Heart Failure

Matthew Alonso

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: end stage/refractory HF, symptoms interfered with daily life and recurrent hospitalizations

NY Heart Association (NYHA) Functional Classes of HF

  • Class I: Ordinary physical activity does not cause symptoms of HF. No limitation of physical activity.
  • Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.
  • Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF (such as walking short distances).
  • Class IV: Unable to perform any physical activity without symptoms of HF, or symptoms of HF at rest.

Nomenclature

  • HF with reduced EF (HFrEF): HF with an LVEF of ≤40%
  • HF with mildly reduced EF (HFmrEF): HF with an LVEF of 41% to 49%
  • HF with preserved EF (HFpEF): HF with an LVEF of ≥50%
  • HF with recovered EF (HFrecEF): HF with a baseline LVEF of ≤40%, a ≥ 10-point increase from baseline LVEF, and a second measurement of LVEF of >40%

Etiologies

  • HFrEF (clinical diagnosis + LVEF < 40%)
  • Ischemic (approx. 2/3): Obstructive CAD, previous/current myocardial infarction
  • Non-ischemic:
    • Load: HTN, valvulopathy
    • Arrhythmia: tachyarrhythmia, pacemaker induced
    • Myocardium:
      • Toxins (EtOH, drugs, chemo, radiation)
      • Inflammatory (autoimmune, peripartum CM, infectious, eosinophilic, giant cell, hypersensitivity)
      • Metabolic (thyroid, thiamine deficiency, DM)
      • Infiltrative (amyloid, sarcoid, hemochromatosis)
      • Stress-induced/Takotsubo CM
      • Genetic
      • Idiopathic

HFpEF: HTN, CAD, obesity, DM, CKD, 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
  • Embolus (pulmonary) or COPD
  • Stenosis (worsening AS, RAS)

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 reflux, 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 pts)
  • CXR – differentiate other causes of dyspnea
  • TTE
  • Determine hemodynamic and volume profile:

Cardiac Index

Volume Status

Euvolemia

Hypervolemia
Low Warm Extremities
Adequate UOP
Nl Pulse Pressure

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 Pulse Pressure

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
  • Goal is to be net negative (generally 1-2L 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 vs augment with sequential nephron blockade (thiazides, acetazolamide)
  • Continuation/optimization of GDMT (below)

Advanced Diuretic Management

Diuretic Conversion

  • Bumetanide 1mg IV = Furosemide 40mg IV (Torsemide not available IV)
  • Bumetanide 1mg PO = Torsemide 20mg PO = Furosemide 80mg PO

Diuretic Resistance & Augmentation strategies

  • Can switch to lasix drip after bolus
  • Consider secondary diuretics: Thiazide (most effective option), Metolazone 2.5-10mg PO (distal tubule) OR Chlorothiazide (Diuril) 250-500mg IV (if IV option needed), Acetazolamide (Diamox) 250-500mg IV (proximal tubule)

Use of SGLT2i in Acute HF

  • Dapagliflozin/Empagliflozin can be initiated in hospitalized patients on the first day even if they are not diabetic.

Guideline-Directed Medical Therapy for HFrEF

General Principles

  • Starting pts 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 w/ rescue diuretic plan (pm dose for 3lbs in 1 day, 5lbs in 1 week)

Common Drugs

Indication

Mechanism/Benefits

Precautions
Beta Blockers

Carvedilol

Metoprolol succinate

Bisoprolol

HFrEF <40 %

Stage C HF (NYHA class I – IV)

 Blocks catecholamines. Decreased HR/myocardial oxygen demand Less adverse remodeling.

Avoid if pt is decompensated (cold); “start low and go slow”

Can continue during exacerbation if pt 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/ARBs

Lisinopril

Enalapril

Losartan

Valsartan

HFrEF < 40%

Stage C HF (NYHA class I – IV)

Blocks RAAS activation

Reduces adverse cardiac and vascular remodeling

Risk of angioedema
Monitor renal function and K

Preference for ARB > ACEi if plans to start ARNI
MRAs

Eplerenone

Spironolactone

 NYHA class II-IV and GFR >30 and K <5 Diuretic and blood pressure lowering effects and blocks deleterious effects of aldosterone on the heart (including hypertrophy and fibrosis)

Hyperkalemia
SGLT2i

Dapagliflozin

Empagliflozin

HFrEF <40% with and without DM

NYHA class II-IV

 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 pts 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 pts

 Hypotension
Ivabradine
Ivabradine

HFrEF <35%, on maximally tolerated BB, sinus rhythm with HR > 70

NYHA class II or III

I(f) 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–IV, LVEF ≤35% with QRS ≥150 ms and left bundle branch block (LBBB)
  • ICD
    • Class I indication: primary prevention for ischemic or non-ischemic CM, NYHA class II–III with LVEF ≤35% (must have >1yr expected survival and 40+ days from MI)
    • Secondary prevention for patients who have survived cardiac arrest due to ventricular fibrillation or hemodynamically unstable ventricular tachycardia
  • Mitra Clip
    • Criteria: moderate-to-severe or severe secondary mitral regurgitation, on maximally tolerated GDMT, an EF >20% and <50%, and a left ventricle end-systolic dimension < 7cm

CardioMEMS

  • NYHA II-III symptoms who have had a hospitalization for HF in the past year or with elevated BNP to reduce risk of subsequent HF hospitalizations

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)

Consider GLP1-agonists patients with concomitant obesity.

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