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Phenotype Phebruary Day 16 - Heart Failure (Chronic Heart Failure, Acute Decompensated HF, Cor-Pulmonale)

#1

Reserved - for summary

Weekly OHDSI Digest-21Feb2022
#2

Clinical description - Chronic Heart Failure

Chronic Heart Failure
Overview: Abnormal cardiac function or structure that results in clinical symptoms (e.g. dyspnea, fatigure) and
signs (e.g., edema, pulmonary crackles), hospitalizations, poor quality of life, mortality.

Presentation: The symptoms of cardiac failure are non-specific and due to inadequate tissue perfusion (e.g. fatigue) and elevated
			intracardiac pressure (dyspnea, orthopnea, paroxysmal noctural dyspnea) with most people in a compensatory state. 
			The symptoms are commonly insidiuous (slow in onset) but initial presentation is usually due to an inciting event that
			precipitated cardiac decompensation. 

Assessment:
	Search for history of cardiac disease and underlying cardiac pathology: Most people with newly diagnosed heart failure would have a history of cardiac disease. 
		1) Reduced ejection fraction/systolic failure: depressed systolic ventricular function. e.g. Coronary artery disease, dilated cardiomyopathy, 
				valvular disease, congential heart disease
		2) Preserved ejection fraction/diastolic failure: restrictive cardiomyopathy, hypertrophic cardiomyopathy, cardiac fibrosis.
	Look for precipiating factors:
		1) excessive Na, physical stress, infection, exacerbation of hypertension, arrythmia, pulmonary embolism, anemia, thyrotoxicosis, kidney failure
	Common tests:
		Chest X-ray, Echocardiography with doppler, B-type natriuretic peptide (BNP)
		
Differential diagnosis: 
	Chronic bronchitis, emphysema, asthma, Cor Pulmonale
	
Plan:
	Fluid management: restrict salt, avoid NSAIDs, use diuretics if volume overloaded, ACE-/ARB for cardiac remodeling in systolic heart failure, 
	Beta blocker + ACE-/ARB, Aldosterone antagonist (advanced heart failure), digitalist/digoxin
	Need for implantable cardiac defibrilators, manage/prevent arrythmia
	Specific management for underlying cardiac disease/systemic disease.
	
Prognosis:
	Chronic heart failure would have good long term prognosis if acute decompensations are prevented.
	A person may remain in compensated state with mild or no symptoms.
	
	Recurrent acute decompensation may occurr if the underlying pathology is not management/cannot be managed. This might lead to 
	progressive loss of function, increased symptoms and ultimately mortality.
#3

Clinical description - acute decompensated heart failure

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Acute Decompensated Heart Failure
Overview: Persons with history of chronic heart failure, whose symptoms worsen needing hospitalization with management such as IV loop diuretics for
volume overload, IV inotropic agents such as dobutamine and mirinone
Presentation: decompensation with severe symptoms needing hospitalization
Assessment: hemodynamic monitoring/assessment of hemodynamic profile
Plan: same as heart failure, with (IV if needed) medications and hemodynamic monitoring as required.
Prognosis: acute episode would end after symptoms are well controlled, but may reoccur if patient is unable to maintain compensated state.

#4

Clinical description - cor pulmonale

Cor Pulmonale:
Overview: Right ventricular failure/right heart failure due to primary lung disease
Pulmonary parenchymal/airway disease - COPD, ILD,bronchiectasis, cystic fibrosis
Pulmonary vasculature - pulmonary emboli, PAH, vasculitis, sickle cell anemia
Chronic hypoventillation
Presentation:
Similar to chronic heart failure + pulmonary symptoms - sputum
Assessment:
CXR, Echo may show right heart involvment
Right heart catheterization confirms presence of pulmonary hypertension and exclude left heart failure.
Plan:
Treat underlying cause
Symptom management
Prognosis:

#5

Evaluation of phenotypes for Heart Failure

(reserved)

#6

Evaluation of phenotypes for Acute Decompensated Heart Failure

(reserved)

#7

Evaluation of phenotypes for Cor-Pulmonale

(reserved)

#8

reserved

(reserved)

#9

Evaluation of relationships between Heart Failure/Chronic Heart Failure/Acute Decompensated Heart Failure/Cor-Pulmonale

(reserved)

#10

Not sure why this is here. These are different phenotypes, I would say. The classic HF is a chronic left ventricular loss of function. It can decompensate, but again, that’s a new phenotype. Since it is chronic with no sharp onset you cannot optimize index day. You also cannot get out of it, unless you get a heart transplant, which will make you a very different patient. So, I would say:

Optimize for:

  • No sensitivity (there are tons of patients, unless you need it for outcome rate calculation)
  • Some specificity (don’t think there is rule out diagnosis, but there is differential diagnosis. Not sure we want to exclude chronic bronchitis, emphysema, asthma: these cause right ventricular failure, but otherwise patients can have them on top of HF)
  • No index date
  • Censor by heart transplantation.
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