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 ==
  
  +
*Two broad types:
  +
**Heart failure with reduced ejection fraction <40% (HFrEF or systolic dysfunction)
  +
**Heart failure with preserved ejection fraction (HFpEF or diastolic dysfunction)
   
  +
===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).
  
   
  +
*'''Stage A:''' no structural heart disease or symptoms but high risk for developing HF (e.g., patients with diabetes mellitus or hypertension)
−
== Etiology ==
  
  +
*'''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===
−
* HFrEF
  
−
** Coronary artery disease
  
−
** Myocardial infarction
  
−
** Hypertension
  
−
* HFpEF
  
−
** Myocardial infarction
  
−
** Hypertension
  
   
  +
====By Subtype====
−
== Differential Diagnosis ==
  
   
  +
*Reduced ejection fraction (LVEF ≤40%)
−
* Common
  
  +
**[[Coronary artery disease]] (most common)
−
** Tachyarrhythmia
  
  +
**[[Hypertension]] (most common)
−
** Valvular disease
  
  +
**[[Myocarditis]], including viral infection
−
** If CAD risk factors:
  
  +
**Chronic alcohol use
−
*** Coronary artery disease
  
  +
**[[Valvular heart disease]]
−
*** Hypertensive cardiomyopathy
  
  +
**[[Chemotherapy]], such as [[doxorubicin]] or [[trastuzumab]]
−
* Other risks
  
  +
**[[Peripartum cardiomyopathy]]
−
** Toxic agents: alcohol, amphetamines, cocaine, steroids, chemotherapy, heavy metals, radiation
  
  +
**[[Idiopathic dilated cardiomyopathy]]
−
** Pregnancy: PPCM, pre-eclampsia, gestational diabetes
  
  +
**Genetic causes of [[cardiomyopathy]]
−
** Inflammatory or infectious: myocarditis, sarcoidosis, infectious hypereosinophilia, giant celll lymphocytic, auto-immune diseases
  
  +
*Preserved ejection fraction (LVEF ≥50%)
−
** Metabolic: diabetes, thyroid disease, adrenal insufficiency, pheochromocytoma, Cushing disease
  
  +
**[[Hypertension]] (most common)
−
** Nutritional: thiamine deficiency, selenium deficiency, malnutrition, obesity
  
  +
**[[Myocardial infarction]]
−
** Infiltrative: amyloidosis, glycogen storage disease, Fabry disease
  
  +
*Mildly reduced ejection fraction (LVEF 41-49%)
−
** Hereditary: hypertrophic cardiomyopathy, ARVC, LV noncompaction, hemochromatosis
  
−
** Acute respiratory distress syndrome (ARDS)
  
   
  +
====By Cardiomyopathy====
−
== Epidemiology ==
  
   
  +
*Dilated cardiomyopathy: toxins (alcohol, cocaine, chemotherapy), myocarditis, Chagas disease, peripartum cardiopmyopathy, familial cardiomyopathies
−
* 6-10% of people over age 65
  
  +
*Hypertrophic cardiomyopathy: hypertension
  +
*Restrictive cardiomyopathy
  +
*Arrhythmogenic right ventricular cardiomyopathy
  +
*Unclassified cardiomyopathy: [[Takotsubo cardiomyopathy]], [[non-compaction cardiomyopathy]]
   
−
== Risk Factors ==
 +
====By Risk Factor====
   
  +
*Common
−
* Previous episode of acute heart failure
  
  +
**Tachyarrhythmia
−
* Prior atrial fibrillation or coronary bypass surgery
  
  +
**Valvular heart disease
−
* Myocardial infarction
  
  +
**If CAD risk factors:
−
* Coronary artery disease
  
  +
***Coronary artery disease
−
* Diabetes
  
  +
***Hypertensive cardiomyopathy
−
* Hypertension
  
  +
*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)
   
  +
===Epidemiology===
−
== Clinical Manifestations ==
  
   
  +
*6-10% of people over age 65
−
=== History ===
  
   
  +
===Risk Factors===
−
* Hx of heart failure, MI, or CAD
  
−
* Dyspnea on exertion
  
−
* Paroxysmal nocturnal dyspnea
  
−
* Orthopnea
  
−
* Fatigue
  
−
* Determine [[NYHA classification of functional status]]
  
   
  +
*Previous episode of [[acute heart failure]]
−
=== Signs & Symptoms ===
  
  +
*Prior [[atrial fibrillation]] or [[coronary artery bypass surgery]]
  +
*[[Myocardial infarction]]
  +
*[[Coronary artery disease]]
  +
*[[Diabetes mellitus]]
  +
*[[Hypertension]]
   
  +
==Clinical Manifestations==
−
* Cardiac exam: S3 present, abdominojugular reflux, elevated JVP
  
−
* Respiratory exam: crackles/rales
  
−
* Lower extremity edema
  
   
  +
===History===
−
{|
  
  +
  +
*Hx 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
  +
**Natriuretic peptide (if diagnosis uncertain)
  +
***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==
−
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===
−
* Replace iron-deficiency with IV iron (improves quality of life)
  
  +
−
* Avoid treating diabetes with glitazones, prefer SGLT-2 inhibitors
  
−
* Treat hypertension, especially in HFpEF
 +
*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
  +
|
  +
|97/103 mg bid
  +
|If on ACEi, need 36 hour washout period before starting
  +
|-
  +
! colspan="5" |SGLT2 Inhibitors
  +
|-
  +
|
  +
|
  +
|
  +
|
  +
|
  +
|}
   
  +
===Procedures===
−
==== Pharmacologic treatments ====
  
   
  +
*Cardiac resynchronization therapy is indicated when LVEF&lt;30%, LBBB, and QRS &gt; 150ms
−
* Treat cardiovascular risk factors (hypertension, dyslipidemia, atherosclerotic disease)
  
  +
*Devices
−
** Previous MI: ASA 81mg po daily if indicated for secondary prevention
  
  +
**ICD if EF &lt;35%
−
** Atrial fibrillation: warfarin or other anticoagulation
  
  +
**CRT +/- ICD if reduced EF and LBBB
−
* Overall approach is triple therapy: ACEi, beta-blockers, aldosterone agonists
  
  +
*Implantable hemodynamic monitor (CardioMEMS)
−
* Reassess NYHA class after maximizing treatment
  
  +
**Pulmonary artery pressure sensor
−
** NYHA I: continue
  
  +
**Better than daily weights for predicting heart failure exacerbations
−
** NYHA II-IV and sinus rhythm with HR ≥70: add ivabradine and switch ACEi to ARNI (Entresto)
  
  +
**Reduces hospitalizations by 30%
−
** NYHA II-IV and sinus rhythm with HR &lt; 70bpm or AF or pacemaker: switch ACEi to ARNI (Entresto)
  
  +
**Studied in HFpEF and HFrEF
−
* Reassess LVEF
  
  +
**Expensive! $20k
−
** If NYHA I-III and LVEF ≤35%: consider ICD/CRT
  
  +
*Surgery: see advanced therapies, below
−
** 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
  
   
−
==== Procedures ====
 +
===Advanced Therapies===
   
  +
*Consider advanced therapies such as [[left ventricular assist device]] or [[cardiac transplantation]] when heart failure is severe and refractory
−
* Cardiac resynchronization therapy is indicated when LVEF&lt;30%, LBBB, and QRS &gt; 150ms
  
  +
*Possible indications include:
−
* Devices
  
−
** ICD if EF &lt;35%
 +
**LVEF &lt;25%
  +
**End-organ dysfunction
−
** CRT +/- ICD if reduced EF and LBBB
  
  +
**Recurrent hospitalizations 2x/12months unexplained
−
* Implantable hemodynamic monitor (CardioMEMS)
  
  +
**Unable to tolerate medical therapies, including hypotension
−
** Pulmonary artery pressure sensor
  
  +
**Diuretic refractory
−
** Better than daily weights for predicting heart failure exacerbations
  
  +
**Inotropic support
−
** Reduces hospitalizations by 30%
  
  +
**Pulmonary hypertension and right heart failure
−
** Studied in HFpEF and HFrEF
  
  +
**Six-minute walk test &lt;300m
−
** Expensive! $20k
  
  +
**Increased 1yr mortality &gt;20%
−
* Surgery
  
  +
**Renal or hepatic dysfunction
−
** Ventricular assist devices
  
  +
**Chronic hyponatremia &lt;134 chronically
−
** CABG
  
  +
**Cardiac cachexia
−
** Transplant
  
  +
**Unable to tolerate ADLs
   
−
== Prognosis ==
 +
==Prognosis==
   
−
* 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 ==
 +
==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)]
−
* [http://www.ccs.ca/images/Guidelines/Guidelines_POS_Library/HF_CC_2006.pdf CCS Heart Failure Guidelines Update 2006]
 +
*[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 11:26, 20 October 2021

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)

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

  • 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 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)

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
    • Natriuretic peptide (if diagnosis uncertain)
      • NT-proBNP > 450 pg/mL if age < 50 years and > 900 pg/mL if age > 50 years; <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 > 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 97/103 mg bid If on ACEi, need 36 hour washout period before starting
SGLT2 Inhibitors

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

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

Palliative Care

Further Reading

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