Clinical Profile of Acute Heart Failure in Rural Trivandrum

Anil Roby,a Noufal Ab

a. Department of Medicine,  Sree Gokulam Medical College, Trivandrum, Kerala; b. Directorate of Health Services, Kerala

Abstract

Heart  Failure  is  a  common  cardiovascular  condition, the incidence and  prevalence  of which are  increasing  as the population ages.  Heart failure is more common in men than in women until the age of 65 years.

Clinical  profile  and  management  of  patients  with the  diagnosis of  heart failure  who were  admitted  in the cardiology  department  of   Sree Gokulam Medical  College, Trivandrum  between  January  2011  and  December  2012  were  analysed. A  total  of   169  patients  who presented  with  heart  failure  during  the  study  period  were  included.

Majority  of  patients  with  heart failure  were  between  the  ages  50  and 80  years.  Coronary  artery  heart disease  was  the  leading  cause of  heart  failure among 74 patients (43.7%) followed   by  Rheumatic  heart  disease    (n=45, 26.6%),  Dilated  Cardiomyopathy (n=20,11.83%)  and  Hypertension  (n=17 , 10.05%).  Systolic heart failure was seen in 92 (54.3%) patients and diastolic heart failure was seen in  77(5.56%).  The commonest presenting symptom was breathlessness (84.51%) and the commonest sign was bilateral basal crackles (89.94%). In  the  acute setting  I.V nitroglycerine and I.V loop diuretics  were  used in 68.6% and 82.8%  of cases respectively  and  Angiotensin  converting  enzyme inhibitors, Beta-blockers  and  sprinolactone   were  used in  71%, 71% and  62.1%  of cases respectively   before  discharge.

Coronary  artery disease  was the  leading  cause of  heart  failure in  our centre. Majority   of our patients  received the  current  evidence  based  treatment  for heart failure.

Keywords: , , ,

Introduction

Heart Failure is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.  The primary manifestation of Heart Failure are dyspnoea and fatigue which leads to exercise intolerance and fluid overload which can result in pulmonary congestion and peripheral oedema.  Heart Failure signs and symptoms have been classified as being due to Left ventricular failure (LVF) or Right ventricular failure (RVF).  Although most patient initially have LVF, both ventricle eventually fail and contribute to Heart Failure.1,2  Based  on  the ejection  fraction,  Heart Failure  can be  classified  into   Heart Failure with  reduced ejection fraction (HFrEF)  also referred to as systolic HF  (EF < 40%)  and  Heart Failure with  preserved  ejection  fraction (HFpEF) also  referred to as  diastolic  Heart Failure ( EF > 50%).  In the ARIC study, the 30-day, 1-year, and 5-year case fatality rates after hospitalization for HF were 10.4%, 22%, and 42.3%, respectively.5  ACC / ACCF  has  staged Heart Failure into 4 stages, Stage  A, At risk of Heart Failure, stage B, Asymptomatic  Heart Failure, stage C , Symptomatic Heart Failure and Stage D as Refractory Heart Failure.3,4,5 

Materials and Methods

This  was  a  record based   study  analysing  registered  data  of   Heart Failure  admissions  in cardiology   department  of  Sree  Gokulam  Medical  College, Trivandrum  between January 2011  to  December  2012.  A  total  of  169    patients  who presented  with  stage 3  and  stage 4   Heart Failure, and   Acute  heart failure  based  on  Framingham  Criteria  were included    in the  study.  Detailed  clinical   history, risk factors assessment, physical examination, EC,  Xray  chest, cardiac  enzymes, and   Echocardiogram  were  done  for  all  patients. Patients with isolated   right heart failure were also included in the study.  Coronary angiogram was done in selected patients. 

Results

Table 1. Age distribution  of  Patients  admitted  with  heart   Failure

Table 1. Age distribution of Patients admitted with heart Failure

Data  of  169   patients  who were  admitted   in  the  cardiology  department  of   Sree  Gokulam Medical  College, Trivandrum, with the  diagnosis  of  heart  failure  from  January  2012  to December 2012  were  analysed.  Out of 169 patients 101 (59.7%)  were male and 68 (40.2%)  were  female.   Age  distribution  of the  patients  are  given in  Table 1  and  the various  causes  of  heart  failure  are listed  in  Table 2.

Table 2. Causes of Heart failure

Table 2. Causes of Heart failure

Patients were treated using a variety of non-invasive and invasive methods. Drugs used are shown in Table 3.  Non-invasive Ventilation was used in 64 patients and   invasive  ventilation in 13 patients CRT/ICD  was  implanted in 5 patients. CABG was done in 8 patients, Mitral Valve replacement in 7  patients, Aortic valve replacement  in  4  patients  and  double valve replacement  in 3  patients.  PTCA  was done in  21  patients. The   commonest  presenting  symptom  was  breathlessness (84.51%)  followed  by palpitation (32.54%) , Chest pain (30.76%), leg  swelling   (26.6%)  and   fatigue (22.48%).

Table 3. Drugs used in the treatment of Heart Failure

Table 3. Drugs used in the treatment of Heart Failure

The  commonest sign were bilateral  basal crackles  (89.94%), Elevated  JVP (85%), peripheral edema  (32.5%), Atrial  fibrillation  (23.01%)  and  cardiogenic  shock  (18.5%).  Arrhythmias   other  than   atrial  fibrillation  like  Atrial  flutter (n=4), Sustained  monomorphic  Ventricular  tachycardia  (n=12) , Sustained  polymorphic  tachycardia (n=10) Asystole  (n=7) and Complete heart block (6)   were also seen.  A case fatality of 13.01% (n=22) was observed. Refractory  heart  failure was  cause  of  death in 12 patients, Mechanical  complications  like  VSD (3 patients) and  MR (5 patients) and  SCD (8 patients)  was  the  cause of  death  in the remaining  cases. Majority  of  patients  with  heart failure  were  between  the  ages  of 50  and 80  years.  Coronary  Artery  Heart Disease  was  the  leading  cause of  heart  failure with 74 (43.7%) cases followed   by  Rheumatic  heart  disease    45 (26.6%),  Dilated  Cardiomyopathy 20(11.83%)  and  Hypertension  17 (10.05%).   Heart failure  due  to  reduced ejection fraction (Systolic heart  failure)  was  seen in  92 (54.43%)  patients  and   heart  failure due  to preserved  Ejection  fraction  (diastolic  heart failure)  was  seen  in  77 (45.56%) patients.

Discussion

Heart Failure is a major and growing   public health problem in developed  countries. Coronary  artery  disease, Hypertension and  dilated  cardiomyopathy are  the  major  causes of  heart  failure  in the Western world.6  The overall incidence of heart failure is likely to increase in the future, because of both an aging population and therapeutic advances in the management of acute myocardial infarction leading to improved survival in patients with impaired cardiac function.  Data from the Framingham study indicate that the incidence of congestive heart failure increases with age and is higher in men than in women as also seen above in this study.7 Factors involved in the development of Heart Failure includes cardiovascular diseases like MI, hypertension and diabetes mellitus.  Rheumatic heart disease is still a common cause of heart failure in Indians.8  In the present study coronary artery disease was the leading cause of heart failure (43.7%) followed by rheumatic heart disease (26.6%).  Heart failure  due  to  reduced ejection fraction (Systolic heart  failure)  was  seen in  92 (54.43%)  patients  and   heart  failure due  to preserved  Ejection  fraction  (diastolic  heart failure)  was  seen  in  77 (45.56%) patients in the present  study.

Progression  of  Heart failure is mostly altered  by  activation of certain  neurohormonal systems  such as renin – angiotensin – aldosterone  system  and  the  sympathetic nervous  system  after the  disease is established. The  aforementioned  neurohormonal  systems assisting  the  failing  heart  in the short term would ultimately  be  associated  with undesired  effects on myocardial function over time; hence resulting in increased  hospitalization and  death rates. Angiotensin converting enzymes inhibitors, Beta-blockers and Spirinolactone have been documented to  improve  heart failure patients’   clinical status  and  survival.9 In the  present  study  Angiotensin  converting  enzyme inhibitors, Beta-blockers  and  sprinolactone   were  used in  71%, 71% and  62.1%  of cases respectively. 

Conclusion

Heart failure in India has reached epidemic proportions. Despite the advance in our understanding of the aetiology, pathophysiology and pharmacotherapy of Heart Failure, the prognosis with these disorders remain grim. Early evaluation and appropriate treatment during the initial stage can prevent the progression of Heart Failure and better prognosis. As the appropriate use of diagnostic and therapeutic management of HF became increasingly complex, a multidisciplinary approach is required for the efficient management of HF.

References

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Author Information

  1. Anil Roby D, Associate Professor, Department of Medicine, Sree Gokulam Medical College, Trivandrum, Kerala
  2. Noufal A, Pharmacist, Directorate of Health Services, Kerala

Conflict of Interest: None declared

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