A case from practice
Systolic left ventricular failure is more common with age and is associated with a high mortality rate. It is also associated with severe restrictions on the patients’ daily lives and frequent hospitalizations. However, adequate drug and non-drug therapy can often help to stabilize and improve the situation for those affected. The following review article presents the current treatment of systolic heart failure using a typical case study from primary care practice.
Left ventricular failure is common and is divided into two major etiologic groups [1, 2]: heart failure with reduced systolic and left ventricular systolic function (LV). Recently, this is increasingly being referred to as HFrEF ("heart failure with reduced ejection fraction") or HFpEF ("heart failure with preserved ejection fraction") abbreviated. In German-speaking countries, the distinction is in "systolic" and "diastolic" Heart failure usual. However, patients have with "systolic" Heart failure often causes severe diastolic disturbances – so this term is not precise. Both forms occur approximately equally frequently. The prevalence in Germany is estimated at about 2 – 3% of the total population, among the > 70-year-olds > 10%. Systolic heart failure has a mortality rate of about 50% in five years. With regard to the course, one differentiates between acute and chronic forms, each of which requires specific treatment measures.
This article is dedicated specifically to systolic left ventricular failure. Possible causes include coronary heart disease, valvular aorta (aortic stenosis, insufficiency), myocarditis, sarcoidosis, various forms of cardiomyopathy (hypertrophic, dilatative, arrhythmogenic-right ventricular, restrictive forms) and atrial fibrillation ("Tachymyopathie").
The case: anamnesis and findings
A male patient (first presentation, 69 years old) comes into the practice because of a few days of increasing shortness of breath. Last night, he could no longer sleep flat, he gets bad air when walking. Swollen lower legs exist for months, this has increased in recent weeks.
The history includes several older myocardial infarctions. In the past, coronary angiography was performed and stents were implanted; currently there are no symptoms of angina pectoris. He gave up smoking; His medication (acetylsalicylic acid and simvastatin) he takes regularly. No further medication, no further illnesses. The last cardiological examination took place three years ago.
The physical examination shows a slight acrocyanosis with congestion of the jugular veins. Impressive pretibial edema is confirmed on both sides. The pulse is rhythmic and norm-frequent. Kardial shows a clearly auscultable 3rd heart sound with laterally dislocated peak of the heart. The lungs show wet rales in the basal sections.
The resting ECG (Fig. 1) shows a normofrequent sinus rhythm with an overstretched right type and peripheral low voltage (QRS amplitude
Classification and further diagnostics
On the basis of the medical history and the finding, left heart failure (stage NYHA III) is to be assumed (see Table 1). The ECG in Z. n. Myocardial infarctions suggests a reduced systolic LV function (HFrEF). Further diagnostics include echocardiography (for the differential diagnosis of the aetiology), an x-ray thorax image (to exclude other causes of shortness of breath and, if necessary, detection of pulmonary diseases) and a laboratory blood test with blood count and determination of NT-proBNP ("brain natriuretic peptide"), in particular to evaluate concomitant problems (eg, hepatic congestion, anemia, renal function, electrolyte status). A normal NT-proBNP value (for acute complaints 100 / min) can be used.
If the patient is symptomatic, recovery of the sinus rhythm should be attempted. Antiarrhythmic therapy should only be given with amiodarone as all other antiarrhythmic substances (eg class I antiarrhythmics, dronedarone, sotalol) are contraindicated. Especially in patients with heart failure, antiarrhythmic therapy should always be performed prior to cardioversion, as the rate of recurrent VHF recurrence without concomitant antiarrhythmic medication is very high.
ICD and cardiac resynchronization therapy
The primary prophylactic implantation of an ICD is generally in patients with systolic heart failure (EF → Literature
Conflicts of interest: Text conflict of interest
Published in: The GP, 2015; 37 (14) pages 42-46
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