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Heart Failure

Leonie Dupuis


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


  • 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


  • 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


  • 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
Cardiac Index Euvolemia Hypervolemia

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


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


Metoprolol succinate


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

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


Risk of angioedema






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





HFrEF <40 %

Stage C HF (NYHA class I – IV)



Preference for ARB > ACEi if plans to start ARNI




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



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)



Isosorbide Dinitrate

Persistently symptomatic black patients despite ARNI/ BB/ MRA/ SGLT2i


Reduces cardiac afterload and preload and may also enhance nitric oxide bioavailability

Reduction in mortality for African American patients


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)