Volume II - Issue 3 Academic Medical Journal of India 99

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*

Corresponding Author: Anil Roby D, Associate Professor, Department of Medicine, Sree Gokulam Medical College, Trivandrum, Kerala, Email: anilrobyklm@gmail.com

AbstractHeart 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 Rheu-matic heart disease (n=45, 26.6%), Dilated Cardiomyopathy

Introduction

Heart Failure is a complex clinical syndrome that results from any structural or functional impair-ment 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 clas-sified 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

Data of 169 patients who were admitted in the cardiol-ogy department of Sree Gokulam Medical College, Trivan-drum, 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

ORIGINAL RESEARCH

Published on 20th November, 2014

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(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 respec-tively 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.

Key Words: Heart Failure, Clinical Profile, coronary artery disease, Rheumatic heart disease

Cite this article as: Roby A, Ahammed N. Clinical Profile of Acute Heart Failure in rural Trivandrum. Academic Medical Journal of India. 2014 Nov 20;2(3):99–101.

*See End Note for complete author details

Table 1. Age distribution of Patients admitted with heart FailureAge n (%)

20 - 29 4 ( 2. 36%)

30 – 30 7 ( 4.14 %)

40- 49 17 (10.05%)

50 – 59 37 ( 21.89%)

60 -69 40 ( 23.66%)

70 – 79 42 ( 24 .85%)

>80 22 (13.01%)

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distribution of the patients are given in Table 1 and the various causes of heart failure are listed in Table 2.

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 (dias-tolic heart failure) was seen in 77 (45.56%) 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%). The commonest sign were bilateral basal crackles (89.94%), Elevated JVP (85%), peripheral edema (32.5%), Atrial fibril-lation (23.01%) and cardiogenic shock (18.5%). Arrhyth-mias 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.

Patients were treated using a variety of non-invasive and inva-sive methods. Drugs used are shown in Table 3. Non-invasive Ventilation was used in 64 patients and invasive ventila-tion 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.

Discussion

Heart Failure is a major and growing public health problem in developed countries. Coronary artery disease, Hyperten-sion 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 im-proved 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 – angio-tensin - 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 con-verting enzymes inhibitors, Beta-blockers and Spirinolactone have been documented to improve heart failure patients’ clinical status and survival.9 In the present study Angio-tensin 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

Table 2. Causes of Heart failureCauses (%) Number (n=169) Percentage

Coronary Artery Disease 74 43.7%

Rheumatic Heart Disease 45 26.6%

Dilated Cardiomyopathy 20 11.83%

Hypertension 17 10.05%

Myocarditis 4 2.3%

Thyrotoxicosis 4 2.3%

Cor Pulmonale 5 2.9%

Table 3. Drugs used in the treatment of Heart Failure

Number of Patients Percentage

IV Nitroglycerine 116 68.6%

IV Loop Diuretic 140 82.8%

Dobutamine 22 13.01%

Dopamine 19 11.24%

ACE inhibitor (Enalapril) 120 71%

ARB (Losarten) 30 17.75%

Spirinolactone 105 62.1%

Beta-blockers 120 71%

Digoxin 42 24.85%

Ivabradine 15 8.8%

Amiodarone 10 5.91%

Warfarin 39 23.07%

Anil Roby and Noufal A. Clinical Profile of Acute Heart Failure in Rural Trivandrum

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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.

End Note

Author Information

1. Anil Roby D, Associate Professor, Department of Medi-cine, Sree Gokulam Medical College, Trivandrum, Kerala

2. Noufal A, Pharmacist, Directorate of Health Services, Kerala

Conflict of Interest: None declared

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Anil Roby and Noufal A. Clinical Profile of Acute Heart Failure in Rural Trivandrum