Ischemic heart failure
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Ischemic Heart Failure: Pathophysiology, Management, and Prognosis
Introduction to Ischemic Heart Failure
Ischemic heart failure (HF) is a complex clinical syndrome primarily caused by reduced blood flow to the heart muscle, often due to coronary artery disease (CAD). This condition leads to myocardial ischemia, which can result in heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF) . Understanding the underlying mechanisms and effective management strategies is crucial for improving patient outcomes.
Pathophysiology of Ischemic Heart Failure
Role of Coronary Artery Disease
Coronary artery disease is the leading cause of ischemic heart failure, characterized by the presence of obstructive plaques that reduce coronary blood flow, leading to myocardial ischemia and subsequent heart failure . The pathophysiological process involves not only large epicardial arteries but also the coronary microcirculation, where dysfunction can lead to hypoxia, fibrosis, and tissue death, further impairing myocardial function.
Myocardial Ischemia and Heart Failure
Myocardial ischemia is a self-propagating process that irreversibly impairs cardiac function and negatively impacts prognosis. Structural or functional alterations in coronary circulation, such as increased parietal stress or non-obstructive coronary disease, contribute to this condition. Additionally, impaired myocardial perfusion and inflammation due to multiple comorbidities are key mechanisms in HFpEF.
Clinical Manifestations and Prognosis
Ejection Fraction Categories
Heart failure is categorized based on ejection fraction (EF) into HFrEF (EF <40%), HFmrEF (EF 40%-50%), and HFpEF (EF ≥50%). The pathogenic role of ischemic heart disease (IHD) is well established in HFrEF, but its significance in HFmrEF and HFpEF is less explored. Studies show that HFmrEF resembles HFrEF more closely regarding the prevalence of IHD and the risk of new IHD events.
Risk of Ischemic Stroke
Patients with chronic heart failure are at an increased risk of ischemic stroke, with a 2- to 3-fold higher risk compared to the general population. This risk is associated with thrombus formation and is exacerbated by comorbid conditions such as atrial fibrillation . Stroke in HF patients is often more severe and associated with higher mortality and recurrence rates.
Management Strategies
Medical Therapy
The management of ischemic heart failure involves neurohumoral inhibition, which has been shown to reduce adverse outcomes in HFrEF but not in HFpEF. This discrepancy may be due to the heterogeneity in the underlying pathophysiology of HFpEF. Current guidelines recommend anticoagulation for HF patients with atrial fibrillation to reduce the risk of stroke, but not for those in sinus rhythm.
Emerging Treatments
Emerging evidence suggests that targeting coronary microvascular dysfunction and ion channels may offer new therapeutic avenues. These treatments aim to address the imbalance in coronary blood flow regulatory mechanisms, potentially improving myocardial perfusion and reducing ischemic damage.
Conclusion
Ischemic heart failure remains a significant cause of morbidity and mortality worldwide. Understanding the complex interplay between coronary artery disease, myocardial ischemia, and heart failure is essential for developing effective management strategies. While current treatments have shown efficacy in HFrEF, there is a need for more targeted therapies for HFpEF and HFmrEF. Ongoing research into the role of coronary microcirculation and ion channels may provide new insights and therapeutic options for this challenging condition.
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