance on formal testing.^[15]
In its 2001 guidelines the American College of Cardiology/American Heart Association working group introduced four stages of heart failure:^[16]

• Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder;
• Stage B: a structural heart disorder but no symptoms at any stage;
• Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment;
• Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.

The ACC staging system is useful in that Stage A encompasses "pre-heart failure" - a stage where intervention with treatment can presumably prevent progression to overt symptoms. ACC stage A does not have a corresponding NYHA class. ACC Stage B would correspond to NYHA Class I. ACC Stage C corresponds to NYHA Class II and III, while ACC Stage D overlaps with NYHA Class IV.

[edit] Signs and symptoms

A man with congestive heart failure and marked jugular venous distension. External jugular vein marked by an arrow.

[edit] Signs

[edit] Left-sided failure

Common respiratory signs are tachypnea (increased rate of breathing) and increased work of breathing (non-specific signs of respiratory distress). Rales or crackles, heard initially in the lung bases, and when severe, throughout the lung fields suggest the development of pulmonary edema (fluid in the alveoli). Cyanosis which suggests severe hypoxemia, is a late sign of extremely severe pulmonary edema.
Additional signs indicating left ventricular failure include a laterally displaced apex beat (which occurs if the heart is enlarged) and a gallop rhythm (additional heart sounds) may be heard as a marker of increased blood flow, or increased intra-cardiac pressure. Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g., mitral regurgitation) of the heart failure.

[edit] Right-sided failure

Physical examination can reveal pitting peripheral edema, ascites, and hepatomegaly. Jugular venous pressure is frequently assessed as a marker of fluid status, which can be accentuated by the hepatojugular reflux. If the right ventriclar pressure is increased, a parasternal heave may be present, signifying the compensatory increase in contraction strength.

[edit] Biventricular failure

Dullness of the lung fields to finger percussion and reduced breath sounds at the bases of the lung may suggest the development of a pleural effusion (fluid collection in between the lung and the chest wall). Though it can occur in isolated left- or right-sided heart failure, it is more common in biventricular failure because pleural veins drain both into the systemic and pulmonary venous system. When unilateral, effusions are often rightld,rki5mpp[s';sx='/'d[c;e'f]f=qq]=]g'rl.e/2p[q'/W]dS s\1 w\\r][t[pr5lp5y5klthep;e

[edit] Symptoms

Heart failure symptoms are traditionally and somewhat arbitrarily divided into "left" and "right" sided, recognizing that the left and right ventricles of the heart supply different portions of the circulation. However, heart failure is not exclusively backward failure (in the part of the circulation which drains to the ventricle).
There are several other exceptions to a simple left-right division of heart failure symptoms. Left sided forward failure overlaps with right sided backward failure. Additionally, the most common cause of right-sided heart failure is left-sided heart failure. The result is that patients commonly present with both sets of signs and symptoms.

[edit] Left-sided failure

Backward failure of the left ventricle causes congestion of the pulmonary vasculature, and so the symptoms are predominantly respiratory in nature. Backward failure can be subdivided into failure of the left atrium, the left ventricle or both within the left circuit. The patient will have dyspnea (shortness of breath) on exertion (dyspnée d'effort) and in severe cases, dyspnea at rest. Increasing breathlessness on lying flat, called orthopnea, occurs. It is often measured in the number of pillows required to lie comfortably, and in severe cases, the patient may resort to sleeping while sitting up. Another symptom of heart failure is paroxysmal nocturnal dyspnea a sudden nighttime attack of severe breathlessness, usually several hours after going to sleep. Easy fatigueability and exercise intolerance are also common complaints related to respiratory compromise.
"Cardiac asthma" or wheezing may occur.
Compromise of left ventricular forward function may result in symptoms of poor systemic circulation such as dizziness, confusion and cool extremities at rest.

[edit] Right-sided failure

Backward failure of the right ventricle leads to congestion of systemic capillaries. This generates excess fluid accumulation in the body. This causes swelling under the skin (termed peripheral edema or anasarca) and usually affects the dependent parts of the body first (causing foot and ankle swelling in people who are standing up, and sacral edema in people who are predominantly lying down). Nocturia (frequent nighttime urination) may occur when fluid from the legs is returned to the bloodstream while lying down at night. In progressively severe cases, ascites (fluid accumulation in the abdominal cavity causing swelling) and hepatomegaly (enlargement of the liver) may develop. Significant liver congestion may result in impaired liver function, and jaundice and even coagulopathy (problems of decreased blood clotting) may occur.


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Следствия сердечной недостаточности

Застой крови, поскольку ослабленная сердечная мышца не обеспечивает кровообращения. Преимущественная недостаточность левого желудочка сердца протекает с застоем крови в лёгких (что сопровождается одышкой, цианозом, кровохарканьем и т. д.), а правого желудочка — с венозным застоем в большом круге кровообращения (отёки, увеличенная печень и др.). В результате сердечной недостаточности возникают гипоксия органов и тканей, ацидоз и другие нарушения метаболизма.

[править] Острая сердечная недостаточность

Острая сердечная недостаточность чаще бывает левожелудочковой и может проявляться в виде сердечной астмы, отёка легких или кардиогенного шока.
В зависимости от результатов физикального исследования определялся класс по шкале Killip:

• I (нет признаков СН),
• II (слабо выраженная СН, мало хрипов),
• III (более выраженная СН, больше хрипов),
• IV (кардиогенный шок, систолическое артериальное давление ниже 90 мм рт. ст)

Лечение

[править] Стандартная терапия

• Бета-блокаторы
• Ингибиторы АПФ
• Диуретики (мочегонные препараты)
• Сердечные гликозиды
• Нитраты короткого действия(Нитроглицерин)
• Наркотические анальгетики (морфин).