Warning:
• Do not ignore the diagnosis before a little debilitating or wheezing dyspnea.
• Diagnosis is echocardiographic and biological (determination of NT-proBNP) ++.
• Treatment is symptomatic and etiological
• ACE inhibitors and diuretics are the first line of treatment, at the stage NYHA II.
• Beta-blockers to appropriate dose should be prescribed widely (expert opinion).
• In case of decompensation, search and treat ischemia, pulmonary embolism, arrhythmia (atrial fibrillation ++), a respiratory infection, a diet gap, anemia, hyperthyroidism, taking a negative inotropic substance, therapeutic non-compliance …
Diagnostic:
Left heart failure (CHF):
exertional dyspnea, rest dyspnea, dyspnea decubitus (orthopnea) or paroxysmal nocturnal; asthenia, pallor, oliguria.
Right heart failure (DCI):
leg edema, or postprandial hepatalgia effort.
Classification of the New York Heart Association (1994) functional capacity (classes I to IV) and objective assessment (paraclinique, stage AD) patients:
– Class I: has heart disease (eg ultrasound), but not limited physical activity (asymptomatic)
– Class II: heart disease resulting in slight limitation of physical activity (dyspnea for greater efforts than ordinary activity)
– Class III: heart disease resulting in marked limitation of physical activities (dressing, grooming, daily life …)
– Class IV: any physical activity prevents heart disease, even discomfort at rest worsen the least effort,
– Stage A: no objective evidence of heart disease,
– Stage B: objective signs of heart disease “minimal”
– Stage C: objective signs of heart disease “moderately severe”
– Stage D: objective signs of a “severe” heart disease.
Physical examination:
++ Tachycardia (except treatment bradycardia), signs of ICG (gallop left, blows functional mitral regurgitation, possibly signs of valvular disease causal, bilateral crackles), signs of DCI (sloping edema, jugular turgor, abdominojugular test , sometimes pulsatile hepatomegaly, breath of functional tricuspid regurgitation), signs of pulmonary hypertension (pulmonary burst of B2 at home), sometimes pleural effusion blade.
Additional tests:
– ECG: do not give the diagnosis … but possibly associated or etiological signs: sinus tachycardia, arrhythmias (extrasystoles, atrial fibrillation), cavitary hypertrophy, ischemic signs (former necrosis subepicardial ischemia …), conduction disorders (block atrioventricular bundle branch block).
– Chest X-ray: cardiomegaly or not, vascular redistribution toward the summit, Kerley lines, or even alveolar interstitial edema, pleurisy.
– Especially echocardiographic: confirms the diagnosis of heart failure
1 / systolic or by objectifying a lowering of +++ LV ejection fraction,
2 / or diastolic (LV filling disorders, restrictive mitral flow profile)
3 / and evaluate the expansion cavities (OG, VG), wall thickness, the presence / importance of kinetic disorders or valvular heart disease, including the tricuspid regurgitation that evaluates pulmonary artery pressure (and therefore the tolerance of a left heart disease).
– Organic: the plasma level of brain natriuretic factor (NT-proBNP) provides diagnostic argument if it is very high.
– A mild exercise testing or Holter monitoring, as appropriate, assess the significance of arrhythmias, sometimes paroxysmal and sometimes serious, with two floors.
Treatment nonpharmacological:
Plan without the: even stricter than the IC is serious, allows the reduction of congestive signs; avoid salt at the table, delicatessen, appetizer biscuits, preserves, cheeses … possibly potassium salt or salt-type XAL BOUILLET.
Physical Activity: bed rest is recommended that during episodes of decompensation; to fight against the deconditioning, regular physical exercise of low intensity (walk) are recommended, strenuous exercise should be avoided.
Fight against obesity and other risk factors.
Smoking cessation.
Etiological treatment: treatment of atrial arrhythmias, valvular correction, myocardial revascularization with bypass surgery and / or angioplasty with ischemic heart disease; in some cases exceeded: transplantation, external ventricular assist to consider …
Vaccinations influenza and pneumococcal.
Pharmacological treatment:
Principles of prescription of an ACE inhibitor: avoid pre excessive diuresis, diuretics stop 24 hours before;establish the treatment evening at bedtime to avoid hypotension; start with low doses; monitor blood pressure frequently, the electrolytes and creatinine every 5 to 7 days at the beginning; avoid potassium-sparing diuretics, nonsteroidal anti-inflammatory; IEC of the target dosage in the IC, to achieve if the blood pressure permits, are: LOPRIL [captopril] 150 mg per day, Renitec [enalapril] 20 mg per day, ZESTRIL [lisinopril] 20 mg per day, Acuitel [quinapril] 20 mg daily or COVERSYL [perindopril erbumine] 5 mg per day or ODRIK [trandopril] 4 mg per day.
From Class I (asymptomatic) should be prescribed IEC: they delay the onset longer term signs of IC.
In Class II and III: IEC, loop diuretics rather than thiazides (less efficient), possibly adding nitrate or molsidomine.
In class IV: IEC, loop diuretics in high doses, digitalis except ischemic heart disorders threatening ventricular arrhythmias, or nitro molsidomine.
An antagonist of angiotensin II, candesartan (Atacand or KENZEN given 4 to 32 mg / day) can replace the IEC in case of intolerance to it (allergy, cough). The limitation rules are the same as with an ACE inhibitor.
In class II and III, in the absence of recent decompensation (4 weeks), we recommend turning the beta blocker +++.Four blockers have a marketing authorization (MA) for this indication: carvedilol (KredEx); bisoprolol (CARDENSIEL), metoprolol (SELOZOK) and nebivolol (rash things). Carvedilol has an additional vasodilator effect but must be taken two times per day.
These beta-blockers protect against the deleterious effect of catecholamines and demonstrated a reduction in mortality in the IC. They are provided very gradually, externally in town, even in the most sensitive cases in hospitals. Expert advice is essential. The increase in dosage is usually in increments of a few weeks, depending on the clinical (weight, pulse, blood pressure, congestive signs), ECG, and echocardiographic data sometimes.
The test dose of KredEx is 3.125 mg, that of CARDENSIEL 1.25 mg, that of SELOZOK LP 12.5 mg and the 1.25 mg of rash things.
Finally, in case of bed rest, do not forget the prescription of a low molecular weight heparin to prevent phlebitis ++.
Order No. 1: Class I heart failure
– Plan bit salty.
– Adapted Physical Activity.
– COVERSYL [perindopril], 2.5 mg, 1 tablet in the evening, up to 5 mg.
– In case of intolerance to ACE inhibitors KENZEN [Candesartan], 4 mg to go up to 16 mg or more if possible,
– Lasix [furosemide], 20 to 40 mg / day or Burinex [bumetanide] 1 tab daily, only in case of congestive signs (edema).
Ordinance No. 2: II-III heart failure classes
– Plan bit salty.
– Adapted Physical Activity (do at least 30 minutes of walking per day).
– IEC idem, low dose at first, gradually rising to the maximum tolerated doses (see dose-target).
– Lasix [furosemide] 20 mg and 40 mg / day or Burinex [bumetanide] 1 tablet per day in case of congestive signs (edema).
– CARDENSIEL [bisoprolol], cp 1 to 1.25 mg per day, prescribed by the cardiologist, to go up to 10 mg if possible,
– Possibly adding CORVASAL [molsidomine] 2 to 4 mg, 3 tab daily or nitrates (DISCOTRINE [NTG]patch 10 to 15 mg) monitoring of blood pressure.
– We can offer the power antiplatelet like aspirin 160 mg daily.
No.3: atrial fibrillation associated: imperative specialist opinion
– DIGOXIN or HEMIGOXINE [digoxin] 1 tab per day so rapid heart rate
– Anticoagulants: low molecular weight heparin (LMWH) with curative dose relayed by vitamin K antagonist (VKA), such PREVISCAN [fluindione] or SINTROM [acenocoumarol] according to the INR.
– Echocardiography looking for expansion or atrial thrombosis ++ (before attempting to diagnose reduction, including CORDARONE [amiodarone]).
– Assays basic thyroid.
Ordinance No. 4: IC Class IV
– Salt without strict regime.
– Minimum physical activity.
– IEC ditto.
– Lasix [furosemide] 40 to 80 mg or Burinex [bumetanide] 2 4 mg / day.
– Anticoagulants.
– The indication for implantation of a biventricular pacemaker (also known pacemaker “multi-site”) and / or an implantable cardioverter defibrillator, devices that enhance life / functional outcome, noted cardiologist (center Rhythm).
Ordinance No. 5: decompensated HF, treatment joins that of the PAO
– Resting in a sitting position, or nasal oxygen mask.
– Hospitalization ++ in most cases:
– Lasix [furosemide] IV 40 to 80 mg, in fact adapted to the diuretic response to
congestive signs, tolerance to creatinine.
– Treatment of the triggering factor (eg passage atrial fibrillation, diet gap, lung infection …).
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