Heart failure clinics
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Heart failure clinics · Apr 2009
ReviewRole of the pulmonary artery catheter in diagnosis and management of heart failure.
The pulmonary artery catheter will likely earn a place in the history of medicine as one of the most useful tools that shaped our understanding and management of various diseases. An intense assessment of its application in nonacute and nonshock decompensated heart failure has been provided by the ESCAPE trial, a landmark investigation that showed an overall neutral impact of pulmonary artery catheter-guided therapy over therapy guided by clinical evaluation and judgment alone. The current guidelines reserve the use of a pulmonary artery catheter for the management of refractory heart failure and select conditions. The pulmonary artery catheter remains a useful instrument in clinical situations when clinical and laboratory assessment alone is insufficient in establishing the diagnosis and pathophysiologic condition, and in guiding effective, safe therapy.
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Heart failure clinics · Apr 2009
ReviewThe role of echocardiography in hemodynamic assessment in heart failure.
Echocardiography now is recommended as the most useful diagnostic test for routine evaluation and management of heart failure. This article reviews the role of echocardiography (M-mode, two-dimensional, spectral, and tissue Doppler) for qualitative and quantitative hemodynamic assessment of the patient who has heart failure. It highlights the echocardiographic parameters that have the most diagnostic and/or prognostic relevance for patients who have advanced heart failure. The importance of right heart failure and heart failure with preserved ejection fraction is increasingly recognized, and therefore the echocardiographic evaluation of these conditions is emphasized also.
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The evolution of prehospital treatment of decompensated congestive heart failure has in some ways come full circle: rather than emphasizing a battery of new pharmacotherapies, out-of-hospital providers have a renewed focus on aggressive use of nitrates, optimization of airway support, and rapid transport. The use of furosemide and morphine has become de-emphasized, and a flurry of research activity and excitement revolves around the use of noninvasive positive-pressure ventilation. Further research will clarify the role of bronchodilators and angiotensin-converting enzyme inhibitors in the prehospital setting.
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Heart failure clinics · Jan 2009
ReviewPharmacologic stabilization and management of acute heart failure syndromes in the emergency department.
Effective use of diuretics, vasodilators, and inotropes to stabilize acute heart failure (AHF) relies on matching the most appropriately tailored therapy to specific clinical profiles. Some of the drugs may be harmful, and therefore the emphasis should be on patient safety and the attempt to minimize the deleterious effects of these therapies. To date, successful treatment has been limited because no agent has been shown to reduce postdischarge mortality or readmission rates, and patients frequently remain symptomatic after treatment. Ongoing research is needed to further examine these agents and to develop novel therapies to address the unmet needs of the patient who has AHF.
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Optimal medical therapy may ameliorate acute cardiogenic shock and long-term congestive heart failure symptoms; however, in certain cases mechanical circulatory assistance may be helpful or even required. Different devices can be considered based on the anticipated duration of need and the acuity of the cardiovascular failure being treated. A working knowledge of balloon pumps and ventricular assist devices, their indications, function, and potential complications, allows the physician to provide optimal care for those patients presenting with such a device.