Page 82 - Clinical Pearls in Cardiology

70 Clinical Pearls in Cardiology

is important to note that symptom severity correlates
poorly with ventricular function, and patients with mild
symptoms may still have a relatively high absolute risk
of hospitalization and death (Table 5).
Table 5: NYHA classification of heart failure
Class I Ordinary physical activity does not cause symptoms
of heart failure
Class II Ordinary physical activity results in symptoms of
heart failure
Class III Less than ordinary physical activity results in
symptoms of heart failure
Class IV Symptoms of heart failure even at rest
15. What is the importance of differentiating systolic heart
failure from diastolic heart failure?
Differentiating systolic heart failure (ejection fraction
<50%) from diastolic failure is very essential because
their treatment plans are different. ACE inhibitors are
the first-line of treatment in patients with systolic heart
failure. But fluid retention can attenuate many of the
benefits of ACE inhibitors like ventricular remodeling.
So ACE inhibitors should be used in combination with
a diuretic.
In those with diastolic heart failure (i.e. heart
failure with ejection fraction >50%), the cornerstones
of treatment depend on the underlying etiology of
dysfunction. In these patients, diuretics should be used
with caution. If required, they should be initiated at low
doses to avoid hypotension and fatigue. Beta-blockers
and calcium channel blockers are frequently used
when diastolic dysfunction is secondary to ischemia or
hypertension. They will also produce symptomatic relief
by controlling the heart rate.