Chronic heart failure: Difference between revisions
From IDWiki
m (Text replacement - "Clinical Presentation" to "Clinical Manifestations") |
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− | == |
+ | == 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 ==== |
+ | *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 |
+ | ==== 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 |
− | ! |
+ | !Wet |
|- |
|- |
||
− | | |
+ | |Warm |
− | | |
+ | |Less congested<br />Better-perfused |
− | | |
+ | |More congested<br />Better-perfused |
|- |
|- |
||
− | | |
+ | |Cold |
− | | |
+ | |Less congested<br />Poorly perfused |
− | | |
+ | |Less congested<br />Poorly perfused |
− | |} |
+ | |}<br /> |
+ | ==Investigations== |
||
+ | *Lab |
||
− | == Investigations == |
||
+ | **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== |
||
− | * 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 |
||
+ | * 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 < 90 / MAP < 60 |
||
− | ** Consider dopamine or other vasopressor |
||
− | ** Consider dobutamine |
||
− | * SBP 90-100 / MAP 60-65: |
||
− | ** Consider PA catheter |
||
− | ** Consider dobutamine or milrinone |
||
− | * SBP >100 or MAP>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 <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 |
||
+ | *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 < 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 |
||
− | * Replace iron-deficiency with IV iron (improves quality of life) |
||
+ | *Devices |
||
− | * Avoid treating diabetes with glitazones, prefer SGLT-2 inhibitors |
||
+ | **ICD if EF <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 |
||
− | + | === 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 <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 < 70bpm or AF or pacemaker: switch ACEi to ARNI (Entresto) |
||
+ | **Pulmonary hypertension and right heart failure |
||
− | * Reassess LVEF |
||
+ | **Six-minute walk test <300m |
||
− | ** If NYHA I-III and LVEF ≤35%: consider ICD/CRT |
||
+ | **Increased 1yr mortality >20% |
||
− | ** NYHA IV: consider hydralazine/nitrates, referral for mechanical support or transplant, refer to palliative care |
||
+ | **Renal or hepatic dysfunction |
||
− | * HFrEF: |
||
+ | **Chronic hyponatremia <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<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 |
||
− | ** Ventricular assist devices |
||
− | ** CABG |
||
− | ** Transplant |
||
− | == |
+ | ==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 |
− | == |
+ | ==Palliative Care== |
− | == |
+ | ==Further Reading== |
− | * |
+ | *[http://accessmedicine.mhmedical.com.myaccess.library.utoronto.ca/content.aspx?bookid=331§ionid=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] |
− | * |
+ | *[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 22:11, 21 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
- HFrEF
- Coronary artery disease (most common)
- Hypertension (most common)
- Viral infection
- Chronic alcohol use
- Valvular heart disease
- Chemotherapy, such as doxorubicin or trastuzumab
- Peripartum cardiomyopathy
- Idiopathic dilated cardiomyopathy
- Genetic causes of cardiomyopathy
- HFpEF
- Hypertension (most common)
- Myocardial infarction
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
- 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 |
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
- Systolic heart failure
Management
- See also Acute heart failure 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