BEST CARDIOLOGY HOSPITALS IN BANGALORE
Cardiac failure is an increasingly common condition affecting about 1% of the population but
much higher proportions of older people. It is responsible for an increasing number of hospital
admissions. The various aetiologies have been discussed above, but the most common cause is
now ischaemic heart disease rather than hypertensive heart disease. This reflects the improved
modern management of hypertension in the population.
The definition of heart failure has always included reference to the inability of the heart to
meet the metabolic needs of the body. The earliest concepts of heart failure were of inadequate
cardiac pump function and associated salt and water retention. Treatment was aimed at
improving cardiac contractility and removing salt and water from the body.
In the 1970s the concept of after-load reduction was introduced. This was based partly
on the realisation that vasoconstriction was part of the problem. This has led to the modern
concept of heart failure. It is clear that many of the features of cardiac failure
are a result of stimulation of the renin-angiotensin-aldosterone system and sympathetic
stimulation. These responses of the body to the fall in cardiac output temporarily increase
cardiac performance and blood pressure by increasing vascular volumes, cardiac contractility
and systemic resistance. In the medium and longer term these responses are maladaptive. They
increase cardiac work and left ventricular volumes and lead to myocardial fibrosis with further
loss of myocytes.
Most recently it has become clear that heart failure is also an inflammatory condition, with
evidence of cytokine activation. Work is underway to establish a role for treatment of this part
of the condition.
Current drug treatment has been successful in blocking many of the maladaptive aspects of
neuro-hormonal stimulation. Many of these treatments have become established after benefits
have been ascertained in large randomised controlled trials. These trials have also led to the
abandoning of certain drugs (often those that increase cardiac performance) that were shown
to have a detrimental effect on survival (e.g. Milrinone).
The principles of treatment of heart failure are as follows:
1 Remove the exacerbating factors.
2 Relieve fluid retention.
3 Improve left ventricular function and reduce cardiac work; improve prognosis.
4 Protect against the adverse effects of drug treatment.
5 Assess for further management (e.g. revascularisation, transplant).
6 Manage complications (e.g. arrhythmias).
7 Protect high-risk patients from sudden death.