Therapeutic Strategies for Heart Failure

By Naoki Sato

This book introduces pathophysiology and practical heart failure (HF) management at the acute, in-hospital stages during hospitalization and also in the end-stages of HF. Given its increasing incidence and prevalence, we live in a world that is essentially facing an HF pandemic. A country with an ageing population, Japan is unique in terms of the selection of medical treatment, diagnostic techniques, team managing and other approaches. This book sheds new light on the clinical challenges involved in reducing re-hospitalization and improving patients’ prognosis and ADL/QOL, while also reporting on the status quo in Japan. By highlighting these challenges and the methods used to address them, it will encourage experts around the globe to intensively discuss and accelerate research in this field. Including contributions by authors who have played central roles in managing HF in Japan, the book offers an indispensable guide not only for clinicians, technicians and nurses inthis field, but also for general physicians, emergency physicians and all others who are involved in the management of acute and end-stage HF.

• Language: English
• Publisher: Springer
• Release date: Jan 24, 2018
• ISBN: 9784431560654

Book preview

Editor

Naoki Sato

Therapeutic Strategies for Heart Failure

../images/334504_1_En_BookFrontmatter_Figa_HTML.png

Editor

Naoki Sato

Nippon Medical School, Musashi Kosugi Hospital, Cardiology and Intensive Care Unit, Kawasaki, Kanagawa, Japan

ISBN 978-4-431-56063-0e-ISBN 978-4-431-56065-4

https://doi.org/10.1007/978-4-431-56065-4

Library of Congress Control Number: 2017964366

© Springer Japan 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.

The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer Japan KK

The registered company address is: Shiroyama Trust Tower, 4-3-1 Toranomon, Minato-ku, Tokyo 105-6005, Japan

Preface

Heart failure (HF) is the most important burden of the cardiovascular field in the world. Unfortunately no drug has been developed over the past several decades in terms of improvement of outcome in patients with HF for hospitalization (HHF). What are the reasons for it? One of the reasons is that pathophysiological conditions of HF had not been fully understood. In most of cardiovascular textbooks, HF is defined as cardiac dysfunction due to various etiologies, and reduced cardiac output with peripheral malperfusion is considered as the main pathophysiological condition of HF. However, lots of registries of HHF suggested that the main pathophysiological condition was congestion. Congestion, which has been historically recognized as the main condition of HF from 1500 BC, should be refocused to improve outcome of patients with HHF. Therefore, we should always consider congestion as well as low cardiac output as pathophysiological conditions of HF to treat HHF patients.

Given the increasing incidence and prevalence of HHF, we live in a world facing an HF pandemic. As one of the countries with outstanding longevity, Japan has unique characteristics concerning the selection of medical therapies, diagnostic techniques, team-managing, and other treatments. The present book was written by HF experts in Japan, who have discussed with each other the pathophysiology and management for HF based on evidences and their own clinical experiences. We have tried to clarify what we know and what we do not know about HF and suggested some therapeutic directions for HF management to young cardiologists through HF meetings since 2008. The present book was written as our integrated achievement and explains current understanding of HF pathophysiology and management from comprehensive views. The theme of each chapter was decided by each HF expert. The contents included the concept of HF and treatments from acute to chronic phases, HF management guided by B-type natriuretic peptide, the concept of congestion and the importance of early intervention for congestion, pharmacological and non-pharmacological management for refractory HF, and multidisciplinary approaches for end-stage HF including palliative care.

Our major aim in the present textbook was to provide current understanding of HF from the viewpoints of Japanese HF experts. To improve management of HF, we should always consider pathophysiology and appropriate therapies for it. It means that precise evaluation of pathophysiological condition of HF patients is the most important to manage them. Excellent physicians always think of the present status of clinical and hemodynamic congestion and peripheral perfusion of the patient in front of them. If an evaluation of pathophysiological condition is wrong, we cannot make a patient happy. This book includes lots of tips for appropriate evaluation of pathophysiology and the best therapies based on experiences and deep considerations of each HF expert. We hope the readers can find some of them and improve their skills for management of patients with HF.

Naoki Sato

Kawasaki, Japan

Acknowledgements

This book would not have been written without the support of Ms. Mariko Kubota and Ms. Chihiro Haraguchi of Springer Japan. We appreciate their patience and efforts. We thank our wives and children for their support.

Contents

1 The Concept of Heart Failure:​ Chronic Diseases Accompanied by an Attack of Acute Exacerbation 1

Mahoto Kato

2 Biomarkers:​ New Horizon for Heart Failure Practice 17

Takayuki Inomata

3 Congestion:​ Historical and Pathophysiologic​al Review and the Concept of Fundamental Management for Hospitalized Heart Failure 39

Naoki Sato

4 Therapeutic Strategies of Refractory Heart Failure 55

Yasushi Sakata, Fusako Sera and Kei Nakamoto

5 Multidisciplinar​y Management of End-Stage Heart Failure 73

Yukihito Sato

© Springer Japan 2018

Naoki Sato (ed.)Therapeutic Strategies for Heart Failurehttps://doi.org/10.1007/978-4-431-56065-4_1

1. The Concept of Heart Failure: Chronic Diseases Accompanied by an Attack of Acute Exacerbation

Mahoto Kato¹  

(1)

Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan

Mahoto Kato

Email: [e-mail]

Abstract

Heart failure is an ambiguous technical terminology. It can either refer to the presence of ventricular dysfunction or a decompensated state with symptoms and signs of clinical congestion. Diagnostic criteria for congestive heart failure, called the Framingham criteria, has not been changed for approximately half a century; the therapeutic strategy, however, has been modified considerably, resulting in improved management of congestion and consequent relief of symptoms and signs in heart failure patients. Ironically, that makes the term heart failure even more complex and obscure. Chronic heart failure is a new concept that was constructed based on NYHA (New York Heart Association) functional classification to evaluate the degree of symptoms and heart failure stages as per the degree of myocardial remodeling due to neurohumoral activation. This covers all states of heart failure and provides the appropriate management for patients in each stage. A better understanding of the concept of chronic heart failure is beneficial in the clinical management of patients with this condition, not only for cardiologists but also for all attending physicians.

Keywords

Heart failureNYHA functional classificationStage of heart failureRemodeling

1.1 Introduction

The term heart failure is an ambiguous medical term, as proven in the following examples:

Example 1: One grandson, with regard to his grandfather’s regular visit, said, "His doctor said Grandpa had a bad heart. That’s heart failure."

Example 2: A doctor on night duty said early in the morning, "I could not sleep at all last night, because patient with heart failure visited emergency room."

Both these examples use the term heart failure. However, the conditions that the term refers to are quite different. In example 1, heart failure refers to abnormal function of the heart, while in example 2, heart failure indicates failure of hemodynamics. Then, of course, coping with each heart failure also differs. In example 1, observation may be sufficient, but in example 2, emergency hospitalization is required.

In this review, we will use this ambiguous term heart failure and introduce the concept of new chronic heart failure.

1.2 What Is Heart Failure?

1.2.1 Diagnostic Criteria for Congestive Heart Failure: Framingham Criteria

The diagnostic criteria for heart failure were first reported in 1971 by the Framingham Study Group of Harvard University [1]. Although this diagnostic criteria have been reported over 40 years ago, it is still cited in heart failure guidelines all over the world, including Japan, with almost no change from the original (Table 1.1). The criteria are described by dividing the symptoms and signs occurring in patients with congestive heart failure into large symptoms and small symptoms. Presence of two or more major symptoms or one major symptom and two or more minor symptoms results in a definitive diagnosis. Most of the symptoms are identified by interview or physical findings, which indicate the importance of physical examination in heart failure diagnosis.

Table 1.1

Framingham criteria for congestive heart failure [1]

For establishing a definite diagnosis of congestive heart failure in this study, two major or one major and two minor criteria had to be present concurrently

The point to keep in mind about the Framingham criteria is that these diagnostic criteria define congestive heart failure, and the main focus is placed on the evaluation of the existence of congestion.

1.2.2 CHF: From Congestion to Chronic

Although the diagnostic criteria for congestive heart failure have remained unchanged for about 40 years, great progress has been made with respect to its treatment. Especially with diuretics, symptoms and signs caused by congestion have dramatically improved from treatment with mercury chloride during the sixteenth century to treatment with loop diuretics beginning in the 1990s. As a result, it became necessary to consider the concept of disease by removing congestion from the term congestive heart failure. The definition of this condition is unclear and is confronted with scientific doubt. The conditions of patients who experience congestive heart failure are not well understood. Patients who have no abnormality in the heart do not suddenly develop congestive heart failure, and it is necessary to have prior organic heart function abnormality. This disease state in which cardiac dysfunction exists is called symptomatic/sign less or chronic heart failure. Therefore, the concept of heart failure does not rely on the existence of congestion.

Moreover, what is abnormal cardiac function? From the viewpoint of maintaining hemodynamics, cardiac function is divided into (1) contractility, (2) dilatability, and (3) valve function. If any one or more of these are impaired, there is cardiac dysfunction, and we diagnose this condition as chronic heart failure (with or without symptoms due to congestion). In other words, the diagnostic criteria for chronic heart failure are proof of the existence of cardiac dysfunction. If a contraction disorder, dilation disorder, or valvular disease is observed,