Chronic heart failure: Difference between revisions

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====By Subtype====
  
====By Subtype====
   
  +
*Reduced ejection fraction (LVEF ≤40%)
−
*HFrEF
  
 
**[[Coronary artery disease]] (most common)
  
**[[Coronary artery disease]] (most common)
 
**[[Hypertension]] (most common)
  
**[[Hypertension]] (most common)
−
**Viral infection
 +
**[[Myocarditis]], including viral infection
 
**Chronic alcohol use
  
**Chronic alcohol use
 
**[[Valvular heart disease]]
  
**[[Valvular heart disease]]
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**[[Idiopathic dilated cardiomyopathy]]
  
**[[Idiopathic dilated cardiomyopathy]]
 
**Genetic causes of [[cardiomyopathy]]
  
**Genetic causes of [[cardiomyopathy]]
  +
*Preserved ejection fraction (LVEF ≥50%)
−
*HFpEF
  
 
**[[Hypertension]] (most common)
  
**[[Hypertension]] (most common)
 
**[[Myocardial infarction]]
  
**[[Myocardial infarction]]
  +
*Mildly reduced ejection fraction (LVEF 41-49%)
   
 
====By Cardiomyopathy====
  
====By Cardiomyopathy====
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*Common
  
*Common
 
**Tachyarrhythmia
  
**Tachyarrhythmia
−
**Valvular disease
 +
**Valvular heart disease
 
**If CAD risk factors:
  
**If CAD risk factors:
 
***Coronary artery disease
  
***Coronary artery disease
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*Lower extremity edema
  
*Lower extremity edema
   
  +
{| class="wikitable"
⚫
{|
  
 
!
  
!
 
!Dry
  
!Dry
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|}
  
|}
   
−
=== Prognosis ===
 +
===Prognosis===
   
−
* Following an admission, 25% risk of 30-day readmission and 37% 1-year mortality
 +
*Following an admission, 25% risk of 30-day readmission and 37% 1-year mortality
−
* 3-year all-cause mortality is 24% in HFpEF and 32% in HFrEF
 +
*3-year all-cause mortality is 24% in HFpEF and 32% in HFrEF
−
* Sudden cardiac death is the cause of 50% of deaths
 +
*Sudden cardiac death is the cause of 50% of deaths
  +
*Many risk calculators exist, including the [http://www.heartfailurerisk.org/ MAGICC risk score]
   
 
==Investigations==
  
==Investigations==
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==Management==
  
==Management==
   
−
*See also [[Acute heart failure management]]
 +
*See also [[Acute heart failure#Management|Acute heart failure management]]
   
 
===Non-Pharmacologic Management===
  
===Non-Pharmacologic Management===
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**Previous MI: [[ASA]] 81 mg PO daily if indicated for secondary prevention
  
**Previous MI: [[ASA]] 81 mg PO daily if indicated for secondary prevention
 
**[[Atrial fibrillation]]: [[warfarin]] or other anticoagulation
  
**[[Atrial fibrillation]]: [[warfarin]] or other anticoagulation
  +
⚫
*Overall approach is triple therapy: ACEi, β-blockers, aldosterone agonists
  
  +
==== HFrEF ====
  ⚫
*For symptomatic HFrEF ≤40%, the overall approach is quadruple therapy: ARNI or ACEi/ARB, β-blockers, aldosterone agonists, and SGLT2 inhibitors
  +
**Start with β-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
  
**Titrate up every 4 to 8 weeks
 
**Monitor renal function and electrolytes 1 and 4 weeks after any increase, then monthly for 2 months, every 3 months for 9 months, and every 4 months indefinitely
  
**Monitor renal function and electrolytes 1 and 4 weeks after any increase, then monthly for 2 months, every 3 months for 9 months, and every 4 months indefinitely
 
*Reassess NYHA class after maximizing treatment
  
*Reassess NYHA class after maximizing treatment
 
**NYHA I: continue
  
**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 resting HR ≥70: consider adding [[ivabradine]]
  +
**NYHA III/IV: consider referral for advanced HF therapies including mechanical supprot
−
**NYHA II-IV and sinus rhythm with HR < 70bpm or AF or pacemaker: switch ACEi to ARNI (Entresto)
  
−
*Reassess LVEF
 +
*Reassess LVEF after maximizing treatment
 
**If NYHA I-III and LVEF ≤35%: consider ICD/CRT
  
**If NYHA I-III and LVEF ≤35%: consider ICD/CRT
−
**NYHA IV: consider hydralazine/nitrates, referral for mechanical support or transplant, refer to palliative care
 +
**NYHA IV: consider [[hydralazine]]/[[nitrates]], referral for mechanical support or transplant, refer to palliative care
  ⚫
*If congestive symptoms:
−
*HFrEF:
  
  ⚫
**First-line: loop diuretic at lowest minimal dose required to control symptoms
−
**First-line: ACE inhibitor (second-line: ARB; third-line: ARNI)
  
  ⚫
**Second-line: consider adding [[Thiazides|thiazide]] or low-dose [[metolazone]]
−
**First-line: beta-blocker (second-line: CCB)
  
  ⚫
**Last-line: consider adding [[digoxin]] if severe symptoms or poorly-controlled [[atrial fibrillation]]
−
***Titrate slowly, doubling dose q2-4 weeks
  
  +
−
***Objective improvement may take 6-12 months
  
  +
===== SGLT2 Inhibitors =====
−
**If NYHA II-IV and LVEF ≤35%: aldosterone antagonist ([[spironolactone]] or [[eplerenone]])
  
  +
−
**If LVEF ≤40%, recent MI, and symptoms or diabetes: aldosterone antagonist
  
  +
*Contraindicated in GFR <25ish (depending on agent)
−
**If African-American: consider adding ISDN
  
  +
*Increased risk of genital mycotic infections
⚫
**If congestive symptoms:
  
⚫
***First-line: loop diuretic at lowest minimal dose required to control symptoms
  
⚫
***Second-line: consider adding thiazide or low-dose [[metolazone]]
  
⚫
***Last-line: consider adding digoxin if severe symptoms or poorly-controlled atrial fibrillation
  
−
*Monitor blood pressure while titrating up medication
  
   
−
==== Doses ====
 +
====Doses====
 
{| class="wikitable"
  
{| class="wikitable"
 
!Medication
  
!Medication
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!Titration
  
!Titration
 
!Usual Dose
  
!Usual Dose
  +
!Notes
 
|-
  
|-
−
! colspan="4" |Diuretics: Loop
 +
! colspan="5" |Diuretics: Loop
 
|-
  
|-
 
|[[furosemide]]
  
|[[furosemide]]
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|
  
|
 
|40-240 mg/d
  
|40-240 mg/d
  ⚫
|
 
|-
  
|-
 
|[[torasemide]]
  
|[[torasemide]]
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|
  
|
 
|10-20 mg/d
  
|10-20 mg/d
  +
|
 
|-
  
|-
−
! colspan="4" |Diuretics: Thiazide-Like
 +
! colspan="5" |Diuretics: Thiazide-Like
 
|-
  
|-
 
|[[chlorthalidone]]
  
|[[chlorthalidone]]
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|
  
|
 
|25-100 mg/d
  
|25-100 mg/d
  +
|
 
|-
  
|-
 
|[[hydrochlorothiazide]]
  
|[[hydrochlorothiazide]]
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|
  
|
 
|12.5-100 mg/d
  
|12.5-100 mg/d
  +
|
 
|-
  
|-
 
|[[indapamide]]
  
|[[indapamide]]
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|
  
|
 
|2.5-5 mg/d
  
|2.5-5 mg/d
  +
|
 
|-
  
|-
−
! colspan="4" |Diuretics: Potassium-Sparing
 +
! colspan="5" |Diuretics: Potassium-Sparing
 
|-
  
|-
 
|[[amiloride]]
  
|[[amiloride]]
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|
  
|
 
|5-10 mg/d
  
|5-10 mg/d
  +
|
 
|-
  
|-
 
|[[eplerenone]]
  
|[[eplerenone]]
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|
  
|
 
|50 mg/d
  
|50 mg/d
  +
|
 
|-
  
|-
 
|[[spirolonactone]]
  
|[[spirolonactone]]
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|
  
|
 
|50 mg/d
  
|50 mg/d
  +
|
 
|-
  
|-
−
! colspan="4" |β-Blockers
 +
! colspan="5" |β-Blockers
 
|-
  
|-
 
|[[bisoprolol]]
  
|[[bisoprolol]]
 
|1.25 mg daily
  
|1.25 mg daily
 
|2.5, 3.75, 5, 7, 10
  
|2.5, 3.75, 5, 7, 10
  +
|
 
|
  
|
 
|-
  
|-
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|3.125 mg bid
  
|3.125 mg bid
 
|6.25, 12.5, 25, 50
  
|6.25, 12.5, 25, 50
  +
|
 
|
  
|
 
|-
  
|-
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|12.5-25 mg daily
  
|12.5-25 mg daily
 
|25, 50, 100, 200
  
|25, 50, 100, 200
  +
|
 
|
  
|
 
|-
  
|-
−
! colspan="4" |Angiotensin Antagonists: ACE Inhibitors
 +
! colspan="5" |Angiotensin Antagonists: ACE Inhibitors
 
|-
  
|-
 
|[[enalapril]]
  
|[[enalapril]]
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|
  
|
 
|10-20 mg bid
  
|10-20 mg bid
  +
|
 
|-
  
|-
 
|[[captopril]]
  
|[[captopril]]
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|
  
|
 
|50 mg tid
  
|50 mg tid
  +
|
 
|-
  
|-
 
|[[lisinopril]]
  
|[[lisinopril]]
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|
  
|
 
|20-35 mg daily
  
|20-35 mg daily
  +
|
 
|-
  
|-
 
|[[ramipril]]
  
|[[ramipril]]
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|
  
|
 
|5 mg daily
  
|5 mg daily
  +
|
 
|-
  
|-
 
|[[trandolapril]]
  
|[[trandolapril]]
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|
  
|
 
|4 mg daily
  
|4 mg daily
  +
|
 
|-
  
|-
−
! colspan="4" |Angiotensin Antagonists: ARBs
 +
! colspan="5" |Angiotensin Antagonists: ARBs
 
|-
  
|-
 
|[[candesartan]]
  
|[[candesartan]]
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|
  
|
 
|32 mg daily
  
|32 mg daily
  +
|
 
|-
  
|-
 
|[[valsartan]]
  
|[[valsartan]]
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|
  
|
 
|160 mg bid
  
|160 mg bid
  +
|
 
|-
  
|-
 
|[[losartan]]
  
|[[losartan]]
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|
  
|
 
|150 mg daily
  
|150 mg daily
  +
|
 
|-
  
|-
−
! colspan="4" |Angiotensin Antagonists: ARB/ARNI
 +
! colspan="5" |Angiotensin Antagonists: ARB/ARNI
 
|-
  
|-
 
|[[valsartan/sacubitril]]
  
|[[valsartan/sacubitril]]
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|
  
|
 
|97/103 mg bid
  
|97/103 mg bid
  +
|If on ACEi, need 36 hour washout period before starting
  +
|-
  +
! colspan="5" |SGLT2 Inhibitors
  +
|-
  +
|
  +
|
  +
|
  +
|
  +
|
 
|}
  
|}
   
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===Advanced Therapies===
  
===Advanced Therapies===
   
−
*Consider advanced therapies such as ventricular assist device or cardiac transplantation when heart failure is severe and refractory
 +
*Consider advanced therapies such as [[left ventricular assist device]] or [[cardiac transplantation]] when heart failure is severe and refractory
 
*Possible indications include:
  
*Possible indications include:
 
**LVEF &lt;25%
  
**LVEF &lt;25%

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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