Heart failure

심부전(Heart failure, HF)

임상 양상

• dyspnea, orthopnea, nocturnal dyspnea, Cheyne-Stokes respiration, 교대맥, S3 gallop

진단

• BNP
  • < 100 pg/mL - HF unlikely
  • >400 pg/mL - HF likely
  • 100-400 pg/mL - Use clinical judgment
• 심초음파

Stage

• AHA and ACC
  • Stage A
    • People at high risk of developing heart failure (pre-heart failure), including people with:
      • High blood pressure
      • Diabetes
      • Coronary artery disease
      • Metabolic syndrome
      • History of cardiotoxic drug therapy
      • History of alcohol abuse
      • History of rheumatic fever
      • Family history of cardiomyopathy
  • Stage B
    • People who have developed structural heart disease that is strongly associated with the development of heart failure (such as those with a history of heart attack, those with a low ejection fraction, valve disease with no symptoms) but without signs and symptoms of heart failure.
  • Stage C
    • Patients with known systolic heart failure and current or prior symptoms(Shortness of breath, Fatigue, Reduced ability to exercise)
  • Stage D
    • Patients with systolic heart failure and presence of advanced symptoms after receiving optimum medical care
• NYHA
  • Stage I
    • No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
  • Stage II
    • Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
  • Stage III
    • Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
  • Stage IV
    • Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

급성 심부전

• 만성 심부전의 급성악화나 허혈성 심질환, 고혈압 등 다른 기저 질환에 의해 생김

치료

• Warm & Wet: acute pulmonary edema에 준해 치료(MAIL DONi)
  • Diuretics, vasodilator; nitrate, nitroprusside
• Cold & Wet: Cardiogenic shock에 준해 치료
  • IV vasodilator, dobutamine, dopamine(low dose)
• Cold & dry: PCWP<12이면 수액 보충

만성 심부전

• 확장기 심부전: 나이 많고 고혈압이 있는 비만한 여성에서 흔하다.

	확장기 심부전	수축기 심부전
연령	>70세	50~70세
성별	여자	남자
좌심실구혈율	정상, 40% 이상	감소, 40% 이하
좌심실용적	정상	증가
흉부단순촬영	폐울혈	심비대, 폐울혈
청진	제4심음	제3심음
고혈압	++++	++
당뇨	+++	++
심근경색 병력	+	+++
비만	+++	+
만성 폐질환	++	0
수면무호흡증	++	++
장기적투석	++	0
심방세동	+(paroxysmal)	+(persistent)

치료

• Stage 별 치료 진행
  • salt restriction, 운동 -> ACEi, BB -> AB+digitalis, diuretics -> 기계적 보조장치(biventricular pacing, CRT), 심장이식 등
  • Biventricular pacing indication
    • Sinus rhythm with EF <35%
    • QRS > 120ms
    • Symptomatic CHF(NYHA class III-IV
• 생존율 증가 약제
  • ACEi: NYHA class II 이상에서 1st line
  • ARB: ACEi를 사용할 수 없는 경우 1st line
  • BB 중 carvedilol, bisoprolol, metoprolol
    • acute HF에서는 악화시킬 수 있어 주의
  • Aldosterone antagonist: spironolactone, eplerenone
    • NYHA class III 이상에서만 이득
  • Direct vasodilator: hydralazine+isosorbide dinitrate
• 폐부종, 체액 저류시: diuretics 우선 사용
  • furosemide: 모든 HF에서 효과적
• 부정맥 동반시
  • 이뇨제에 의한 hypokalemia 확인
  • Amiodarone: AF 동반시 TOC
  • ICD: 급사 위험시 예방적 사용

예후 인자

• NYHA classification: 가장 중요