Chronic heart failure - Revision history

Aidan at 16:20, 9 December 2024

2024-12-09T16:20:30Z

← Older revision		Revision as of 16:20, 9 December 2024
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	===Stages===		===Stages===

	*'''Stage A:''' no structural heart disease or symptoms but high risk for developing HF (e.g., patients with diabetes mellitus or hypertension)		*'''Stage A:''' no structural heart disease or symptoms but high risk for developing HF (e.g., patients with [[diabetes mellitus]] or [[hypertension]])
	*'''Stage B:''' structural heart disease without symptoms of HF (e.g., patients with a previous MI and asymptomatic LV dysfunction)		*'''Stage B:''' structural heart disease without symptoms of HF (e.g., patients with a previous MI and asymptomatic LV dysfunction)
	*'''Stage C:''' structural heart disease with symptoms of HF (e.g., patients with a previous MI with dyspnea and fatigue)		*'''Stage C:''' structural heart disease with symptoms of HF (e.g., patients with a previous MI with dyspnea and fatigue)
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	====By Cardiomyopathy====		====By Cardiomyopathy====

	*Dilated cardiomyopathy: toxins (alcohol, cocaine, chemotherapy), myocarditis, Chagas disease, peripartum cardiopmyopathy, familial cardiomyopathies		*Dilated cardiomyopathy: toxins (alcohol, cocaine, chemotherapy), myocarditis, [[Chagas disease]], [[peripartum cardiopmyopathy]], familial cardiomyopathies
	*Hypertrophic cardiomyopathy: hypertension		*Hypertrophic cardiomyopathy: [[hypertension]]
	*Restrictive cardiomyopathy		*Restrictive cardiomyopathy
	*Arrhythmogenic right ventricular cardiomyopathy		*Arrhythmogenic right ventricular cardiomyopathy
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	**Valvular heart disease		**Valvular heart disease
	**If CAD risk factors:		**If CAD risk factors:
	***Coronary artery disease		***[[Coronary artery disease]]
	***Hypertensive cardiomyopathy		***Hypertensive cardiomyopathy
	*Other risks		*Other risks
	**Toxic agents: alcohol, amphetamines, cocaine, steroids, chemotherapy, heavy metals, radiation		**Toxic agents: alcohol, amphetamines, cocaine, steroids, chemotherapy, heavy metals, radiation
	**Pregnancy: PPCM, pre-eclampsia, gestational diabetes		**Pregnancy: [[PPCM]], [[pre-eclampsia]], [[gestational diabetes]]
	**Inflammatory or infectious: myocarditis, sarcoidosis, infectious hypereosinophilia, giant ~~celll~~ lymphocytic, auto-immune diseases		**Inflammatory or infectious: [[myocarditis]], [[sarcoidosis]], infectious hypereosinophilia, giant cell lymphocytic, auto-immune diseases
	**Metabolic: diabetes, thyroid disease, adrenal insufficiency, pheochromocytoma, Cushing disease		**Metabolic: [[Diabetes mellitus\|diabetes]], thyroid disease, [[adrenal insufficiency]], [[pheochromocytoma]], [[Cushing disease]]
	**Nutritional: thiamine deficiency, selenium deficiency, malnutrition, obesity		**Nutritional: [[thiamine deficiency]], [[selenium deficiency]], malnutrition, obesity
	**Infiltrative: amyloidosis, glycogen storage disease, Fabry disease		**Infiltrative: [[amyloidosis]], glycogen storage disease, [[Fabry disease]]
	**Hereditary: hypertrophic cardiomyopathy, ARVC, LV noncompaction, hemochromatosis		**Hereditary: [[hypertrophic obstructive cardiomyopathy]], ARVC, LV noncompaction, [[hereditary hemochromatosis]]
	**Acute respiratory distress syndrome (ARDS)		**[[Acute respiratory distress syndrome]] (ARDS)

	===Epidemiology===		===Epidemiology===
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	===History===		===History===

	*Hx of heart failure, MI, or CAD		*History of heart failure, MI, or CAD
	*Dyspnea on exertion		*Dyspnea on exertion
	*Paroxysmal nocturnal dyspnea		*Paroxysmal nocturnal dyspnea

Aidan at 16:18, 9 December 2024

2024-12-09T16:18:11Z

← Older revision		Revision as of 16:18, 9 December 2024
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	*30-40% of patients die within 1 year of diagnosis and 60-70% die within 5 years		*30-40% of patients die within 1 year of diagnosis and 60-70% die within 5 years
	*NYHA II have a 5-10% annual mortality rate		*NYHA II have a 5-10% annual mortality rate
	*NYHA IV have a 30--70% annual mortality rate		*NYHA IV have a 30-70% annual mortality rate
	*[https://www.mdcalc.com/maggic-risk-calculator-heart-failure MAGGIC risk score]		*[https://www.mdcalc.com/maggic-risk-calculator-heart-failure MAGGIC risk score]
	**Estimates 1 and 3 year survival		**Estimates 1 and 3 year survival

	==Palliative Care==

	==Further Reading==		==Further Reading==

	*[http://accessmedicine.mhmedical.com.myaccess.library.utoronto.ca/content.aspx?bookid=331&sectionid=40727009 Harrison's 19e (Ch 234)]		*[http://accessmedicine.mhmedical.com.myaccess.library.utoronto.ca/content.aspx?bookid=331&sectionid=40727009 Harrison's 19e (Ch 234)]
			*[https://doi.org/10.1161/CIR.0000000000001063 AHA/ACC/HFSA Guidelines 2022]
	*[http://www.ccs.ca/images/Guidelines/Guidelines_POS_Library/HF_CC_2006.pdf CCS Heart Failure Guidelines Update 2006]
	*[https://doi.org/10.1001/jama.294.15.1944 Does this dyspneic patient in the emergency department have congestive heart failure? JAMA RCE 2005]		*[https://doi.org/10.1001/jama.294.15.1944 Does this dyspneic patient in the emergency department have congestive heart failure? JAMA RCE 2005]

Aidan at 05:05, 9 December 2024

2024-12-09T05:05:33Z

@@ Line 4: / Line 4: @@
 *A syndrome of volume overload and poor tissue perfusion that is caused by cardiac dysfunction and is characterized by dyspnea, fatigue, and edema
 ===Stages===
@@ Line 115: / Line 130: @@
 *Lab
 **Troponins
 ***NT-proBNP &gt; 450 pg/mL if age &lt; 50 years and &gt; 900 pg/mL if age &gt; 50 years; &lt;100 pg/mL helps rule it out
 *Imaging
 **Chest X-ray showing pulmonary venous or interstitial edema, cardiomegaly, or pleural effusions
@@ Line 159: / Line 178: @@
 ==== HFrEF ====
-*For symptomatic HFrEF ≤40%, the overall approach is quadruple therapy: ARNI or ACEi/ARB, β-blockers, aldosterone agonists, and SGLT2 inhibitors
+*For symptomatic HFrEF ≤40%, the overall approach is '''quadruple therapy: ARNI or ACEi/ARB, β-blockers, aldosterone agonists, and SGLT2 inhibitors'''
 **Start with β-blocker plus SGLT2i, then ARNI, then MRA, so that they are on all four after a few weeks
 ***SGLT2i has very quick benefit, regardless of diabetes, and should be started early
@@ Line 319: / Line 338: @@
 |-
 |[[valsartan/sacubitril]]
-|24/26 mg bid
+|24/26 mg bid to 49/51 mg bid
+|
 |97/103 mg bid
@@ Line 326: / Line 345: @@
 ! colspan="5" |SGLT2 Inhibitors
 |-
+|
+|
+|
+|
+|
 |}
@@ Line 364: / Line 415: @@
 **Cardiac cachexia
 **Unable to tolerate ADLs
 ==Prognosis==

Aidan: /* Management */

2021-10-20T15:26:18Z

Management

← Older revision		Revision as of 15:26, 20 October 2021
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	==Management==		==Management==

	*See also [[Acute heart failure management]]		*See also [[Acute heart failure#Management\|Acute heart failure management]]

	===Non-Pharmacologic Management===		===Non-Pharmacologic Management===

Aidan at 17:53, 14 October 2021

2021-10-14T17:53:34Z

Show changes

Aidan at 17:28, 14 October 2021

2021-10-14T17:28:56Z

← Older revision		Revision as of 17:28, 14 October 2021
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	====By Subtype====		====By Subtype====

	*~~HFrEF~~ (LVEF ≤40%)		*Reduced ejection fraction (LVEF ≤40%)
	**[[Coronary artery disease]] (most common)		**[[Coronary artery disease]] (most common)
	**[[Hypertension]] (most common)		**[[Hypertension]] (most common)
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	**[[Idiopathic dilated cardiomyopathy]]		**[[Idiopathic dilated cardiomyopathy]]
	**Genetic causes of [[cardiomyopathy]]		**Genetic causes of [[cardiomyopathy]]
	*~~HFpEF~~ (LVEF ≥50%)		*Preserved ejection fraction (LVEF ≥50%)
	**[[Hypertension]] (most common)		**[[Hypertension]] (most common)
	**[[Myocardial infarction]]		**[[Myocardial infarction]]
	*~~HFmrEF~~ (LVEF 41-49%)		*Mildly reduced ejection fraction (LVEF 41-49%)

	====By Cardiomyopathy====		====By Cardiomyopathy====
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	*Common		*Common
	**Tachyarrhythmia		**Tachyarrhythmia
	**Valvular disease		**Valvular heart disease
	**If CAD risk factors:		**If CAD risk factors:
	***Coronary artery disease		***Coronary artery disease
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	**Previous MI: [[ASA]] 81 mg PO daily if indicated for secondary prevention		**Previous MI: [[ASA]] 81 mg PO daily if indicated for secondary prevention
	**[[Atrial fibrillation]]: [[warfarin]] or other anticoagulation		**[[Atrial fibrillation]]: [[warfarin]] or other anticoagulation

⚫	*~~Overall~~ approach is ~~triple~~ therapy: ACEi, β-blockers, aldosterone agonists
			==== HFrEF ====
		⚫	*For symptomatic HFrEF ≤40%, the overall approach is quadruple therapy: ARNI or ACEi/ARB, β-blockers, aldosterone agonists, and SGLT2 inhibitors
			**Start with β-blocked plus SGLT2i, then ARNI, then MRA, so that they are on all four after a few weeks
	**Titrate up every 4 to 8 weeks		**Titrate up every 4 to 8 weeks
	**Monitor renal function and electrolytes 1 and 4 weeks after any increase, then monthly for 2 months, every 3 months for 9 months, and every 4 months indefinitely		**Monitor renal function and electrolytes 1 and 4 weeks after any increase, then monthly for 2 months, every 3 months for 9 months, and every 4 months indefinitely
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	**NYHA II-IV and sinus rhythm with HR ≥70: add [[ivabradine]] and switch ACEi to ARNI (Entresto)		**NYHA II-IV and sinus rhythm with HR ≥70: add [[ivabradine]] and switch ACEi to ARNI (Entresto)
	**NYHA II-IV and sinus rhythm with HR < 70bpm or AF or pacemaker: switch ACEi to ARNI (Entresto)		**NYHA II-IV and sinus rhythm with HR < 70bpm or AF or pacemaker: switch ACEi to ARNI (Entresto)
			**NYHA III/IV, consider referral for advanced HF therapies including mechanical supprot
	*Reassess LVEF
			*Reassess LVEF after maximizing treatment
	**If NYHA I-III and LVEF ≤35%: consider ICD/CRT		**If NYHA I-III and LVEF ≤35%: consider ICD/CRT
	**NYHA IV: consider hydralazine/nitrates, referral for mechanical support or transplant, refer to palliative care		**NYHA IV: consider hydralazine/nitrates, referral for mechanical support or transplant, refer to palliative care
		⚫	*If congestive symptoms:
	*HFrEF:
		⚫	**First-line: loop diuretic at lowest minimal dose required to control symptoms
	**First-line: ACE inhibitor (second-line: ARB; third-line: ARNI)
		⚫	**Second-line: consider adding thiazide or low-dose [[metolazone]]
	**First-line: beta-blocker (second-line: CCB)
		⚫	**Last-line: consider adding digoxin if severe symptoms or poorly-controlled atrial fibrillation
	***Titrate slowly, doubling dose q2-4 weeks
	***Objective improvement may take 6-12 months
	**If NYHA II-IV and LVEF ≤35%: aldosterone antagonist ([[spironolactone]] or [[eplerenone]])
	**If LVEF ≤40%, recent MI, and symptoms or diabetes: aldosterone antagonist
	**If African-American: consider adding ISDN
⚫	**If congestive symptoms:
⚫	***First-line: loop diuretic at lowest minimal dose required to control symptoms
⚫	***Second-line: consider adding thiazide or low-dose [[metolazone]]
⚫	***Last-line: consider adding digoxin if severe symptoms or poorly-controlled atrial fibrillation
	*Monitor blood pressure while titrating up medication

	====Doses====		====Doses====

Aidan: /* Etiologies */

2021-10-09T18:24:33Z

Etiologies

← Older revision		Revision as of 18:24, 9 October 2021
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	====By Subtype====		====By Subtype====

	*HFrEF		*HFrEF (LVEF ≤40%)
	**[[Coronary artery disease]] (most common)		**[[Coronary artery disease]] (most common)
	**[[Hypertension]] (most common)		**[[Hypertension]] (most common)
	**~~Viral~~ infection		**[[Myocarditis]], including viral infection
	**Chronic alcohol use		**Chronic alcohol use
	**[[Valvular heart disease]]		**[[Valvular heart disease]]
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	**[[Idiopathic dilated cardiomyopathy]]		**[[Idiopathic dilated cardiomyopathy]]
	**Genetic causes of [[cardiomyopathy]]		**Genetic causes of [[cardiomyopathy]]
	*HFpEF		*HFpEF (LVEF ≥50%)
	**[[Hypertension]] (most common)		**[[Hypertension]] (most common)
	**[[Myocardial infarction]]		**[[Myocardial infarction]]
			*HFmrEF (LVEF 41-49%)

	====By Cardiomyopathy====		====By Cardiomyopathy====

Aidan: /* Signs & Symptoms */

2021-03-23T19:36:41Z

Signs & Symptoms

← Older revision		Revision as of 19:36, 23 March 2021
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	*Lower extremity edema		*Lower extremity edema

			{\| class="wikitable"
	{\|
	!		!
	!Dry		!Dry

Aidan: /* Prognosis */

2021-02-25T10:54:33Z

Prognosis

← Older revision		Revision as of 10:54, 25 February 2021
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	\|}		\|}

	=== Prognosis ===		===Prognosis===

	* Following an admission, 25% risk of 30-day readmission and 37% 1-year mortality		*Following an admission, 25% risk of 30-day readmission and 37% 1-year mortality
	* 3-year all-cause mortality is 24% in HFpEF and 32% in HFrEF		*3-year all-cause mortality is 24% in HFpEF and 32% in HFrEF
	* Sudden cardiac death is the cause of 50% of deaths		*Sudden cardiac death is the cause of 50% of deaths
			*Many risk calculators exist, including the [http://www.heartfailurerisk.org/ MAGICC risk score]

	==Investigations==		==Investigations==
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	*Monitor blood pressure while titrating up medication		*Monitor blood pressure while titrating up medication

	==== Doses ====		====Doses====
	{\| class="wikitable"		{\| class="wikitable"
	!Medication		!Medication

Aidan: /* Pharmacologic Treatments */

2021-02-22T02:46:34Z

Pharmacologic Treatments

Show changes