What is ischemic heart failure?

It is a condition in which left ventricular dysfunction is caused by chronic myocardial ischemia and/or the sequelae of infarction, often with remodeling and fibrosis.

What are the main risk factors?

Previous myocardial infarction, arterial hypertension, diabetes mellitus, dyslipidemia, obesity, cigarette smoking.

How is ischemic heart failure diagnosed?

Diagnosis is based on instrumental tests: ECG, echocardiogram, cardiac MRI, myocardial scintigraphy, and coronary angiography in patients eligible for revascularization.

What is the treatment for ischemic heart failure?

It includes lifestyle modifications, drugs (ACE inhibitors, ARBs, beta-blockers, diuretics, aldosterone antagonists), revascularization (PCI/CABG), and in advanced cases, implantable devices or transplantation.

What is the prognosis?

It is a chronic disease at risk of serious complications, but optimized management can significantly improve survival and quality of life.

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Ischemic Heart Failure

Article written and reviewed by Dr Luca Moretti

Ischemic heart failure is a clinical condition characterized by left ventricular dysfunction secondary to chronic myocardial ischemia or previous myocardial infarction.
It is one of the main causes of heart failure with reduced ejection fraction (HFrEF) and is associated with high mortality and morbidity.
The main risk factor for ischemic heart failure is previous myocardial infarction, which results in irreversible myocardial necrosis and ventricular remodeling.
Other cardiovascular risk factors, such as arterial hypertension, dyslipidemia, diabetes mellitus, obesity, and cigarette smoking, contribute to the progression of atherosclerosis and reduced myocardial perfusion, accelerating the decline in cardiac function.

The involved pathophysiological mechanisms include:

Myocardial necrosis and fibrosis: Loss of cardiomyocytes leading to decreased contractility.
Ventricular remodeling: Dilation and alteration of ventricular geometry, impairing systolic function.
Neurohormonal activation: Increase in catecholamines, angiotensin II, and aldosterone, worsening myocardial dysfunction.
Persistent ischemia: Insufficient coronary blood flow to meet myocardial metabolic demands.

Clinical Presentation and Diagnosis

Ischemic heart failure manifests with the typical symptoms of heart failure.
Patients may present with:

Exertional dyspnea and orthopnea.
Peripheral edema and venous congestion.
Exercise intolerance and fatigue.
Palpitations and ventricular arrhythmias.
Angina in the case of persistent ischemia.

Diagnostic tests include:

ECG: Signs of previous ischemia (Q waves) or conduction abnormalities.
Echocardiogram: Assesses ejection fraction, ventricular remodeling, and segmental wall motion abnormalities.
Cardiac Magnetic Resonance Imaging: Identifies areas of myocardial fibrosis and residual viability.
Myocardial scintigraphy: Differentiates areas of reversible ischemia from necrotic tissue.
Coronary angiography: Essential for the evaluation of coronary anatomy and for planning revascularization.

Treatment of Ischemic Heart Failure

Treatment aims to improve cardiac function, reduce symptoms, and prevent cardiovascular events.

Lifestyle modifications:
A low-sodium diet, controlled physical activity, smoking cessation, and blood pressure control improve prognosis.

Pharmacological therapy:

ACE inhibitors and ARBs: Reduce afterload and ventricular remodeling.
Beta-blockers: Improve ventricular function and reduce mortality.
Aldosterone antagonists: Counteract myocardial fibrosis.
Diuretics: Control pulmonary and peripheral congestion.
Anticoagulants: Essential in patients with atrial fibrillation or intracardiac thrombi.

Myocardial revascularization:
In patients with significant myocardial ischemia, revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) can improve ventricular function and reduce mortality.

Advanced therapy:
In patients with advanced heart failure, the following may be required:

Implantable cardioverter-defibrillator (ICD) for prevention of sudden cardiac death.
Cardiac resynchronization therapy (CRT) in patients with ventricular dyssynchrony.
Heart transplantation in the most severe cases.

Prognosis and Complications

Ischemic heart failure is a progressive condition, with a high risk of refractory heart failure, ventricular arrhythmias, and sudden cardiac death. However, optimized treatment can significantly improve quality of life and survival.

References

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McDonagh TA, et al. Heart failure management in coronary artery disease. J Am Coll Cardiol. 2021;77(19):2392-2405.
Groenewegen A, et al. Epidemiology of heart failure. J Am Coll Cardiol. 2020;75(12):1475-1487.
Cleland JGF, et al. Medical therapy in ischemic cardiomyopathy. BMJ. 2018;360:k134.
Felker GM, et al. Management of dilated cardiomyopathy. NEJM. 2018;379(25):2524-2536.
Jessup M, et al. Left ventricular assist devices in advanced heart failure. Circulation. 2017;135(24):2591-2602.
Goldberger JJ, et al. Implantable cardioverter-defibrillators in heart failure. JAMA. 2020;323(11):1045-1055.
Velagaleti RS, et al. Risk factors for the development of heart failure. J Am Coll Cardiol. 2019;73(22):2701-2710.