Defining Heart Failure


The MD Magazine Peer Exchange: Advances in Heart Failure Management features expert opinion and analysis from leading physician specialists on the latest developments in heart failure research, diagnosis, and management.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

  • Michael Felker, MD, MHS, Professor of Medicine, Chief of the Heart Failure Section, Director of the Heart Center Clinical Research Unit, and Director of the Advanced Heart Failure Fellowship at Duke University School of Medicine
  • Jim Januzzi, MD, Roman W. DeSanctis Endowed Distinguished Clinical Scholar in Medicine at Massachusetts General Hospital and Hutter Professor of Medicine at Harvard Medical School
  • Christian Schulze, MD, PhD, Associate Professor of Medicine, Division of Cardiology at Columbia University Medical Center, and Director of Research for the Center of Advanced Cardiac Care at Columbia University Medical Center

In this segment of the Peer Exchange, the panelists discuss heart failure symptoms and the clinical characteristics and presentation of the various forms of this condition, and how this can affect treatment. They particularly focus on the diagnostic challenges posed by the often nonspecific symptoms associated with heart failure.

Dr. Januzzi says heart failure “is not a specific diagnosis; it presents in a number of different ways. There are different types of heart failure.” For example, he says there is “heart failure with reduced ejection fraction where the heart is dilated with reduction in LV contraction versus heart failure with preserved ejection fraction where the heart is relatively non-dilated and its ejection fraction is, by definition, normal.”

“They may manifest very similarly in terms of symptoms and signs, and the compensatory mechanisms for heart failure in both are pretty similar surprisingly, but the treatment for both types is very, very different,” says Dr. Januzzi.

The panelists also discuss several ways in which the heart tries to compensate for the presence of heart failure, noting that there are several mechanisms by which this occurs, including increased left ventricular mass leading to hypertrophied heart muscle ( particularly in the presence of normal ejection fraction), increased heart rate, and increased systemic vascular resistance to support adequate cardiac output as well as blood pressure.

Dr. Felker says that a central tenet of heart failure pathophysiology is that “all these adaptations that are adaptive in the short-term are chronically maladaptive in the long run.” In fact, he says that “most of our successes in treating heart failure have actually been going after those chronic maladaptive mechanisms and trying to address them.”

Dr. Schulze notes that although these compensatory mechanisms may enable the heart to sustain the ability to pump enough blood into the body, eventually “there will be a phase where progressive symptoms develop and our patients develop symptoms. And this is usually associated with symptoms such as shortness of breath, dyspnea, and progressive fatigue, objective symptoms such as reduced exercise tolerance, the recurrence of fluid retention, peripheral edema, and also changes in congestive patterns in the liver, in the lungs, and in other parts of the body.”

Because many symptoms associated with heart failure are nonspecific, patients often live with his condition for years before receiving a diagnosis. Dr. Felker says that this makes early recognition and diagnosis all the more important, especially because “the population at risk for heart failure is huge.”

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