Internal Medicine

0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

Chronic Heart Failure 321

■Assess nature and degree of patient’s functional limitation, NYHA

Class (a dynamic scale)

➣I: no limitation of physical activity, no symptoms with ordinary

physical activity

➣II: slight limitation of physical activity, comfortable at rest, symp-

tomatic with ordinary activity

➣III: marked limitation of physical activity, comfortable at rest,

symptomatic with less than ordinary activity

➣IV: inability to perform physical activity without discomfort,

symptoms may be present at rest

■Assess ACC/AHA clinical stage of heart failure (a one-way scale)

➣A: High risk for developing heart failure without current struc-

tural heart disease or symptoms of heart failure (i.e., patients

with hypertension, atherosclerosis, diabetes, obesity, metabolic

syndrome, etc.)

➣B: Structural heart disease without signs or symptoms of heart

failure (prior myocardial infarction, left ventricular hypertrophy

or enlargement, reduced ejection fraction, valvular disease)

➣C: Structural heart disease with prior or current signs or symp-

toms of heart failure (known structural heart disease and dysp-

nea, exercise intolerance, etc.)

➣D: Refractory heart failure requiring specialized interventions

(marked symptoms at rest despite maximal therapy)

■Assess presence and severity of fluid retention: body weight (may

decrease long-term solely due to cardiac cachexia), physical exam-

ination, especially jugular venous distention, hepatojugular reflux,

rales, hepatomegaly, edema

General Measures

■Prevent development of heart failure:

➣Control coronary risk factors (smoking, hyperlipidemia, hyper-

tension, weight reduction in obese patients, diabetes)

➣Discontinue alcohol use

➣In acute MI patients, limit MI size with reperfusion (thrombolyt-

ics, PTCA) and adverse ventricular remodeling/neurohormonal

activation (ACE inhibitors, beta blockers, aldosterone antago-

nists, ARB)

➣In patients with asymptomatic LV dysfunction, limit adverse ven-

tricular remodeling/neurohormonal activation (ACE inhibitors

[ARB if intolerant to ACE inhibitor], beta blockers)

■Correct reversible causes: valvular, ischemia, arrhythmia, alcohol

or drug use, high output states, cardiac shunts, drugs that cause/