Chronic heart failure: Difference between revisions
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== |
==Background== |
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===Definition=== |
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* A syndrome of volume overload and poor tissue perfusion that is caused by cardiac dysfunction and is characterized by dyspnea, fatigue, and edema |
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* Two broad types: |
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** Heart failure with reduced ejection fraction <40% (HFrEF or systolic dysfunction) |
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** Heart failure with preserved ejection fraction (HFpEF or diastolic dysfunction) |
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*A syndrome of volume overload and poor tissue perfusion that is caused by cardiac dysfunction and is characterized by dyspnea, fatigue, and edema |
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== Stages == |
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=== Classification by LVEF === |
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* '''Stage A:''' no structural heart disease or symptoms but high risk for developing HF (e.g., patients with diabetes mellitus or hypertension) |
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{| class="wikitable sortable" |
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* '''Stage B:''' structural heart disease without symptoms of HF (e.g., patients with a previous MI and asymptomatic LV dysfunction) |
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!LVEF |
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* '''Stage C:''' structural heart disease with symptoms of HF (e.g., patients with a previous MI with dyspnea and fatigue) |
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!Classification |
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* '''Stage D:''' refractory HF requiring special interventions (e.g., patients with refractory HF who are awaiting cardiac transplantation). |
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|- |
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|≤40% |
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|Heart failure with reduced ejection fraction (HFrEF) |
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|- |
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|≤40% that improves >40% on repeat |
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|Heart failure with improved ejection fraction (HFimpEF) |
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|- |
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|41-49% |
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|Heart failure with mildly reduced ejection fraction (HFmrEF) |
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|- |
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|≥50% |
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|Heart failure with preserved ejection fraction (HFpEF) |
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|} |
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== |
===Stages=== |
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*'''Stage A:''' no structural heart disease or symptoms but high risk for developing HF (e.g., patients with [[diabetes mellitus]] or [[hypertension]]) |
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* HFrEF |
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*'''Stage B:''' structural heart disease without symptoms of HF (e.g., patients with a previous MI and asymptomatic LV dysfunction) |
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** Coronary artery disease |
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*'''Stage C:''' structural heart disease with symptoms of HF (e.g., patients with a previous MI with dyspnea and fatigue) |
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** Myocardial infarction |
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*'''Stage D:''' refractory HF requiring special interventions (e.g., patients with refractory HF who are awaiting cardiac transplantation). |
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** Hypertension |
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* HFpEF |
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** Myocardial infarction |
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** Hypertension |
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===Etiologies=== |
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== Differential Diagnosis == |
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====By Subtype==== |
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* Common |
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** Tachyarrhythmia |
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** Valvular disease |
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** If CAD risk factors: |
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*** Coronary artery disease |
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*** Hypertensive cardiomyopathy |
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* Other risks |
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** Toxic agents: alcohol, amphetamines, cocaine, steroids, chemotherapy, heavy metals, radiation |
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** Pregnancy: PPCM, pre-eclampsia, gestational diabetes |
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** Inflammatory or infectious: myocarditis, sarcoidosis, infectious hypereosinophilia, giant celll lymphocytic, auto-immune diseases |
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** Metabolic: diabetes, thyroid disease, adrenal insufficiency, pheochromocytoma, Cushing disease |
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** Nutritional: thiamine deficiency, selenium deficiency, malnutrition, obesity |
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** Infiltrative: amyloidosis, glycogen storage disease, Fabry disease |
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** Hereditary: hypertrophic cardiomyopathy, ARVC, LV noncompaction, hemochromatosis |
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** Acute respiratory distress syndrome (ARDS) |
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*Reduced ejection fraction (LVEF ≤40%) |
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== Epidemiology == |
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**[[Coronary artery disease]] (most common) |
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**[[Hypertension]] (most common) |
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**[[Myocarditis]], including viral infection |
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**Chronic alcohol use |
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**[[Valvular heart disease]] |
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**[[Chemotherapy]], such as [[doxorubicin]] or [[trastuzumab]] |
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**[[Peripartum cardiomyopathy]] |
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**[[Idiopathic dilated cardiomyopathy]] |
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**Genetic causes of [[cardiomyopathy]] |
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*Preserved ejection fraction (LVEF ≥50%) |
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**[[Hypertension]] (most common) |
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**[[Myocardial infarction]] |
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*Mildly reduced ejection fraction (LVEF 41-49%) |
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====By Cardiomyopathy==== |
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* 6-10% of people over age 65 |
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*Dilated cardiomyopathy: toxins (alcohol, cocaine, chemotherapy), myocarditis, [[Chagas disease]], [[peripartum cardiopmyopathy]], familial cardiomyopathies |
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== Risk Factors == |
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*Hypertrophic cardiomyopathy: [[hypertension]] |
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*Restrictive cardiomyopathy |
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*Arrhythmogenic right ventricular cardiomyopathy |
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*Unclassified cardiomyopathy: [[Takotsubo cardiomyopathy]], [[non-compaction cardiomyopathy]] |
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====By Risk Factor==== |
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* Previous episode of acute heart failure |
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* Prior atrial fibrillation or coronary bypass surgery |
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* Myocardial infarction |
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* Coronary artery disease |
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* Diabetes |
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* Hypertension |
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*Common |
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== Clinical Presentation == |
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**Tachyarrhythmia |
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**Valvular heart disease |
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**If CAD risk factors: |
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***[[Coronary artery disease]] |
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***Hypertensive cardiomyopathy |
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*Other risks |
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**Toxic agents: alcohol, amphetamines, cocaine, steroids, chemotherapy, heavy metals, radiation |
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**Pregnancy: [[PPCM]], [[pre-eclampsia]], [[gestational diabetes]] |
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**Inflammatory or infectious: [[myocarditis]], [[sarcoidosis]], infectious hypereosinophilia, giant cell lymphocytic, auto-immune diseases |
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**Metabolic: [[Diabetes mellitus|diabetes]], thyroid disease, [[adrenal insufficiency]], [[pheochromocytoma]], [[Cushing disease]] |
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**Nutritional: [[thiamine deficiency]], [[selenium deficiency]], malnutrition, obesity |
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**Infiltrative: [[amyloidosis]], glycogen storage disease, [[Fabry disease]] |
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**Hereditary: [[hypertrophic obstructive cardiomyopathy]], ARVC, LV noncompaction, [[hereditary hemochromatosis]] |
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**[[Acute respiratory distress syndrome]] (ARDS) |
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=== |
===Epidemiology=== |
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* |
*6-10% of people over age 65 |
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* Dyspnea on exertion |
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* Paroxysmal nocturnal dyspnea |
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* Orthopnea |
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* Fatigue |
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* Determine [[NYHA classification of functional status]] |
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=== |
===Risk Factors=== |
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*Previous episode of [[acute heart failure]] |
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* Cardiac exam: S3 present, abdominojugular reflux, elevated JVP |
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*Prior [[atrial fibrillation]] or [[coronary artery bypass surgery]] |
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* Respiratory exam: crackles/rales |
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*[[Myocardial infarction]] |
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* Lower extremity edema |
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*[[Coronary artery disease]] |
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*[[Diabetes mellitus]] |
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*[[Hypertension]] |
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==Clinical Manifestations== |
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{| |
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===History=== |
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*History of heart failure, MI, or CAD |
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*Dyspnea on exertion |
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*Paroxysmal nocturnal dyspnea |
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*Orthopnea |
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*Fatigue |
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*Determine [[NYHA classification of functional status]] |
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===Signs & Symptoms=== |
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*Cardiac exam: S3 present, abdominojugular reflux, elevated JVP |
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*Respiratory exam: crackles/rales |
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*Lower extremity edema |
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{| class="wikitable" |
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! |
! |
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! |
!Dry |
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! |
!Wet |
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|- |
|- |
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| |
|Warm |
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| |
|Less congested<br />Better-perfused |
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| |
|More congested<br />Better-perfused |
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|- |
|- |
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|Cold |
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|Less congested<br />Poorly perfused |
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|Less congested<br />Poorly perfused |
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|} |
|} |
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===Prognosis=== |
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== Investigations == |
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*Following an admission, 25% risk of 30-day readmission and 37% 1-year mortality |
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* Lab |
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*3-year all-cause mortality is 24% in HFpEF and 32% in HFrEF |
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** Troponins |
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*Sudden cardiac death is the cause of 50% of deaths |
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** Natriuretic peptide (if diagnosis uncertain) |
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*Many risk calculators exist, including the [http://www.heartfailurerisk.org/ MAGICC risk score] |
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*** NT-proBNP > 450 pg/mL if age < 50 years and > 900 pg/mL if age > 50 years; <100 pg/mL helps rule it out |
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* Imaging |
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** Chest X-ray showing pulmonary venous or interstitial edema, cardiomegaly, or pleural effusions |
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* Other |
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** EKG showing new atrial fibrillation, ischemic changes, or any other abnormality |
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** Echocardiography |
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*** Systolic heart failure |
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**** Reduced LV ejection fraction (LVEF) |
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*** Diastolic heart failure |
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**** E/A ratio less than 1 |
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**** MV deceleration time > 220ms |
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== |
==Investigations== |
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*Lab |
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=== Acute heart failure === |
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**Troponins |
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**B-type natriuretic peptide |
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***NT-proBNP > 450 pg/mL if age < 50 years and > 900 pg/mL if age > 50 years; <100 pg/mL helps rule it out |
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***Can be used in diagnosis of heart failure as a cause of dyspnea |
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***Can also be used for risk stratification in patients with chronic HF and prognosis in patients admitted for HF |
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***Predischarge BNP can also help with ongoing management |
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**Routine initial investigations: CBC, urinalysis, electrolytes, creatinine, glucose, lipid panel, liver panel, iron studies, TSH |
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*Imaging |
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**Chest X-ray showing pulmonary venous or interstitial edema, cardiomegaly, or pleural effusions |
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*Other |
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**EKG showing new atrial fibrillation, ischemic changes, or any other abnormality |
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**Echocardiography |
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***Systolic heart failure |
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****Reduced LV ejection fraction (LVEF) |
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***Diastolic heart failure |
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****E/A ratio less than 1 |
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****MV deceleration time > 220ms |
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==Management== |
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See also [[Acute heart failure management]] |
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*See also [[Acute heart failure#Management|Acute heart failure management]] |
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* Position the patient upright, ideally with legs over bed to aid venous pooling and decrease preload |
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* Supplemental oxygen, stepping up from nasal prongs to face mask to BiPAP to intubation and ventilation, as necessary |
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* Furosemide IV 40-80mg depending on severity, for volume reduction; or infusion 5-20mg/h |
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* Fluid and salt restrict |
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* Monitor urine output |
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* Monitor daily weights |
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** Target 1kg (0.5-1.5) weight loss with 3L urine output daily |
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* Can escalate up to 20mg/h furosemide with 5mg BID metolazone |
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* SBP < 90 / MAP < 60 |
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** Consider dopamine or other vasopressor |
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** Consider dobutamine |
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* SBP 90-100 / MAP 60-65: |
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** Consider PA catheter |
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** Consider dobutamine or milrinone |
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* SBP >100 or MAP>65 |
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** Nitroglycerin transdermal patch 0.4-0.8mg/h, for afterload reduction |
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** Alternate: nitroglycerin infusion titrated to maintain BP |
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* Supportive care with morphine or hydromorphone, for pain and dyspnea |
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* At discharge: |
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** Document weight (should be lower than admission) |
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** Document BNP (should be lower than admission) |
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* HFpEF |
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** Control blood pressure (most common cause is hypertension) |
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** ACEi/ARB, especially candesartan, is probably best for ACEi |
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** Consider aldosterone antagonist |
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** Monitor and maintain volume status |
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* Advanced HF therapies (mechanical support, transplant) |
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** LVEF <25% |
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** End-organ dysfunction |
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** Recurrent hospitalizations 2x/12months unexplained |
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** Unable to tolerate medical therapies, including hypotension |
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** Diuretic refractory |
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** Inotropic support |
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** Pulmonary hypertension and right heart failure |
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** Six-minute walk test <300m |
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** Increased 1yr mortality >20% |
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** Renal or hepatic dysfunction |
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** Chronic hyponatremia <134 chronically |
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** Cardiac cachexia |
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** Unable to tolerate ADLs |
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===Non-Pharmacologic Management=== |
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=== Chronic heart failure === |
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*Consider referral to multidisciplinary outpatient clinic |
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==== Non-pharmacologic management ==== |
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*Diet |
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**No-added-salt diet (2-3 g/day); 1-2g/day if severe fluid retention |
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**Fluid limited to 1.5 L/day to 2 L/day from all sources, if diuretics fail |
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*Exercise: regular exercise 3-5 times a week for 30-45 min per session (after stress test) |
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*Lifestyle |
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**Smoking cessation |
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**Decrease or eliminate alcohol intake |
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*Monitor body weight regularly for sudden increases (e.g. 2 kg increase in 3 days) |
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*Pneumococcal and annual influenza vaccines |
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*Avoid, when possible: NSAIDs (including COX-2 inhibitors), glucocorticoids, class I antiarrhythmics, sotalol and ibutilide,TCAs, dronedarone, verapamil and diltiazem (except in HFpEF), α-blockers, moxonidine, metformin, thiazolidinediones, anthracyclines |
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===Manage Comorbidities=== |
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* Regular exercise 3-5 times a week for 30-45 min per session (after stress test) |
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* No-added-salt diet (2-3 g/day); 1-2g/day if severe fluid retention |
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* Fluid limited to 1.5 L/day to 2 L/day from all sources, if diuretics fail |
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* Consider referral to multidisciplinary outpatient clinic |
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*Replace iron-deficiency with IV iron (improves quality of life) |
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==== Comorbidities ==== |
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*Avoid treating diabetes with glitazones, prefer SGLT-2 inhibitors |
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*Treat hypertension, especially in HFpEF |
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===Pharmacologic Treatments=== |
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*Treat cardiovascular risk factors (hypertension, dyslipidemia, atherosclerotic disease) |
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**Previous MI: [[ASA]] 81 mg PO daily if indicated for secondary prevention |
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**[[Atrial fibrillation]]: [[warfarin]] or other anticoagulation |
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==== HFrEF ==== |
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*For symptomatic HFrEF ≤40%, the overall approach is '''quadruple therapy: ARNI or ACEi/ARB, β-blockers, aldosterone agonists, and SGLT2 inhibitors''' |
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**Start with β-blocker plus SGLT2i, then ARNI, then MRA, so that they are on all four after a few weeks |
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***SGLT2i has very quick benefit, regardless of diabetes, and should be started early |
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***ARNIs have diuretic effect, so may need to decrease [[furosemide]] |
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**Titrate up every 4 to 8 weeks |
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**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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*Reassess NYHA class after maximizing treatment |
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**NYHA I: continue |
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**NYHA II-IV and sinus rhythm with resting HR ≥70: consider adding [[ivabradine]] |
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**NYHA III/IV: consider referral for advanced HF therapies including mechanical supprot |
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*Reassess LVEF after maximizing treatment |
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**If NYHA I-III and LVEF ≤35%: consider ICD/CRT |
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**NYHA IV: consider [[hydralazine]]/[[nitrates]], referral for mechanical support or transplant, refer to palliative care |
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*If congestive symptoms: |
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**First-line: loop diuretic at lowest minimal dose required to control symptoms |
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**Second-line: consider adding [[Thiazides|thiazide]] or low-dose [[metolazone]] |
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**Last-line: consider adding [[digoxin]] if severe symptoms or poorly-controlled [[atrial fibrillation]] |
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===== SGLT2 Inhibitors ===== |
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*Contraindicated in GFR <25ish (depending on agent) |
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*Increased risk of genital mycotic infections |
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====Doses==== |
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{| class="wikitable" |
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!Medication |
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!Starting Dose |
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!Titration |
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!Usual Dose |
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!Notes |
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|- |
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! colspan="5" |Diuretics: Loop |
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|- |
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|[[furosemide]] |
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|20-40 mg/d |
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| |
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|40-240 mg/d |
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| |
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|- |
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|[[torasemide]] |
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|5-10 mg/d |
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| |
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|10-20 mg/d |
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| |
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|- |
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! colspan="5" |Diuretics: Thiazide-Like |
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|- |
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|[[chlorthalidone]] |
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|12.5-25 mg/d |
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| |
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|25-100 mg/d |
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| |
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|- |
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|[[hydrochlorothiazide]] |
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|25 mg/d |
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| |
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|12.5-100 mg/d |
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| |
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|- |
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|[[indapamide]] |
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|2.5 mg/d |
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| |
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|2.5-5 mg/d |
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| |
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|- |
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! colspan="5" |Diuretics: Potassium-Sparing |
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|- |
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|[[amiloride]] |
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|2.5 mg/d |
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| |
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|5-10 mg/d |
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| |
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|- |
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|[[eplerenone]] |
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|25 mg/d |
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| |
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|50 mg/d |
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| |
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|- |
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|[[spirolonactone]] |
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|12.5-25 mg/d |
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| |
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|50 mg/d |
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| |
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|- |
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! colspan="5" |β-Blockers |
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|- |
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|[[bisoprolol]] |
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|1.25 mg daily |
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|2.5, 3.75, 5, 7, 10 |
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| |
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| |
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|- |
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|[[carvedilol]] |
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|3.125 mg bid |
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|6.25, 12.5, 25, 50 |
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| |
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| |
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|- |
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|[[metoprolol succinate]] CR |
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|12.5-25 mg daily |
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|25, 50, 100, 200 |
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| |
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| |
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|- |
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! colspan="5" |Angiotensin Antagonists: ACE Inhibitors |
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|- |
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|[[enalapril]] |
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|2.5 mg bid |
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| |
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|10-20 mg bid |
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| |
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|- |
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|[[captopril]] |
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|6.25 mg tid |
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| |
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|50 mg tid |
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| |
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|- |
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|[[lisinopril]] |
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|2.5-5 mg daily |
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| |
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|20-35 mg daily |
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| |
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|- |
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|[[ramipril]] |
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|2.5 mg daily |
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| |
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|5 mg daily |
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| |
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|- |
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|[[trandolapril]] |
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|0.5 mg daily |
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| |
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|4 mg daily |
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| |
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|- |
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! colspan="5" |Angiotensin Antagonists: ARBs |
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|- |
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|[[candesartan]] |
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|4-8 mg daily |
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| |
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|32 mg daily |
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| |
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|- |
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|[[valsartan]] |
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|40 mg bid |
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| |
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|160 mg bid |
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| |
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|- |
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|[[losartan]] |
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|50 mg daily |
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| |
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|150 mg daily |
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| |
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|- |
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! colspan="5" |Angiotensin Antagonists: ARB/ARNI |
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|- |
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|[[valsartan/sacubitril]] |
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|24/26 mg bid to 49/51 mg bid |
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| |
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|97/103 mg bid |
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|If on ACEi, need 36 hour washout period before starting |
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|- |
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! colspan="5" |SGLT2 Inhibitors |
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|- |
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|[[dapagliflozin]] |
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|10 mg daily |
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| |
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|10 mg daily |
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| |
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|- |
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|[[empagliflozin]] |
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|10 mg daily |
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| |
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|10 mg daily |
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| |
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|- |
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! colspan="5" |Others |
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|- |
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|ISDN and hydralazine |
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|20-30 mg and 25-50 mg tid to qid |
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| |
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|120 mg TDD and 300 mg TDD |
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| |
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|- |
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|[[ivabradine]] |
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|5 mg bid |
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| |
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|7.5 mg bid |
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| |
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|- |
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|[[vericiguat]] |
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|2.5 mg daily |
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| |
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|10 mg daily |
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| |
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|- |
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|[[digoxin]] |
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|0.125-0.25 mg daily |
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| |
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|serum concentration 0.5-0.9 ng/mL |
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| |
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|} |
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===Procedures=== |
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* Replace iron-deficiency with IV iron (improves quality of life) |
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* Avoid treating diabetes with glitazones, prefer SGLT-2 inhibitors |
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* Treat hypertension, especially in HFpEF |
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*Cardiac resynchronization therapy is indicated when LVEF<30%, LBBB, and QRS > 150ms |
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==== Pharmacologic treatments ==== |
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*Devices |
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**ICD if EF <35% |
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**CRT +/- ICD if reduced EF and LBBB |
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*Implantable hemodynamic monitor (CardioMEMS) |
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**Pulmonary artery pressure sensor |
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**Better than daily weights for predicting heart failure exacerbations |
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**Reduces hospitalizations by 30% |
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**Studied in HFpEF and HFrEF |
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**Expensive! $20k |
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*Surgery: see advanced therapies, below |
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===Advanced Therapies=== |
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* Treat cardiovascular risk factors (hypertension, dyslipidemia, atherosclerotic disease) |
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** Previous MI: ASA 81mg po daily if indicated for secondary prevention |
|||
** Atrial fibrillation: warfarin or other anticoagulation |
|||
* Overall approach is triple therapy: ACEi, beta-blockers, aldosterone agonists |
|||
* Reassess NYHA class after maximizing treatment |
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** NYHA I: continue |
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** NYHA II-IV and sinus rhythm with HR ≥70: add ivabradine and switch ACEi to ARNI (Entresto) |
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** NYHA II-IV and sinus rhythm with HR < 70bpm or AF or pacemaker: switch ACEi to ARNI (Entresto) |
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* Reassess LVEF |
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** If NYHA I-III and LVEF ≤35%: consider ICD/CRT |
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** NYHA IV: consider hydralazine/nitrates, referral for mechanical support or transplant, refer to palliative care |
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* HFrEF: |
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** First-line: ACE inhibitor (second-line: ARB) |
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** First-line: beta-blocker (second-line: CCB) |
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*** Titrate slowly, doubling dose q2-4 weeks |
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*** Objective improvement may take 6-12 months |
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** If severe symptoms and LVEF<30%: aldosterone antagonist |
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** If African-American: consider adding ISDN |
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** If congestive symptoms: |
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*** 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 |
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* Monitor blood pressure while titrating up medication |
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*Consider advanced therapies such as [[left ventricular assist device]] or [[cardiac transplantation]] when heart failure is severe and refractory |
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==== Procedures ==== |
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*Possible indications include: |
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**LVEF <25% |
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**End-organ dysfunction |
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**Recurrent hospitalizations 2x/12months unexplained |
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**Unable to tolerate medical therapies, including hypotension |
|||
**Diuretic refractory |
|||
**Inotropic support |
|||
**Pulmonary hypertension and right heart failure |
|||
**Six-minute walk test <300m |
|||
**Increased 1yr mortality >20% |
|||
**Renal or hepatic dysfunction |
|||
**Chronic hyponatremia <134 chronically |
|||
**Cardiac cachexia |
|||
**Unable to tolerate ADLs |
|||
=== HFpEF === |
|||
* Cardiac resynchronization therapy is indicated when LVEF<30%, LBBB, and QRS > 150ms |
|||
* Devices |
|||
** ICD if EF <35% |
|||
** CRT +/- ICD if reduced EF and LBBB |
|||
* Implantable hemodynamic monitor (CardioMEMS) |
|||
** Pulmonary artery pressure sensor |
|||
** Better than daily weights for predicting heart failure exacerbations |
|||
** Reduces hospitalizations by 30% |
|||
** Studied in HFpEF and HFrEF |
|||
** Expensive! $20k |
|||
* Surgery |
|||
** Ventricular assist devices |
|||
** CABG |
|||
** Transplant |
|||
* Manage risk factors: |
|||
== Prognosis == |
|||
** Treat [[hypertension]] |
|||
** Treat [[atrial fibrillation]] |
|||
* '''SGLT2 inhibitors''' decrease hospitalizations and cardiovascular mortality |
|||
* In some patients with LVEF at the lower end: mineralocorticoid agonists and ARBs (or even ARNi) |
|||
* Diuretics as needed |
|||
==Prognosis== |
|||
* 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 IV have a 30--70% annual mortality rate |
|||
* [https://www.mdcalc.com/maggic-risk-calculator-heart-failure MAGGIC risk score] |
|||
** Estimates 1 and 3 year survival |
|||
*30-40% of patients die within 1 year of diagnosis and 60-70% die within 5 years |
|||
== Palliative Care == |
|||
*NYHA II have a 5-10% annual mortality rate |
|||
*NYHA IV have a 30-70% annual mortality rate |
|||
*[https://www.mdcalc.com/maggic-risk-calculator-heart-failure MAGGIC risk score] |
|||
**Estimates 1 and 3 year survival |
|||
== |
==Further Reading== |
||
* |
*[http://accessmedicine.mhmedical.com.myaccess.library.utoronto.ca/content.aspx?bookid=331§ionid=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] |
||
[[Category:Cardiology]] |
[[Category:Cardiology]] |
Latest revision as of 16:20, 9 December 2024
Background
Definition
- A syndrome of volume overload and poor tissue perfusion that is caused by cardiac dysfunction and is characterized by dyspnea, fatigue, and edema
Classification by LVEF
LVEF | Classification |
---|---|
≤40% | Heart failure with reduced ejection fraction (HFrEF) |
≤40% that improves >40% on repeat | Heart failure with improved ejection fraction (HFimpEF) |
41-49% | Heart failure with mildly reduced ejection fraction (HFmrEF) |
≥50% | Heart failure with preserved ejection fraction (HFpEF) |
Stages
- 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 C: structural heart disease with symptoms of HF (e.g., patients with a previous MI with dyspnea and fatigue)
- Stage D: refractory HF requiring special interventions (e.g., patients with refractory HF who are awaiting cardiac transplantation).
Etiologies
By Subtype
- Reduced ejection fraction (LVEF ≤40%)
- Coronary artery disease (most common)
- Hypertension (most common)
- Myocarditis, including viral infection
- Chronic alcohol use
- Valvular heart disease
- Chemotherapy, such as doxorubicin or trastuzumab
- Peripartum cardiomyopathy
- Idiopathic dilated cardiomyopathy
- Genetic causes of cardiomyopathy
- Preserved ejection fraction (LVEF ≥50%)
- Hypertension (most common)
- Myocardial infarction
- Mildly reduced ejection fraction (LVEF 41-49%)
By Cardiomyopathy
- Dilated cardiomyopathy: toxins (alcohol, cocaine, chemotherapy), myocarditis, Chagas disease, peripartum cardiopmyopathy, familial cardiomyopathies
- Hypertrophic cardiomyopathy: hypertension
- Restrictive cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy
- Unclassified cardiomyopathy: Takotsubo cardiomyopathy, non-compaction cardiomyopathy
By Risk Factor
- Common
- Tachyarrhythmia
- Valvular heart disease
- If CAD risk factors:
- Coronary artery disease
- Hypertensive cardiomyopathy
- Other risks
- Toxic agents: alcohol, amphetamines, cocaine, steroids, chemotherapy, heavy metals, radiation
- Pregnancy: PPCM, pre-eclampsia, gestational diabetes
- Inflammatory or infectious: myocarditis, sarcoidosis, infectious hypereosinophilia, giant cell lymphocytic, auto-immune diseases
- Metabolic: diabetes, thyroid disease, adrenal insufficiency, pheochromocytoma, Cushing disease
- Nutritional: thiamine deficiency, selenium deficiency, malnutrition, obesity
- Infiltrative: amyloidosis, glycogen storage disease, Fabry disease
- Hereditary: hypertrophic obstructive cardiomyopathy, ARVC, LV noncompaction, hereditary hemochromatosis
- Acute respiratory distress syndrome (ARDS)
Epidemiology
- 6-10% of people over age 65
Risk Factors
- Previous episode of acute heart failure
- Prior atrial fibrillation or coronary artery bypass surgery
- Myocardial infarction
- Coronary artery disease
- Diabetes mellitus
- Hypertension
Clinical Manifestations
History
- History of heart failure, MI, or CAD
- Dyspnea on exertion
- Paroxysmal nocturnal dyspnea
- Orthopnea
- Fatigue
- Determine NYHA classification of functional status
Signs & Symptoms
- Cardiac exam: S3 present, abdominojugular reflux, elevated JVP
- Respiratory exam: crackles/rales
- Lower extremity edema
Dry | Wet | |
---|---|---|
Warm | Less congested Better-perfused |
More congested Better-perfused |
Cold | Less congested Poorly perfused |
Less congested Poorly perfused |
Prognosis
- 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
- Sudden cardiac death is the cause of 50% of deaths
- Many risk calculators exist, including the MAGICC risk score
Investigations
- Lab
- Troponins
- B-type natriuretic peptide
- NT-proBNP > 450 pg/mL if age < 50 years and > 900 pg/mL if age > 50 years; <100 pg/mL helps rule it out
- Can be used in diagnosis of heart failure as a cause of dyspnea
- Can also be used for risk stratification in patients with chronic HF and prognosis in patients admitted for HF
- Predischarge BNP can also help with ongoing management
- Routine initial investigations: CBC, urinalysis, electrolytes, creatinine, glucose, lipid panel, liver panel, iron studies, TSH
- Imaging
- Chest X-ray showing pulmonary venous or interstitial edema, cardiomegaly, or pleural effusions
- Other
- EKG showing new atrial fibrillation, ischemic changes, or any other abnormality
- Echocardiography
- Systolic heart failure
- Reduced LV ejection fraction (LVEF)
- Diastolic heart failure
- E/A ratio less than 1
- MV deceleration time > 220ms
- Systolic heart failure
Management
- See also Acute heart failure management
Non-Pharmacologic Management
- Consider referral to multidisciplinary outpatient clinic
- Diet
- No-added-salt diet (2-3 g/day); 1-2g/day if severe fluid retention
- Fluid limited to 1.5 L/day to 2 L/day from all sources, if diuretics fail
- Exercise: regular exercise 3-5 times a week for 30-45 min per session (after stress test)
- Lifestyle
- Smoking cessation
- Decrease or eliminate alcohol intake
- Monitor body weight regularly for sudden increases (e.g. 2 kg increase in 3 days)
- Pneumococcal and annual influenza vaccines
- Avoid, when possible: NSAIDs (including COX-2 inhibitors), glucocorticoids, class I antiarrhythmics, sotalol and ibutilide,TCAs, dronedarone, verapamil and diltiazem (except in HFpEF), α-blockers, moxonidine, metformin, thiazolidinediones, anthracyclines
Manage Comorbidities
- Replace iron-deficiency with IV iron (improves quality of life)
- Avoid treating diabetes with glitazones, prefer SGLT-2 inhibitors
- Treat hypertension, especially in HFpEF
Pharmacologic Treatments
- Treat cardiovascular risk factors (hypertension, dyslipidemia, atherosclerotic disease)
- Previous MI: ASA 81 mg PO daily if indicated for secondary prevention
- Atrial fibrillation: warfarin or other anticoagulation
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-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
- ARNIs have diuretic effect, so may need to decrease furosemide
- 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
- Start with β-blocker plus SGLT2i, then ARNI, then MRA, so that they are on all four after a few weeks
- Reassess NYHA class after maximizing treatment
- NYHA I: continue
- NYHA II-IV and sinus rhythm with resting HR ≥70: consider adding ivabradine
- NYHA III/IV: consider referral for advanced HF therapies including mechanical supprot
- Reassess LVEF after maximizing treatment
- 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
- 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
SGLT2 Inhibitors
- Contraindicated in GFR <25ish (depending on agent)
- Increased risk of genital mycotic infections
Doses
Medication | Starting Dose | Titration | Usual Dose | Notes |
---|---|---|---|---|
Diuretics: Loop | ||||
furosemide | 20-40 mg/d | 40-240 mg/d | ||
torasemide | 5-10 mg/d | 10-20 mg/d | ||
Diuretics: Thiazide-Like | ||||
chlorthalidone | 12.5-25 mg/d | 25-100 mg/d | ||
hydrochlorothiazide | 25 mg/d | 12.5-100 mg/d | ||
indapamide | 2.5 mg/d | 2.5-5 mg/d | ||
Diuretics: Potassium-Sparing | ||||
amiloride | 2.5 mg/d | 5-10 mg/d | ||
eplerenone | 25 mg/d | 50 mg/d | ||
spirolonactone | 12.5-25 mg/d | 50 mg/d | ||
β-Blockers | ||||
bisoprolol | 1.25 mg daily | 2.5, 3.75, 5, 7, 10 | ||
carvedilol | 3.125 mg bid | 6.25, 12.5, 25, 50 | ||
metoprolol succinate CR | 12.5-25 mg daily | 25, 50, 100, 200 | ||
Angiotensin Antagonists: ACE Inhibitors | ||||
enalapril | 2.5 mg bid | 10-20 mg bid | ||
captopril | 6.25 mg tid | 50 mg tid | ||
lisinopril | 2.5-5 mg daily | 20-35 mg daily | ||
ramipril | 2.5 mg daily | 5 mg daily | ||
trandolapril | 0.5 mg daily | 4 mg daily | ||
Angiotensin Antagonists: ARBs | ||||
candesartan | 4-8 mg daily | 32 mg daily | ||
valsartan | 40 mg bid | 160 mg bid | ||
losartan | 50 mg daily | 150 mg daily | ||
Angiotensin Antagonists: ARB/ARNI | ||||
valsartan/sacubitril | 24/26 mg bid to 49/51 mg bid | 97/103 mg bid | If on ACEi, need 36 hour washout period before starting | |
SGLT2 Inhibitors | ||||
dapagliflozin | 10 mg daily | 10 mg daily | ||
empagliflozin | 10 mg daily | 10 mg daily | ||
Others | ||||
ISDN and hydralazine | 20-30 mg and 25-50 mg tid to qid | 120 mg TDD and 300 mg TDD | ||
ivabradine | 5 mg bid | 7.5 mg bid | ||
vericiguat | 2.5 mg daily | 10 mg daily | ||
digoxin | 0.125-0.25 mg daily | serum concentration 0.5-0.9 ng/mL |
Procedures
- Cardiac resynchronization therapy is indicated when LVEF<30%, LBBB, and QRS > 150ms
- Devices
- ICD if EF <35%
- CRT +/- ICD if reduced EF and LBBB
- Implantable hemodynamic monitor (CardioMEMS)
- Pulmonary artery pressure sensor
- Better than daily weights for predicting heart failure exacerbations
- Reduces hospitalizations by 30%
- Studied in HFpEF and HFrEF
- Expensive! $20k
- Surgery: see advanced therapies, below
Advanced Therapies
- Consider advanced therapies such as left ventricular assist device or cardiac transplantation when heart failure is severe and refractory
- Possible indications include:
- LVEF <25%
- End-organ dysfunction
- Recurrent hospitalizations 2x/12months unexplained
- Unable to tolerate medical therapies, including hypotension
- Diuretic refractory
- Inotropic support
- Pulmonary hypertension and right heart failure
- Six-minute walk test <300m
- Increased 1yr mortality >20%
- Renal or hepatic dysfunction
- Chronic hyponatremia <134 chronically
- Cardiac cachexia
- Unable to tolerate ADLs
HFpEF
- Manage risk factors:
- Treat hypertension
- Treat atrial fibrillation
- SGLT2 inhibitors decrease hospitalizations and cardiovascular mortality
- In some patients with LVEF at the lower end: mineralocorticoid agonists and ARBs (or even ARNi)
- Diuretics as needed
Prognosis
- 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 IV have a 30-70% annual mortality rate
- MAGGIC risk score
- Estimates 1 and 3 year survival