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
- Systolic heart failure
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-blocked plus SGLT2i, then ARNI, then MRA, so that they are on all four after a few 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
- 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)
- 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
Doses
Medication | Starting Dose | Titration | Usual Dose |
---|---|---|---|
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 |
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