Evaluation of the Patient

Patients with CHF need to have a complete history and physical examination with a focus on cardiovascular risk factors that lead to progression of failure. A careful documentation of their volume status, weight, and NYHC for symptoms needs to be done. Diagnostic tests should include a complete blood count (CBC), serum electrolytes, kidney and liver functions, urinaly-sis, blood glucose, thyroid function test, iron saturation test and ferritin, erythrocyte sedimentation rate (ESR), antinuclear antibodies to rule out connective tissue disease, 12-lead ECG, echocardiogram, and coronary angiogram, particularly in those with significant reduction in left ventricular function, to rule out underlying severe CAD. Brain natriuretic peptides (BNP and NT-proBNP) can be useful when a patient presents with symptoms of dyspnea of unclear etiology and the diagnosis of CHF is uncertain (de Lemos et al., 2003; Siebert et al., 2006).

Routine myocardial biopsy or Holter monitoring is not recommended. Levels of catecholamines might be obtained if clinically indicated in patients with severe episodic hypertension and tachycardia. The rapid development of CHF with reduced left ventricular function in the absence of a clear etiology should raise suspicion of a viral cardiomyopathy, especially in younger patients. This can be suspected if the patient had a recent viral syndrome over the past several weeks, followed by a progression of dyspnea and CHF. Findings on cardiac biopsy show mostly an acute inflammatory reaction, and since therapy is generally supportive, an endomyocardial biopsy will not alter treatment or prognosis. Therapy for viral cardiomyopathy and CHF consists of supportive therapy and the use of beta blockers, diuretics, ACE inhibitors, and if failure is advanced (class III and IV), spironolactone.

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