Medicus, Vol. 12 No. 1_ Kardiologija, 2003.
Review article
Modern Principles of the Heart Failure: Diagnostics and Treatment
Davor Miličić
Katija Čatipović-Veselica
Abstract
Heart failure (HF) is a syndrome which could
be caused by various etiological factors unfavorably influencing
myocardial structure and function, from arterial hypertension,
genetic features, valvular and congenital heart diseases,
arrhythmias, toxins, to ischemic heart disease or myocardial
infarction. HF is one of the most common chronic non-infectious
diseases in the modern world, presenting a high proportion
in national health budgets, causing the highest hospitalization
rates and the highest in-hospital mortality. HF is a
malignant disease i.e. life prognosis is usually more unfavorable
than in many widespread malignant tumors. Modern
approach to HF implies the understanding of pathophysiology,
which is based on abnormal neurohormonal activation (RAAS,
adrenergic system and some other mechanisms). Remodelling
is a term which explains the progressive character of heart
dysfunction/decompensation, based on the complex degenerative
transformation of the myocardium, including processes
as apoptosis, necrosis and the fibrosis of myocardial tissue,
furthermore dilatation and deformation of the myocardium, but
also reactivation of some fetal genes, including oncogenes.
Pharmacological involvement in the unfavorable pathophysiological
chain of the HF, primarily in the abnormal neurohormonal
activation, opens the possibility not only to reduce
symptoms and functional capability but also to achieve an
improvement of the remodelling parameters and statistically
significant mortality reduction. While diuretics and digitalis
can only reduce volume overload and improve symptoms, by
using ACE-inhibitors a relative mortality reduction of 20-25%
could be expected. Adding a beta blocker, further favorable
influence on mortality could be achieved i.e. the relative reduction
of 30-35%. Spironolactone on the top of the ”standard”
therapy in patients with moderately severe and severe heart
failure could additionally lower the mortality for about 30%.
Therefore, the strategy of HF treatment has changed. The first
line therapy is an ACE-inhibitor, then the addition of a beta
blocker, and furthermore diuretics and digitalis if necessary. In
more advanced forms of HF, spironolactone has to be added.
The article elaborates treatment strategy in more detail. Furthermore,
some other, non-pharmacological approaches are
briefly discussed, from hemofiltration to heart transplantation.
Resynchronization and implantable cardioverter defibrillators
(ICD) are getting an increasing importance in the HF treatment,
as they can, similarly to the above-mentioned drugs, but
only in selected groups of patients, favorably influence the
clinical course and survival.
Keywords
heart failure; diagnostics; treatment
Hrčak ID:
20529
URI
Publication date:
27.1.2003.
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