Severe heart failure prognosis. The main causes of chronic heart failure - how to get away from heart problems

  • The reasons for this phenomenon
  • Symptoms of the disease
  • Pathogenesis and etiology
  • Treatment of the disease
  • What is the prognosis of life?

Even today, skeptics continue to argue that if heart failure is diagnosed, the prognosis for life is disappointing. It depends on many factors that are not always subject to human control.

At the same time, cardiologists all over the world insist on the thesis that in heart failure, the prognosis of life depends on the effectiveness and timeliness of treatment. This statement fits well with the concept of medical development, and mortality from heart disease is gradually decreasing.

Features of heart failure

In general terms, heart failure is a complex syndrome characterized by disturbances in the filling and ejection of blood from the ventricles. It is not an independent disease, but is caused by serious diseases.

Heart failure is classified according to several characteristics. In the course of the syndrome, it is customary to distinguish the first emerging (acute), transient and chronic forms. According to hemodynamic characteristics, it is divided into systolic, diastolic and mixed insufficiency. Taking into account the mechanism of pathogenesis, it is customary to separate the compensated and decompensated forms.

The pathogenesis process is divided into four stages, and the severity of heart failure is assessed by dividing into four classes (I - IV). The grading system is WHO approved and includes the following criteria. Class I includes an illness in which normal physical activity does not cause perceptible abnormalities (shortness of breath, rapid heartbeat, etc.). Class II recognizes minor restrictions on physical activity, as normal volume causes fatigue and shortness of breath. Class III is characterized by a significant decrease in workload, because even decreased activity causes signs of heart failure. Finally, class IV implies the exclusion of physical activity: any manifestation of it causes attacks of the disease. Complete rest is required - otherwise the prognosis of life is disappointing.

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The reasons for this phenomenon

Heart failure occurs due to diseases of the heart and some other internal organs and the vascular system. The following reasons are currently recognized:

  • genetic predisposition;
  • toxic effects (alcohol, drugs, some medications);
  • inflammatory diseases: myocarditis, tissue diseases, Chagos disease, etc.;
  • tachyarrhythmic effect;
  • postpartum effect;
  • violation of metabolic processes;
  • amyloidosis;
  • exposure to stress.

The most common causes are the following pathologies:

  • ischemic disease (heart attacks, cardiosclerosis);
  • hypertension;
  • valvular heart disease (congenital and acquired);
  • atrial fibrillation;
  • cardiomyopathy of a different acute nature.

Chronic forms appear as a result of an abnormal increase in the size of the heart, for example, due to disease-causing muscle mass for additional release of blood. Another reason is hypertrophy of the left ventricle of the heart under the influence of disease.

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Symptoms of the disease

Shortness of breath and swelling of the extremities are important signs of heart failure. In the initial stages, shortness of breath occurs only with great physical exertion, but as the disease progresses, it occurs more often and with relatively little physical activity. Eventually, this develops into orthoposis, when shortness of breath suddenly manifests itself in a supine state, forcing a person to accept a sedentary state. This phenomenon indicates that the ventricle of the heart cannot cope with the increased blood flow entering it in the supine state of a person. It can also cause a cough at night, which is the body's reflexive defense.

Another syndrome is characteristic of congestive forms of the disease -. Such asthma manifests itself at night and is expressed in severe shortness of breath, forcing a person to sit up quickly. The attack lasts quite a long time (tens of minutes) and causes anxiety, and sometimes even fear.

Edema begins to appear at the end of the working day and at the first stage is formed only on the feet and lower leg, by the morning they disappear. In the process of development of heart failure, edema passes to the calves and thighs. At a severe stage, edema can develop in the lumbar region and sacrum, and sometimes reach the chest and face. Other symptoms include increased heart rate, fatigue, insomnia, irritability, discomfort in the heart area, enlarged liver, and excess fluid in the pleural and abdominal cavity.

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Pathogenesis and etiology

The onset of heart failure is considered to be a decrease in stroke and minute volume, which causes disruptions in tissue perfusion; with ischemic disease, this phenomenon is explained by damage to the myocardium. In myocardial infarction, damage to the heart muscle causes dysfunctions of the left ventricle. If the patient has survived an attack, then heart failure develops against the background of these injuries.

Another mechanism of pathogenesis is caused by the effect of "dormant" myocardium, which is a reflex to reduce blood flow. This state of the myocardium does not allow for the necessary contraction of cardiomyocytes, which also leads to ventricular dysfunction. Prolonged hibernation of the heart muscle leads to tissue necrosis and scarring.

Another component of the pathogenesis is the dysfunction of the endothelium of the coronary vessels. This provokes the activation of neurohormones, which lead to development. At the same time, the permeability of the walls for lipids increases, which cause the progression of atherosclerosis and thrombosis.

Under the influence of the disturbances occurring, the sympathoadrenal system is activated, which ultimately leads to an increase in tissue perfusion. The kidneys increase the production of renin, which contributes to the production of angiotensin. It overloads the myocardium and stimulates aldosterone to accumulate fluid. A number of other mechanisms are involved in the process, but in general, a distortion of neurohumoral regulation due to abnormal tissue perfusion plays an important role in pathogenesis. Expansion of dystrophic changes in the myocardium, accumulation of sodium and water fluid in the body, an increase in the volume of circulating blood leads to improper contraction and relaxation of the heart muscles, dilatation of the cavity, i.e. to manifest characteristic symptoms heart failure.

In this article, we will find out what is heart failure... let's talk about its prevalence among various categories of patients, discuss the prognosis and mortality from heart failure.

Heart failure is understood as the inability of the heart to pump blood, which is necessary to ensure the functioning of organs and tissues, that is, to perform its main, pumping function.

In Russia, there is an increase in the number of patients with heart disease and, accordingly, with chronic heart failure. According to epidemiological forecasts, in the next 20 years, the number of patients with chronic heart failure will increase. This is due to:

  • Change in demographic situation (increase in the number of elderly people)
  • Reduced mortality from cardiovascular disease(heart attacks and strokes)
  • Improving survival in chronic heart failure itself

According to epidemiological studies, the prevalence of chronic heart failure in the general population ranges from 1 to 3%. This indicator increases significantly with age, in elderly patients the prevalence of chronic heart failure is about 15%, and in people over 80 years old and reaches 20%, and is diagnosed in about 70% of patients aged 90 years. A number of researchers note an increase in heart failure in many countries of the world, which is probably associated with an increase in the life expectancy of the world's population.

The incidence of chronic heart failure is higher among men than among women. Persons with preserved left ventricular ejection fraction are characterized by a predominance of elderly people and women.

The annual incidence of heart failure is 0.2-0.3% in people aged 50-59 years and increases by about 10 times by 80-89 years. As a rule, the average age of development of clinical manifestations is 75 years.

One of the main questions that worries all patients with an already identified disease is: heart failure prognosis of life. The only way to answer it is by appealing to the data of multicenter clinical trials. First, chronic heart failure refers to disabling, economically costly pathological conditions that require frequent repeated hospitalizations throughout the year. The quality of life of patients suffers greatly, even more than in severe arthritis and strokes.

  • Mortality from heart failure remains high, it exceeds that in many malignant neoplasms (breast, prostate, and colon cancer).
  • The five-year mortality rate from chronic heart failure (according to the Framingham Study) was 62% for men and 42% for women.
  • The annual survival rate after the onset of decompensation is 30-40%, while the survival rate of patients is higher with the preserved left ventricular ejection fraction (we will talk about how to determine it below).

The cost of treating chronic heart failure is on average 1-2% of the total cost of the health service per year.

Heart Failure Patients are too optimistic. Heart failure life expectancy

Study Shows Patients Overestimate Their Lives

By WebMD Health News

Revised Louise Chang, M.D.

June 3, 2008 - Many people with heart failure can be overly optimistic when it comes to assessing how long they are left to live.

A new study shows nearly two-thirds of people with congestive heart failure overestimate their remaining lives by an average of 40% over what is realistic based on their predictions.

Heart failure, which occurs when the heart is too weak to pump enough blood to meet the body's needs, causes 55,000 deaths annually and indirectly contributes to over 230,000 deaths annually in the United States

Although there have been recent improvements in congestive heart failure treatment, researchers say the prognosis for people with congestive heart failure is still bleak, with about 50% having a life expectancy of less than five years. , almost 90% die within one year.

“Patient perception prognosis is important because it fundamentally influences medical decisions regarding drugs, devices, transplants, and expired care,” write researchers Larry A. Allen, MD, SPM, at the Duke Clinical Research Institute and colleagues at Journal of the American Medical Association.

Heart Failure to meet Unrealistic expectations?

In the study, the researchers surveyed 122 people (mean age 62) with moderate to advanced congestive heart failure about their perceptions of their lives.

They found heart failure patients usually overestimate their lives for about three years. The median estimate of patient survival was 13 years, compared to the validated medical model estimate of 10 years.

Overall, 63% of people with heart failure overestimated their remaining lives by an average of 40% when compared to the medical prognosis model. Those who were younger and with more advanced disease were more likely to overestimate how long they left to live.

During the three-year follow-up period, 29% of the people participating in the survey died. The researchers found no relationship between life expectancy and survival perception.

Life expectancy in customized material

"The specific reasons for this discrepancy are unknown, but they may reflect hope, or may arise from inadequate interactions between clinicians and their patients about prognosis," the researchers write. "Because differences in expectations about prognosis can influence decision-making about advanced treatments and the overdue planning of further studies on both scales and the reasons behind these differences is warranted."

In an editorial that accompanies the study, Clyde W. Yancy, MD, Baylor of the University of Dallas Medical Center, writes that predicting life expectancy in people with heart failure is not an accurate science, and many questions remain about clinical predictive models.

Therefore, as long as these issues are taken into account in full, the person must embark on an individual decision-making process at the end of the service period guided by the physician entering.

SOURCES: Sun, V. Journal of the American Medical Association. June 4, 2008; Volume 299: 2533-2542. Press release, American Medical Association.

Sergey Tereshchenko: Heart failure is not only heart disease

Sudden death, especially of a young man, always raises a lot of questions and guesses. Why? For what reason has a person who had never been sick passed away? Versions are different. Most often, the heart is blamed for everything, it could not stand it. But. Is it always to blame in such situations, or, as they say, heart failure? The columnist for "RG" talks about this with the head of the Department of Myocardial Diseases and Heart Failure of the Russian Cardiological Research and Production Complex, Professor Sergei Tereshchenko.

Sergey Nikolaevich! Heart Failure Consists of More than One Heart Disease?

Sergey Tereshchenko: Heart failure is not a disease at all. This is a complication of various heart diseases: myocardial infarction, arterial hypertension, cardiopathy, rhythm disturbances. And it develops not only because of heart disease, but also for other reasons - because of alcoholism, drug addiction, diseases of the endocrine system, drug overdose and so on.

You are the head of the department that deals with heart failure. Which one? Or all? Do the treatments differ?

Sergey Tereshchenko: Precisely by all. The methods of diagnosis and treatment do not depend on the origin of the deficiency. Patients are sent to our center from all regions of Russia. These are the most difficult and difficult to treat cases.

However, are you treating?

JSINCUT3

Sergey Tereshchenko: Yes, and quite successfully. At the center is a streamlined diagnostic process, and most importantly, qualified personnel. That in our time, you see, a rarity. And these personnel have modern diagnostic equipment. And the treatment, the prognosis of a person's life depends on an accurate diagnosis. We use both modern drugs and the latest surgical methods: the installation of stents, pacemakers, bypass surgery.

What are the main symptoms of heart failure, linking it with the diseases that provoked it?

Sergey Tereshchenko: Heart failure does not have one common symptom. There is a complex of them: shortness of breath, rapid fatigue, swelling of the legs, palpitations, interruptions in the work of the heart, suffocation and an irresistible desire to sleep half-sitting. If a person has similar symptoms, this is a reason to suspect heart failure. And if the patient has a history of arterial hypertension or diabetes, or a previous myocardial infarction, or if the person is an amateur alcoholic beverages, a heavy smoker, the diagnosis is almost one hundred percent.

Is there a special analysis for a more accurate diagnosis of heart failure?

JSINCUT2

Sergey Tereshchenko: Held. It is called "brain natriuretic peptide". Blood is taken from the patient's vein, and literally in 10-15 minutes we see the results. If the level of this peptide (protein) is increased, then this is one hundred percent diagnosis of heart failure. Our center has such equipment. On the whole, unfortunately, it does not exist in Russia. Therefore, we cannot talk about the timely diagnosis of insufficiency. And it is extremely important, however, as in the diagnosis of any disease. But when it comes to the heart. I will give two numbers. In civilized countries, about 4-6% of the population dies from myocardial infarction. In Russia, 13-15%. Other figures are also disappointing. With heart failure, there are periods of its decompensation, that is, a rapid and significant deterioration in the condition. This happens due to a hypertensive crisis, or due to an acute respiratory infection. It is not for nothing that during a flu epidemic we always say that flu is dangerous for its complications, especially heart failure. I cannot but name another very important reason for decompensation: the patient's refusal to take the prescribed drugs. Now a course of therapy has been prescribed, and the patient is clearly taking medication. An improvement has come, and something works in the patient's head: stop taking medications, because they have side effects. And off the pills! And the disease of evil - it takes revenge for negligence, very serious complications begin, which we do not always manage to cope with.

It seems to me that you have not named another reason for the complications. It is no coincidence that an ambulance is called more often on Saturday, Sunday, and on holidays. And the reason for the calls is usually "bad heart". Bad why?

Sergey Tereshchenko: Understood what you are driving at. Drinking alcohol is deadly. The heart cannot withstand alcoholic stress. We even have a term "heart of the day off", when, after cheerful Saturdays and Sundays, friendly feasts, the heart goes out of rhythm, and - decompensation.

The statistics of civilized countries show that about 2 percent of the population suffers from insufficiency. Our at least rough data?

Sergey Tereshchenko: They are not encouraging: 7-9 percent. And their life expectancy is noticeably worse than with cancer. On average, it is equal to 5 years from the beginning of the failure. And in the event of decompensation, even less - up to 10% of patients die within a year.

Chronic heart failure is a disease in which, for various reasons, the heart cannot provide the body with the required amount of blood. Statistics show that this disease is quite common, especially among older women. Some patients, when symptoms of heart failure appear, attribute them to general aging of the body. As a result, for a long time they do not receive the necessary treatment, which often becomes the cause of death.

Much has been written about how to treat heart failure. But it is very important to combine the medication prescribed by the doctor and the patient's appropriate behavior. The patient must completely abandon such bad habits as smoking, excessive alcohol consumption. It is necessary to follow a diet low in salt and maintain a normal weight. It is also very important to have physical activity that corresponds to the patient's condition. For the body, both its complete absence and overvoltage are equally harmful.

This is a series of disorders, which are based on the low contractility of the heart muscle. There is a misconception that heart failure is a heart condition, but it is not. Heart failure is a condition of the body in which the contractile ability of the heart muscle (myocardium) becomes weak, as a result, the heart cannot fully provide the body with the required amount of blood.

Very often people with coronary heart disease and hypertension suffer from heart failure, and heart failure complicates many diseases of the cardiovascular system. Heart failure significantly reduces the quality of life, and sometimes becomes the cause of death of a person.

Heart failure symptoms

Given the nature and course of the disease, heart failure is divided into acute and chronic. The disease manifests itself as a slowdown in the rate of general blood flow, the amount of blood ejected by the heart becomes less, and the pressure rises in the heart chambers. The excess blood volume, which was not coped with, begins to accumulate in the conditionally called "depots" - the veins of the legs and abdominal cavity.

The earliest symptoms of heart failure are weakness and fatigue.

Since the heart cannot handle the entire volume of circulating blood, excess fluid from the bloodstream begins to accumulate in various organs and tissues of the body, usually in the feet, calves, thighs, abdomen and liver.

Due to the increase in pressure and the accumulation of fluid in the lungs, breathing is impaired. In a normal state, oxygen freely passes from the capillary tissue of the lungs into the general bloodstream, but when fluid accumulates in the lungs, which occurs in heart failure, oxygen does not fully pass into the capillaries. Breathing becomes more rapid due to the low concentration of oxygen in the blood. Very often the patient wakes up in the middle of the night from attacks of suffocation.

As an example, consider the American President Roosevelt, who suffered from heart failure. For a very long time he could not sleep while lying down, but slept sitting in a chair due to breathing problems.

Leaking fluid from the bloodstream into tissues and organs can stimulate more than breathing problems and sleep disorders. A person quickly gains weight due to edema of soft tissues in the area of ​​the feet, legs, thighs, and sometimes in the abdomen. When you press with your finger, you can clearly feel the swelling.

In very severe cases, fluid builds up inside the abdominal cavity. A dangerous state begins -. Ascites is a complication of advanced heart failure. When some fluid from the bloodstream is released into the lungs, a condition called pulmonary edema begins. Often pulmonary edema occurs with chronic heart failure, accompanied by pink, with blood sputum when coughing.

Insufficient blood supply negatively affects all organs and systems of the human body. The effect on the central nervous system in elderly people is reflected in a decrease in mental activity.

Left side or right side?

The symptoms of heart failure depend on which side of the heart is involved. The left atrium (the upper chamber of the heart) takes in oxygen-rich blood from the lungs and pumps it into the left ventricle (lower chamber), which pumps this blood to the rest of the organs. If the left side of the heart is not able to fully promote blood, it is thrown back into the pulmonary vessels, and excess fluid seeps through the capillaries into the alveoli, causing breathing difficulties. Another symptom of left-sided heart failure is weakness and excessive mucus production (sometimes even bloody).

Right-sided failure occurs when the blood outflow from the right atrium and right ventricle is obstructed, this happens when the heart valve is not working properly. As a result, pressure rises and fluid accumulates in the veins ending in the right chambers of the heart - the veins of the liver and legs. The liver increases in volume, pains bother, and the legs swell a lot. With right-sided insufficiency, such a phenomenon as nocturia is noticed - increased nighttime urination, exceeding daytime.

With congestive heart failure, the kidneys are unable to absorb large volumes of fluid, as a result of which renal failure is formed. Salt, which is normally excreted by the kidneys along with water, is retained in the body, thereby increasing the swelling. With the elimination of the main cause - heart failure - renal failure disappears.

Chronic heart failure (CHF) is an important problem of modern healthcare. The number of patients with CHF in the general population is at least 10 million people in Europe and about 5 million in North America. Due to the increase in the frequency and prevalence of this pathology with age, CHF is becoming one of the main causes of death and hospitalization in the elderly.

N.P. Kopitsa, N.V. Belaya, N.V. Titarenko, L.T. Small AMS of Ukraine, Kharkov

In recent years, the number of patients who reach the terminal stage of CHF is constantly growing, which is a consequence of the increase in life expectancy due to improved treatment. This group of patients belongs to stage D according to the classification of the American College of Cardiology / American Heart Association and to III-IV functional class (FC) according to the classification of the New York Heart Association (NYHA), characterized by the presence of structural changes in the myocardium and pronounced symptoms of heart failure ( SN) at rest or with minimal physical activity, despite the maximum drug therapy according to existing recommendations (table). Among patients in this category, mortality during the year is about 50%, so such patients need special therapeutic interventions. Treatment methods should prevent the worsening of CHF in the form of myocardial ischemia, tachy- and bradyarrhythmias, valvular regurgitation, pulmonary embolism, infection or renal dysfunction.

Pharmacological therapy of end-stage CHF

Angiotensin-converting enzyme (ACE) inhibitors are recommended as first-line drugs for all patients with reduced left ventricular (LV) systolic function (ejection fraction [EF]< 35-40%) независимо от клинических симптомов (I-IV ФК по NYHA), кроме наличия противопоказаний (таблица). В ходе нескольких широкомасштабных клинических исследований показано, что иАПФ улучшают течение заболевания, снижают частоту госпитализаций и смертельных исходов . Более того, препараты назначают пациентам, у которых ХСН развилась в результате острого инфаркта миокарда, что увеличивает выживаемость и уменьшает частоту repeated heart attacks and hospitalizations. The doses of ACE inhibitors used should not be reduced on the basis of improvement in symptoms, they must be titrated to the target, the effectiveness of which has been proven in large-scale placebo-controlled studies. Treatment should be carefully monitored by regularly measuring blood pressure (standing and lying), as well as determining indicators of renal function, blood electrolytes (especially potassium). In patients with an ACE inhibitor tolerance, angiotensin II receptor antagonists (ARA II) may be used as an alternative to reduce morbidity and mortality.

Pharmacotherapy of terminal CHF

Goal 1. Reduce morbidity and mortality

ACE inhibitors
ARA II (in the presence of tolerance to an ACE inhibitor, or in combination with an ACE inhibitor while persisting symptoms of CHF)
Selective β-blockers
Aldosterone antagonists

Goal 2. Controlling symptoms

Diuretics (thiazides in combination with loop diuretics)
Cardiac glycosides (in low doses)

Selective antiarrhythmics

Goal 3. Symptomatic therapy

Opioids, antidepressants, anxiolytics
Oxygen
Short-term non-glycoside inotropic agents

If, despite optimal treatment, including ACE inhibitors, CHF symptoms persist, ARA II is prescribed in combination with an ACE inhibitor, which leads to an additional reduction in cardiovascular mortality and morbidity. However, an increase in the incidence of hypotension, renal dysfunction and hyperkalemia in combination therapy requires careful monitoring of these parameters.

Patients with end-stage CHF and fluid retention, as well as, if they have been observed before, should be prescribed an ACE inhibitor with diuretics, which usually quickly reduce shortness of breath, increase exercise tolerance, and effectively affect patient survival. Terminal stage CHF usually requires the appointment of loop diuretics, which are used in combination with thiazides in the treatment of refractory fluid retention due to their synergistic action. In addition to standard therapy with ACE inhibitors and diuretics, patients with symptoms of stable systolic CHF (NYHA FC II-IV) are prescribed β-blockers in the absence of contraindications. The results of several large-scale clinical studies have shown that β-adrenergic blockers (carvedilol, bisoprolol, metoprolol) reduce the frequency of hospitalizations and deaths, as well as the FC of CHF. Treatment with β-blockers of stable heart failure should be started in the absence of signs of fluid retention with very low doses, which must be titrated to the targets used in large-scale clinical trials, or to the maximum tolerated. Patients need to monitor indicators of fluid retention, blood pressure and pulse rate.

Patients with progressive CHF (NYHA FC II-IV) are recommended to take aldosterone receptor antagonists in combination with ACE inhibitors, β-blockers and diuretics. As shown in the RALES and EPHESUS studies, they improve survival and reduce morbidity. At the same time, monitoring of the content of potassium levels, renal function and indicators of fluid retention, as well as the development of gynecomastia in the case of spironolactone, should be monitored.

In the absence of contraindications, cardiac glycosides are prescribed to control the heart rate in patients with symptoms of heart failure (NYHA FC I-IV) with tachyarrhythmia due to atrial fibrillation with an adequate dose of β-blockers. The combination of cardiac glycosides with β-blockers is more effective than therapy with each drug separately. In patients with LV systolic dysfunction (EF< 35-40%) и синусовым ритмом, у которых сохраняются симптомы ХСН при лечении иАПФ, β-адреноблокаторами, диуретиками и ингибиторами рецепторов альдостерона, дополнительная терапия сердечными гликозидами в небольших дозах (концентрация в сыворотке крови дигоксина – 0,5-0,8 нг/мл) может улучшить симптомы и уменьшить частоту госпитализаций. Однако применение сердечных гликозидов не снижает летальности . При этом должен осуществляться контроль за частотой сердечных сокращений, атриовентрикулярной проводимостью и уровнем калия, а также функцией почек, поскольку дигоксин элиминируется при помощи почечной экскреции.

For frequent supraventricular and ventricular arrhythmias in heart failure, the class III antiarrhythmic drug amiodarone is effective, which can restore and maintain sinus rhythm or improve the outcome of electrical cardioversion in patients with atrial fibrillation. Treatment with amiodarone has a neutral effect on mortality and is not indicated for the primary prevention of ventricular arrhythmias. Its benefits must be weighed against the potentially serious side effects, including hyper- and hypothyroidism, corneal accumulation, skin photosensitivity, hepatitis, pulmonary fibrosis. Dofetilide is a new class III antiarrhythmic drug without a negative effect on mortality in patients with CHF, in whom the benefit must be weighed against an increased risk of developing bidirectional ventricular fusiform tachycardia.

Anticoagulants are used in patients with CHF in the presence of atrial fibrillation, a history of thromboembolism, with a movable thrombus in the LV, or concomitant myocardial infarction.

Inotropic agents, such as β-adrenoreceptor agonists (dobutamine) and phosphodiesterase inhibitors (milrinone, enoximone), increase mortality with repeated and long-term treatment and are not recommended for the treatment of CHF. Non-glycoside inotropic drugs can be periodically used in cases of severe cardiac decompensation with pulmonary insufficiency and peripheral hypoperfusion, or as a "bridge" to heart transplantation. In this case, complications of treatment, such as proarrhythmia or myocardial ischemia, can be observed, the effect on the prognosis remains unclear. A new calcium synthesizer, levosimendan, improves CHF symptoms with fewer side effects than dobutamine in patients with severe LV dysfunction. However, the data from the REVIVE-II and SURVIVE studies on the use of levosimendan are inconsistent. Thus, the final role of levosimendan in the treatment of CHF needs further study.

To temporarily reduce symptoms, patients with refractory end-stage CHF need further outpatient treatment. Although there is no specific role for direct vasodilators in the management of systolic CHF, combination therapy with hydrolazine and isosorbide dinitrate can reduce the symptoms and course of CHF, which is tolerant to both ACE inhibitors and ARAII.

In addition to the basic therapy of CHF, nitrates reduce anginal pain and shortness of breath, calcium antagonists amlodipine and felodipine are used to treat refractory arterial hypertension and angina pectoris. Opioids are used to reduce symptoms in patients with end-stage CHF in the absence of other therapeutic options to alleviate the patient's condition.

Mechanical and surgical treatment of terminal CHF

The algorithm for treating patients with end-stage CHF is shown in the figure. In patients with ejection fraction< 35%, синусовым ритмом, блокадой левой ножки пучка Гиса или эхокардиографическими признаками желудочковой десинхронизации и длительностью комплекса QRS >120 ms, in which CHF symptoms remain (NYHA FC III-IV), despite optimal drug treatment, cardiac resynchronization (RRMS) using biventricular stimulation reduces symptoms and increases exercise tolerance, reduces the frequency of hospitalizations and deaths. In the COMPANION study, patients with CHF (NYHA FC III-IV) with ejection fraction< 35% и длительностью комплекса QRS >120 ms were randomized to optimal drug treatment and in combination with RPC, or RPC with an implanted cardioverter-defibrillator (ICD). Importantly, while mortality declined in both groups, there were no significant differences in mortality rates between the RMS and RMS / CDI groups. The findings suggest that the use of an ICD in combination with RRMS should be based on appropriate indications.

With regard to secondary prevention of sudden death, studies have shown that ICD reduces mortality from recurrent cardiac arrest in patients with confirmed ventricular tachyarrhythmia. For primary prevention of sudden coronary death with optimal drug treatment, CDI is used to reduce mortality in patients with ejection fraction.< 30% и перенесенным инфарктом миокарда (>40 days), as well as with ischemic and non-ischemic heart failure (II-III FC according to NYHA) with EF< 35% . Эффективность ИКД зависит от времени имплантации. По результатам исследований MADIT II и SCD-HeFT, в ходе которых изучали выживаемость в течение года после имплантации КД, особых преимуществ этого метода не выявлено . Таким образом, решение об имплантации КД у пациентов со стадией D ХСН, которые имеют плохой прогноз и высокую частоту желудочковых аритмий, является комплексным и индивидуальным. Это важно, поскольку применение ИКД не повышает общей летальности, а способствует уменьшению частоты внезапной коронарной смерти и улучшает качество жизни. Важно, что ИКД или обычные пейсмейкеры с правожелудочковой стимуляцией способствуют ухудшению течения ХСН и левожелудочковой дисфункции, а также повышению частоты госпитализаций . Однако ИКД в сочетании с РРС у пациентов с выраженной ХСН (II-III ФК по NYHA) с ФВ ЛЖ 35% и длительностью комплекса QRS >120 ms reduce the clinical symptoms of CHF and reduce mortality.

Heart transplantation is an established surgical method for the treatment of end-stage CHF, which improves exercise tolerance, quality of life and survival compared to conservative treatment. The indications for heart transplant have been revised by S.A. Hunt. Contraindications include drug or alcohol dependence, lack of adherence to therapy, serious uncontrolled mental and concomitant diseases (conditions after treatment of malignant diseases in the remission phase and for less than five years after treatment, systemic infections, severe renal and hepatic failure), persistent pulmonary hypertension. Allograft rejection of the heart is a serious problem during the first year after transplantation, the long-term prognosis is mainly limited by immunosuppression (infection, hypertension, renal failure, malignant tumors and graft vasculopathy). Thus, the five-year survival rate in heart transplant patients receiving triple immunosuppressive therapy is 70-80%.

This heart transplant procedure is limited due to the small number of donors and the growing number of recipients. Intra-aortic balloon counterpulsation can provide short-term hemodynamic stability. In patients with end-stage CHF, whose condition is too unstable to wait for a donor heart, an artificial LV can be used as a "bridge" to transplantation, it improves the quality of life, the survival rate while awaiting transplantation and after it. As shown in studies, in patients with end-stage CHF who cannot undergo heart transplantation, artificial LV implantation improves survival and quality of life. This allows artificial LV to be used as an alternative to transplantation. Complications of artificial LV implantation include infections, bleeding, thromboembolism, and device failure. Recent data indicate that the survival rate of patients who underwent artificial LV implantation as planned while awaiting transplantation is better than when this procedure is performed on an urgent basis.

In patients with end-stage CHF and symptoms of fluid retention refractory to diuretic therapy, hemofiltration and hemodialysis can provide a temporary improvement in the condition. Studies have shown that in patients with severe LV systolic dysfunction and significant relative mitral valve insufficiency, surgery improves quality of life and survival. LV aneurysmectomy is indicated for patients with CHF in the case of a large isolated aneurysm. According to the latest data, other surgical procedures such as cardiomyoplasty or partial ventriculotomy (Batista's operation) are not indicated for the treatment of CHF.

Experimental capabilities

Early clinical studies have shown the possibility of stem and progenitor cell transplantation in the heart and have demonstrated a positive effect on heart function and / or myocardial viability. However, a small scale of research, a small number of people in the control group, an insufficiently studied mechanism of functioning of the transplanted cells, a lack of information about the procedure (optimal cell type, number of cells, time of cell transformation) and the insecurity of some progenitor cells in the form of arrhythmogenicity associated with implantation of skeletal myoblasts, makes it necessary to conduct further basic research and initiate large-scale randomized, double-blind, placebo-controlled clinical trials with endpoints (including mortality) to address the role of cell therapy in CHF.

The use of vasopressin receptor antagonists had a positive hemodynamic effect in the early stages of research, however, the results of long-term clinical studies to determine their role in the treatment of CHF have not yet been obtained. A novel vasodilator, nesiritide (recombinant human brain natriuretic peptide), has been shown to improve symptoms in patients with acute heart failure without affecting clinical outcome. However, in the studies conducted, the effect of this drug on morbidity and mortality has not been identified. Ivabradine, a novel selective and specific sinus node f-channel inhibitor that lowers heart rate without negative inotropic effect, is currently being evaluated in a Phase III clinical trial enrolling patients with stable coronary artery disease and systolic CHF (BEAUTIFUL study).

Absolute and relative indications for heart transplantation (as modified by S.A. Hunt)

Absolute readings

  • Hemodynamic instability in CHF
  • Refractory cardiogenic shock
  • Documented dependence on inotropic agents to maintain adequate organ perfusion
  • Peak VO 2< 10 мл/кг/мин с достижением анаэробного метаболизма
  • Severe symptoms of ischemia that constantly limit daily activity and cannot be eliminated by coronary artery bypass grafting or percutaneous coronary interventions
  • Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic agents
Relative indications
  • Peak VO 2 11-14 ml / kg / min and marked limitation of patients' daytime activity
  • Recurrent unstable angina pectoris not eligible for other intervention
  • Recurrent fluid balance / renal function instability unrelated to medication misuse
Inappropriate readings
  • Low LV ejection fraction
  • The presence of III or IV FC CHF
  • Peak VO 2> 15 ml / kg / min no other indication

The purpose of improving the pumping function of the LV using surgical methods is to prevent its further remodeling and reduce the stiffness of the myocardial walls. This has been achieved with techniques such as myoplasty and the Ancor mechanical restraining mesh, which have shown promising results and have been evaluated in clinical trials for CHF.

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