University of Missouri-Kansas City and Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.
Diabetes Obes Metab. 2023 Jul;25 Suppl 3:15-25. doi: 10.1111/dom.15166. Epub 2023 Jun 20.
Although the prevalence of heart failure has been increasing over time, the presentation of heart failure has been shifting, with a greater proportion of preserved ejection fraction and more slowly progressive symptoms that require recognition in the outpatient setting. These shifts have placed more of the diagnostic responsibility onto primary care physicians, who often are challenged to determine the etiology of common symptoms in patients who often have several other potential reasons for these symptoms. Establishing a diagnosis of heart failure requires a step-wise approach that includes physical exam (looking for multiple signs of hypervolemia), labs (B-type natriuretic peptide levels), and echocardiography (structural and functional measures). Diagnostic algorithms are particularly challenging in patients with obesity, which limits the assessment of intravascular volume on exam, the quality of cardiac imaging, and the diagnostic accuracy of B-type natriuretic peptide levels, which may be falsely low. In these challenging patients, the use of risk scores, invasive testing of intravascular volume, or empiric treatment of hypervolemia may be needed to determine whether symptoms are due to heart failure. Once a diagnosis of heart failure is established, several treatments can be beneficial, from diuretics to relieve congestion to various aspects of guideline-directed medical therapy, some of which vary according to the ejection fraction of the patient. In addition, a diagnosis of heart failure may alter the treatment plan for comorbidities, including selection of anti-hypertensive and glucose-lowering medications, and medical or surgical treatments for obesity. While a diagnosis of heart failure may be challenging in many patients with slowly progressive and non-specific symptoms, early recognition and treatment can be extremely effective at preventing hospitalizations, prolonging survival, and improving quality of life.
尽管心力衰竭的患病率一直在上升，但心力衰竭的表现已经发生了变化，射血分数保留的比例更高，症状进展更缓慢，这需要在门诊环境中得到识别。这些变化使得更多的诊断责任落在了初级保健医生身上，他们常常难以确定经常有其他几种潜在原因导致这些症状的常见症状的病因。诊断心力衰竭需要逐步进行，包括体格检查（寻找多种充血过多的迹象）、实验室检查（B 型利钠肽水平）和超声心动图（结构和功能测量）。在肥胖患者中，诊断算法尤其具有挑战性，因为肥胖限制了对血管内容量的评估、心脏成像的质量以及 B 型利钠肽水平的诊断准确性，B 型利钠肽水平可能会被错误地低估。在这些具有挑战性的患者中，可能需要使用风险评分、血管内容量的有创检查或经验性治疗充血过多来确定症状是否由心力衰竭引起。一旦确立了心力衰竭的诊断，几种治疗方法可能会有益，从利尿剂减轻充血到各种指南指导的医学治疗，其中一些治疗方法因患者的射血分数而异。此外，心力衰竭的诊断可能会改变合并症的治疗计划，包括选择抗高血压和降糖药物，以及肥胖的医学或手术治疗。虽然许多症状进展缓慢且非特异性的患者的心力衰竭诊断可能具有挑战性，但早期识别和治疗可以非常有效地预防住院、延长生存时间和提高生活质量。
