Heart Failure¶

Leonie Dupuis

Background¶

ACC/AHA Stages of HF

Stage A: At risk but without structural heart disease, symptoms, or cardiac biomarkers
Stage B: no symptoms/signs of HF; presence of structural heart disease, incr filling pressures, or incr cardiac biomarkers
Stage C: + structural HD, + prior or current symptoms
Stage D: marked HF, symptoms interfere with daily life and recurrent hospitalizations

NY Heart Association (NYHA) Functional Classes of HF

Class I: Normal physical activity is not limited
Class II: Comfortable at rest; normal physical activity results in HF symptoms
Class III: Comfortable at rest; less than normal activity leads to HF symptoms
Class IV: Inability to perform any physical activity without symptoms

Etiologies¶

HFrEF (Clinical diagnosis + LVEF \< 40%)
- Ischemic (approx. ⅔): Obstructive CAD, previous/current myocardial infarction
- Non-ischemic:
  - Load: HTN, valvulopathy
  - Arrhythmia: tachyarrhythmia, pacemaker induced
  - Myocardium
    - Toxins (EtOH, drugs, chemo, radiation),
    - Inflammatory (infections, autoimmune),
    - Metabolic (thyroid, thiamine deficiency),
    - Infiltrative (amyloid, sarcoid, hemochromatosis)
    - Stress induced/takotsubo CM
    - Genetic
  - Idiopathic
HFpEF: HTN, CAD, obesity, DM, infiltrative, hypertrophic cardiomyopathy

Causes of Heart Failure Exacerbations (FAILURES)¶

Forgetting medications or taking drugs that can worsen HF (e.g. BB, CCB, NSAIDs, TZDs), chemo (anthracyclines, trastuzumab)
Arrhythmia/Anemia: AF, VT, PVCs; Increased arrhythmia burden on device check?
Ischemia/Infarction/Infection: myocarditis; Acute vascular dysfunction (e.g. endocarditis), especially mitral or aortic regurgitation.
Lifestyle choices: Dietary indiscretions - high salt, EtOH, excessive fluid intake. Obesity.
Upregulation (of CO): pregnancy and hyperthyroidism
Renal failure: acute, progression of CKD, or insufficient dialysis (Increased preload)
Embolus (pulmonary) or COPD (leads to increase right-sided afterload)
Stenosis (worsening AS, RAS) leading to hypertensive crisis high left-sided afterload

Presentation¶

Volume overload: shortness of breath, dyspnea on exertion, Orthopnea, PND
Nausea/poor po intake (hepatic and gut congestion)
Confusion (decreased CO)
Exam: Edema (legs, sacrum), rales, S3, S4, murmur (AS, MR), elevated JVD, + hepatojugular reflex, ascites

Evaluation¶

CBC, CMP, Magnesium, Lactate, TSH, iron studies
Troponin, ECG
BNP (Pro-BNP if on Entresto) – high negative predictive value for HF (false negative can occur in obese patients)
CXR – differentiate other causes of dyspnea
TTE
Determine hemodynamic and volume profile
- Cold vs warm
- Dry vs wet

Low

Warm Extremities

Adequate UOP

Normal PPP

Warm and Dry

Forrester Class I

Tx: GDMT as tolerated

Warm and Wet

Forrester Class II

Tx: Diuresis, Vasodilators

Normal

Cardiogenic Shock

Cool Extremities

Renal Failure

Narrow PP

Cold and Dry

Forrester Class III

Tx: Inotropes

Cold and Wet

Forrester Class IV

Tx: Diuresis +Tailored therapy (+/- vasodilators, inotropes)

Management of exacerbations¶

Tele, Daily STANDING weights, 2L fluid restriction, 2g sodium diet, strict I/Os
Diuresis: Place on 2.5 x home dose of IV diuretic, dose BID-TID (DOSE Trial)
Goal is to be net negative (generally 1-2 L per day but patient dependent)
Check BMP BID and Mg QD, keep K>4 and Mg>2
Low threshold for substantial increase (double) in loop vs transition to drip if not diuresing adequately
Can also augment with sequential nephron blockade (thiazides, acetazolamide)
Lasix 40mg PO = Lasix 20mg IV = Torsemeide 20mg PO/IV = Bumex 1mg PO/IV
Continuation/optimization of GDMT (below)

Guideline-Directed Medical Therapy for HFrEF¶

General Principles¶

Starting patients on low dose of multiple agents preferred to max dose of single agent
D/C summary should have discharge weight, GDMT and diuretic regimen, and renal function
Daily home weights with rescue diuretic plan (pm dose for 3 lbs in 1 day, 5 lbs in 3 days

Drug	Indication	Mechanism/ Benefits	Precautions
Beta Blockers
Carvedilol Metoprolol succinate Bisoprolol	HFrEF <40 % Stage C HF (NYHA class I – IV)	Reduces catecholamine stimulation. Decreased HR, myocardial energy demand, less adverse remodeling.	Avoid if pt is decompensated (cold); “start low and go slow” Can continue during exacerbation if patient compensated
ARNIs
Sacubitril/ valsartan	HFrEF < 40% NYHA class II – IV Used in place of ACE/ARB	Prevents vasoactive natriuretic peptide degradation involved in pathogenesis of HF (+ action of ARB)	Need a 36 hr wash-out period if transitioning from ACEi to ARNI Hypotension Risk of angioedema
ACEIs
Lisinopril Enalapril Captopril Ramipril	HFrEF <40 % Stage C HF (NYHA class I – IV)	Blocks harmful effects of RAAS activation and attenuates adverse cardiac and vascular remodeling	Risk of angioedema Monitor renal function and K
ARBs
Losartan Valsartan Candesartan	HFrEF <40 % Stage C HF (NYHA class I – IV)	See ACEIs	See ACEIs Preference for ARB > ACEi if plans to start ARNI
MRAs
Eplerenone Spironolactone	NYHA class II-IV and GFR >30	Diuretic and blood pressure lowering effects and blocks deleterious effects of aldosterone on the heart (including hypertrophy and fibrosis)	Hyperkalemia – avoid if CrCl <30 or K >5
SGLT2i
Dapagliflozin Empagliflozin	HFrEF <40% with and without DM NYHA class II-IV In conjunction with background GDMT	Osmotic diuresis and natriuresis, improve myocardial metabolism, inhibit sodium-hydrogen exchange in myocardium, reduce cardiac fibrosis	UTI/ GU infections Risk of ketoacidosis (both DKA and euglycemic)
Vasodilators
Hydralazine Isosorbide Dinitrate	Persistently symptomatic black patients despite ARNI/ BB/ MRA/ SGLT2i NYHA class III-IV	Reduces cardiac afterload and preload and may also enhance nitric oxide bioavailability Reduction in mortality for African American patients	Hypotension
Ivabradine
Ivabradine	HFrEF <35%, on maximally tolerated BB, sinus rhythm with HR > 70 NYHA class II or III	If current inhibitor involved in SA node activity Decr HR associated with improved outcomes	Need sinus rhythm Caution in sinus node disease and conduction defects
Iron Repletion (IV)
Iron sucrose Ferric carboxymaltose Iron dextran	Ferritin <100 µg/L or ferritin 100-299 µg/L AND transferrin saturation <20%	Decreases HF hospitalizations Improves exercise function and QOL	Risk of anaphylaxis higher in iron dextran

Device therapies (after optimization of medical GDMT for 3 months)¶

Cardiac resynchronization therapy (CRT)
- Class I indication: NYHA class II to IV, LVEF ≤35% with QRS ≥150 ms and left bundle branch block (LBBB)
ICD
- Class I indication: NYHA class II – VI with LVEF \<35% (must have >1yr expected survival and 40+ days from MI)
Mitra Clip
- Criteria: moderate to severe mitral regurgitation (3-4+), on maximally tolerated GDMT, an ejection fraction >20%, and a left ventricle end-systolic dimension of less than 7 cm

Guideline-Directed Medical Therapy for HFpEF¶

Medications overlap with HFrEF treatment (above) but outcomes are less significant
- SGLT2 inhibitors can decrease HF hospitalizations and CV mortality
- MRAs can decrease HF hospitalizations
- ARBs and ARNis can be used to decrease hospitalizations
- Diuretics as needed for congestion (no morbidity or mortality benefit)