TY - CHAP M1 - Book, Section TI - Heart Failure: Management A1 - Desai, Akshay S. A1 - Mehra, Mandeep R. A2 - Loscalzo, Joseph A2 - Fauci, Anthony A2 - Kasper, Dennis A2 - Hauser, Stephen A2 - Longo, Dan A2 - Jameson, J. Larry PY - 2022 T2 - Harrison's Principles of Internal Medicine, 21e AB - Clinical management of patients with heart failure (HF) varies widely based on the clinical phenotype at presentation. Those in the earliest stage of disease with asymptomatic ventricular dysfunction (American College of Cardiology [ACC]/American Heart Association [AHA] stage B) may be amenable to treatment with neurohormonal antagonists, including angiotensin-converting inhibitors and β-adrenergic receptor antagonists, with the goal of facilitating ventricular recovery and preventing the development of clinical HF (not further discussed). Those with symptomatic HF (ACC/AHA stage C) comprise a heterogeneous group in whom the approach to therapy is differentiated largely based on measurement of the left ventricular ejection fraction. Data from prospective, randomized clinical outcomes trials enrolling patients with symptomatic chronic HF and reduced ejection fraction (HFrEF) has provided a rich evidence base that supports the efficacy of stepped pharmacologic therapy with neurohormonal antagonists, including renin-angiotensin-aldosterone system (RAAS) antagonists, neprilysin inhibitors, β-adrenergic receptor antagonists, and mineralocorticoid receptor antagonists, as a complement to device-based treatment with cardiac resynchronization therapy and implantable cardioverter-defibrillators. By contrast, treatment of patients with symptomatic chronic HF and preserved ejection fraction (HFpEF) has remained heavily symptom-focused owing to the lack of evidence to support specific pharmacologic therapies to modify disease progression. Even with effective therapy, patients with both HFrEF and HFpEF are at risk for clinical deterioration, typically as a consequence of progressive sodium and fluid retention that fuels the development of congestive symptoms and acute decompensated HF (ADHF). Management of these exacerbations (frequently hospital-based) is heavily focused on hemodynamic stabilization, decongestion, and institution of appropriate disease-modifying therapy in the transition back to chronic ambulatory management. Recurrent episodes of ADHF despite careful longitudinal follow-up and effective treatment may signal the onset of an advanced or refractory HF phenotype (ACC/AHA stage D) in which the risk of mortality from sudden death or end-stage HF is high, and consideration of salvage therapies including cardiac transplant or mechanical circulatory support may be appropriate prior to escalation of palliative measures (Chap. 260). SN - PB - McGraw-Hill Education CY - New York, NY Y2 - 2024/03/28 UR - accessmedicine.mhmedical.com/content.aspx?aid=1190497301 ER -