Chronic heart failure

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

• 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 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

• 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

• 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

	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

• 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
• 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

Further Reading

• Harrison's 19e (Ch 234)
• CCS Heart Failure Guidelines Update 2006
• Does this dyspneic patient in the emergency department have congestive heart failure? JAMA RCE 2005