Heart Failure

Brittany Saldivar

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Background

ACC/AHA Stages of HF

• Stage A: At risk but without structural heart disease or symptoms
• Stage B: + structural HD, - symptoms
• Stage C: + structural HD, + prior or current symptoms
• Stage D: refractory HF requiring specialized intervention

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: Obstructive CAD, previous/current myocardial infarction
  • Non-ischemic:
    • Load: HTN, valvulopathy
    • Arrhythmia: tachyarrhythmia, pacemaker induced
    • Myocardium
  • Toxins (EtOH, drugs, chemo, radiation),
  • Inflammatory (infections, AI),
  • 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

Cardiac Index		Euvolemia	Hypervolemia
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

• Telemetry, Daily STANDING weights, 2 L 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)
• Continuation/optimization of GDMT (below)

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Guideline-Directed Medical Therapy for HFrEF

Brittany Saldivar

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General Principles

• Starting patients on low dose of multiple agents preferred to max dose of single agent
• D/C summary should have discharge weight, diuretic regimen, and renal function
• Daily weights at home 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)

• Cardiac resynchronization therapy (CRT)
  • Class I indication: NYHA class II to IV, LVEF ≤35% with QRS ≥150 ms and left bundle branch block (LBBB)
  • Class II (consider) If EF \< 35% and:
    • QRSd > 150, without LBBB
    • AF that requires ventricular pacing and AVN ablation
    • Undergoing placement of device with anticipation of >40% ventricular pacing
• 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

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Last update: 2022-05-29 04:05:22