Chronic heart failure: Difference between revisions

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== Definition ==
==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
* Two broad types:
** Heart failure with reduced ejection fraction <40% (HFrEF or systolic dysfunction)
** Heart failure with preserved ejection fraction (HFpEF or diastolic dysfunction)


*A syndrome of volume overload and poor tissue perfusion that is caused by cardiac dysfunction and is characterized by dyspnea, fatigue, and edema
== Stages ==


=== Classification by LVEF ===
* '''Stage A:''' no structural heart disease or symptoms but high risk for developing HF (e.g., patients with diabetes mellitus or hypertension)
{| class="wikitable sortable"
* '''Stage B:''' structural heart disease without symptoms of HF (e.g., patients with a previous MI and asymptomatic LV dysfunction)
!LVEF
* '''Stage C:''' structural heart disease with symptoms of HF (e.g., patients with a previous MI with dyspnea and fatigue)
!Classification
* '''Stage D:''' refractory HF requiring special interventions (e.g., patients with refractory HF who are awaiting cardiac transplantation).
|-
|≤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)
|}


== Etiology ==
===Stages===


*'''Stage A:''' no structural heart disease or symptoms but high risk for developing HF (e.g., patients with [[diabetes mellitus]] or [[hypertension]])
* HFrEF
*'''Stage B:''' structural heart disease without symptoms of HF (e.g., patients with a previous MI and asymptomatic LV dysfunction)
** Coronary artery disease
*'''Stage C:''' structural heart disease with symptoms of HF (e.g., patients with a previous MI with dyspnea and fatigue)
** Myocardial infarction
*'''Stage D:''' refractory HF requiring special interventions (e.g., patients with refractory HF who are awaiting cardiac transplantation).
** Hypertension
* HFpEF
** Myocardial infarction
** Hypertension


===Etiologies===
== Differential Diagnosis ==


====By Subtype====
* Common
** Tachyarrhythmia
** Valvular 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 celll 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 cardiomyopathy, ARVC, LV noncompaction, hemochromatosis
** Acute respiratory distress syndrome (ARDS)


*Reduced ejection fraction (LVEF ≤40%)
== Epidemiology ==
**[[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====
* 6-10% of people over age 65


*Dilated cardiomyopathy: toxins (alcohol, cocaine, chemotherapy), myocarditis, [[Chagas disease]], [[peripartum cardiopmyopathy]], familial cardiomyopathies
== Risk Factors ==
*Hypertrophic cardiomyopathy: [[hypertension]]
*Restrictive cardiomyopathy
*Arrhythmogenic right ventricular cardiomyopathy
*Unclassified cardiomyopathy: [[Takotsubo cardiomyopathy]], [[non-compaction cardiomyopathy]]


====By Risk Factor====
* Previous episode of acute heart failure
* Prior atrial fibrillation or coronary bypass surgery
* Myocardial infarction
* Coronary artery disease
* Diabetes
* Hypertension


*Common
== Clinical Presentation ==
**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 mellitus|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)


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


* Hx of heart failure, MI, or CAD
*6-10% of people over age 65
* Dyspnea on exertion
* Paroxysmal nocturnal dyspnea
* Orthopnea
* Fatigue
* Determine [[NYHA classification of functional status]]


=== Signs & Symptoms ===
===Risk Factors===


*Previous episode of [[acute heart failure]]
* Cardiac exam: S3 present, abdominojugular reflux, elevated JVP
*Prior [[atrial fibrillation]] or [[coronary artery bypass surgery]]
* Respiratory exam: crackles/rales
*[[Myocardial infarction]]
* Lower extremity edema
*[[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

{| class="wikitable"
!
!
! Dry
!Dry
! Wet
!Wet
|-
|-
| Warm
|Warm
| Less congested<br/>Better-perfused
|Less congested<br />Better-perfused
| More congested<br/>Better-perfused
|More congested<br />Better-perfused
|-
|-
| Cold
|Cold
| Less congested<br/>Poorly perfused
|Less congested<br />Poorly perfused
| Less congested<br/>Poorly perfused
|Less congested<br />Poorly perfused
|}
|}


===Prognosis===
== Investigations ==


*Following an admission, 25% risk of 30-day readmission and 37% 1-year mortality
* Lab
*3-year all-cause mortality is 24% in HFpEF and 32% in HFrEF
** Troponins
*Sudden cardiac death is the cause of 50% of deaths
** Natriuretic peptide (if diagnosis uncertain)
*Many risk calculators exist, including the [http://www.heartfailurerisk.org/ MAGICC risk score]
*** 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
* 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 &gt; 220ms


== Management ==
==Investigations==


*Lab
=== Acute heart failure ===
**Troponins
**B-type natriuretic peptide
***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
***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 &gt; 220ms


==Management==
See also [[Acute heart failure management]]


*See also [[Acute heart failure#Management|Acute heart failure management]]
* Position the patient upright, ideally with legs over bed to aid venous pooling and decrease preload
* Supplemental oxygen, stepping up from nasal prongs to face mask to BiPAP to intubation and ventilation, as necessary
* Furosemide IV 40-80mg depending on severity, for volume reduction; or infusion 5-20mg/h
* Fluid and salt restrict
* Monitor urine output
* Monitor daily weights
** Target 1kg (0.5-1.5) weight loss with 3L urine output daily
* Can escalate up to 20mg/h furosemide with 5mg BID metolazone
* SBP &lt; 90 / MAP &lt; 60
** Consider dopamine or other vasopressor
** Consider dobutamine
* SBP 90-100 / MAP 60-65:
** Consider PA catheter
** Consider dobutamine or milrinone
* SBP &gt;100 or MAP&gt;65
** Nitroglycerin transdermal patch 0.4-0.8mg/h, for afterload reduction
** Alternate: nitroglycerin infusion titrated to maintain BP
* Supportive care with morphine or hydromorphone, for pain and dyspnea
* At discharge:
** Document weight (should be lower than admission)
** Document BNP (should be lower than admission)
* HFpEF
** Control blood pressure (most common cause is hypertension)
** ACEi/ARB, especially candesartan, is probably best for ACEi
** Consider aldosterone antagonist
** Monitor and maintain volume status
* Advanced HF therapies (mechanical support, transplant)
** LVEF &lt;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 &lt;300m
** Increased 1yr mortality &gt;20%
** Renal or hepatic dysfunction
** Chronic hyponatremia &lt;134 chronically
** Cardiac cachexia
** Unable to tolerate ADLs


===Non-Pharmacologic Management===
=== Chronic heart failure ===


*Consider referral to multidisciplinary outpatient clinic
==== Non-pharmacologic management ====
*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===
* Regular exercise 3-5 times a week for 30-45 min per session (after stress test)
* 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
* Consider referral to multidisciplinary outpatient clinic


*Replace iron-deficiency with IV iron (improves quality of life)
==== Comorbidities ====
*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
*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 [[Thiazides|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====
{| class="wikitable"
!Medication
!Starting Dose
!Titration
!Usual Dose
!Notes
|-
! colspan="5" |Diuretics: Loop
|-
|[[furosemide]]
|20-40 mg/d
|
|40-240 mg/d
|
|-
|[[torasemide]]
|5-10 mg/d
|
|10-20 mg/d
|
|-
! colspan="5" |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
|
|-
! colspan="5" |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
|
|-
! colspan="5" |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
|
|
|-
! colspan="5" |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
|
|-
! colspan="5" |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
|
|-
! colspan="5" |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
|-
! colspan="5" |SGLT2 Inhibitors
|-
|[[dapagliflozin]]
|10 mg daily
|
|10 mg daily
|
|-
|[[empagliflozin]]
|10 mg daily
|
|10 mg daily
|
|-
! colspan="5" |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===
* Replace iron-deficiency with IV iron (improves quality of life)
* Avoid treating diabetes with glitazones, prefer SGLT-2 inhibitors
* Treat hypertension, especially in HFpEF


*Cardiac resynchronization therapy is indicated when LVEF&lt;30%, LBBB, and QRS &gt; 150ms
==== Pharmacologic treatments ====
*Devices
**ICD if EF &lt;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===
* Treat cardiovascular risk factors (hypertension, dyslipidemia, atherosclerotic disease)
** 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
** NYHA I: continue
** 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 &lt; 70bpm or AF or pacemaker: switch ACEi to ARNI (Entresto)
* Reassess LVEF
** 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
* HFrEF:
** First-line: ACE inhibitor (second-line: ARB)
** First-line: beta-blocker (second-line: CCB)
*** Titrate slowly, doubling dose q2-4 weeks
*** Objective improvement may take 6-12 months
** If severe symptoms and LVEF&lt;30%: 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


*Consider advanced therapies such as [[left ventricular assist device]] or [[cardiac transplantation]] when heart failure is severe and refractory
==== Procedures ====
*Possible indications include:
**LVEF &lt;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 &lt;300m
**Increased 1yr mortality &gt;20%
**Renal or hepatic dysfunction
**Chronic hyponatremia &lt;134 chronically
**Cardiac cachexia
**Unable to tolerate ADLs


=== HFpEF ===
* Cardiac resynchronization therapy is indicated when LVEF&lt;30%, LBBB, and QRS &gt; 150ms
* Devices
** ICD if EF &lt;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 ==
==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]


[[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

By Cardiomyopathy

By Risk Factor

Epidemiology

  • 6-10% of people over age 65

Risk Factors

Clinical Manifestations

History

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

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)

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
  • 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:
  • 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

Further Reading