Chronic Heart Failure: Contemporary Diagnosis and Management

Chronic heart failure (CHF) remains the only cardiovascular disease with an increasing hospitalization burden and an ongoing drain on health care expenditures. The prevalence of CHF increases with advancing life span, with diastolic heart failure predominating in the elderly population. Primary prevention of coronary artery disease and risk factor management via aggressive blood pressure control are central in preventing new occurrences of left ventricular dysfunction. Optimal therapy for CHF involves identification and correction of potentially reversible precipitants, target-dose titration of medical therapy, and management of hospitalizations for decompensation. The etiological phenotype, absolute decrease in left ventricular ejection fraction and a widening of QRS duration on electrocardiography, is commonly used to identify patients at increased risk of progression of heart failure and sudden death who may benefit from prophylactic implantable cardioverter-defibrillator placement with or without cardiac resynchronization therapy. Patients who transition to advanced stages of disease despite optimal traditional medical and device therapy may be candidates for hemodynamically directed approaches such as a left ventricular assist device; in selected cases, listing for cardiac transplant may be warranted.ACC = American College of Cardiology; ACEI = angiotensin-converting enzyme inhibitor; ADHF = acute decompensated heart failure; AF = atrial fibrillation; AHA = American Heart Association; ARB = angiotensin II receptor blocker; CABG = coronary artery bypass grafting; CAD = coronary artery disease; CHF = chronic heart failure; CRT = cardiac resynchronization therapy; ICD = implantable cardioverter-defibrillator; LV = left ventricular; LVAD = LV assist device; LVEF = LV ejection fraction; MI = myocardial infarction; MR = mitral regurgitation; SCD = sudden cardiac death; UF = ultrafiltrationChronic heart failure (CHF) is a progressive syndrome that results in a poor quality of life for the patient and places an economic burden on the health care system. Despite advances in the control of cardiovascular diseases such as myocardial infarction (MI), the incidence and prevalence of CHF continue to increase.¹ An accurate estimate of disease burden is difficult to gather because of the vast number of patients with asymptomatic left ventricular (LV) dysfunction. As the population ages, there is an epidemiological shift toward a greater prevalence of clinical heart failure with preserved LV function, the so-called stiff-heart syndrome. In fact, heart failure with preserved systolic function may account for up to two-thirds of cases in patients older than 70 years.² Regardless of age, the lifetime risk of developing heart failure is approximately 20% for all patients older than 40 years.³Despite the growing prevalence, novel screening techniques and therapeutic directions have improved the outlook for patients with heart failure by focusing not only on symptom control but also on ameliorating the pathophysiology toward a corrective phenotype. This review discusses accepted and emerging therapeutic directions, with an emphasis on practical implications. In light of the available literature and clinical trials, the primary emphasis will be on systolic dysfunction, with a separate brief discussion of heart failure with preserved systolic function.