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


== Differential Diagnosis ==
==== By Subtype ====


*HFrEF
* Common
**[[Coronary artery disease]] (most common)
** Tachyarrhythmia
**[[Hypertension]] (most common)
** Valvular disease
**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
*HFpEF
** 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
** 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 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
===History===
* Lower extremity edema

*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
!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
|}
|}<br />
==Investigations==


*Lab
== Investigations ==
**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==
* Lab
** 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


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


===Non-Pharmacologic Management===
=== Acute heart failure ===


*Regular exercise 3-5 times a week for 30-45 min per session (after stress test)
See also [[Acute heart failure management]]
*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


===Manage Comorbidities===
* 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


*Replace iron-deficiency with IV iron (improves quality of life)
=== Chronic heart failure ===
*Avoid treating diabetes with glitazones, prefer SGLT-2 inhibitors
*Treat hypertension, especially in HFpEF


===Pharmacologic Treatments===
==== Non-pharmacologic management ====


*Treat cardiovascular risk factors (hypertension, dyslipidemia, atherosclerotic disease)
* Regular exercise 3-5 times a week for 30-45 min per session (after stress test)
**Previous MI: ASA 81mg po daily if indicated for secondary prevention
* No-added-salt diet (2-3 g/day); 1-2g/day if severe fluid retention
**Atrial fibrillation: warfarin or other anticoagulation
* Fluid limited to 1.5 L/day to 2 L/day from all sources, if diuretics fail
*Overall approach is triple therapy: ACEi, beta-blockers, aldosterone agonists
* Consider referral to multidisciplinary outpatient clinic
*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


==== Comorbidities ====
===Procedures===


*Cardiac resynchronization therapy is indicated when LVEF&lt;30%, LBBB, and QRS &gt; 150ms
* Replace iron-deficiency with IV iron (improves quality of life)
*Devices
* Avoid treating diabetes with glitazones, prefer SGLT-2 inhibitors
**ICD if EF &lt;35%
* Treat hypertension, especially in HFpEF
**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


==== Pharmacologic treatments ====
=== Advanced Therapies ===


* Consider advanced therapies such as ventricular assist device or cardiac transplantation when heart failure is severe and refractory
* Treat cardiovascular risk factors (hypertension, dyslipidemia, atherosclerotic disease)
* Possible indications include:
** Previous MI: ASA 81mg po daily if indicated for secondary prevention
** LVEF &lt;25%
** Atrial fibrillation: warfarin or other anticoagulation
**End-organ dysfunction
* Overall approach is triple therapy: ACEi, beta-blockers, aldosterone agonists
**Recurrent hospitalizations 2x/12months unexplained
* Reassess NYHA class after maximizing treatment
**Unable to tolerate medical therapies, including hypotension
** NYHA I: continue
**Diuretic refractory
** NYHA II-IV and sinus rhythm with HR ≥70: add ivabradine and switch ACEi to ARNI (Entresto)
**Inotropic support
** NYHA II-IV and sinus rhythm with HR &lt; 70bpm or AF or pacemaker: switch ACEi to ARNI (Entresto)
**Pulmonary hypertension and right heart failure
* Reassess LVEF
**Six-minute walk test &lt;300m
** If NYHA I-III and LVEF ≤35%: consider ICD/CRT
**Increased 1yr mortality &gt;20%
** NYHA IV: consider hydralazine/nitrates, referral for mechanical support or transplant, refer to palliative care
**Renal or hepatic dysfunction
* HFrEF:
**Chronic hyponatremia &lt;134 chronically
** First-line: ACE inhibitor (second-line: ARB)
**Cardiac cachexia
** First-line: beta-blocker (second-line: CCB)
**Unable to tolerate ADLs
*** 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 ====

* 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


== 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]]

Revision as of 02:11, 22 February 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 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


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

  • 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

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 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 < 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<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

  • 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 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