Heart Failure

Elderly patient with history of hypertension, coronary artery disease, valvular heart disease, atrial fibrillation, and diabetes mellitus type 2 presents with dyspnea on exertion, fatigue. Reports new onset orthopnea, nocturnal cough. Heart rate > 120 bpm, jugular venous distention, hepatojugular reflux, bibasilar crackles, S3 gallop, 2+ pitting lower extremity edema on exam.

HFrEF Tx Algorithm.PNG

  • Patient meets Framingham heart failure diagnostic criteria

  • Labs

    • NTpBNP > 400 pg/mL

    • Obtain CBC, ferritin, TIBC, CMP

    • Consider lipid profile, TSH, U/A, HbA1c

  • Imaging

    • Atrial fibrillation on EKG

    • CXR shows cardiomegaly, venous congestion, interstitial edema with Kerley B lines

    • Echocardiogram shows (one of the following patterns):

      • Preserved ejection fraction: LVEF > 50%, elevated LA pressure, impaired LV relaxation, decreased compliance, and E/A reversal

      • Reduced ejection: LVEF < 50%

  • Treatment

    • Patient counseled about weight loss, dietary sodium reduction, smoking cessation

    • ACE inhibitor: Lisinopril

      • Preserved ejection fraction: Start 5 mg daily and increase by 10 mg every two weeks to target dose of 40 mg daily

      • Reduced ejection fraction: Start 10 mg daily and titrate to 20 mg daily as needed for blood pressure control

    • Additional medications

      • EF < 40%: Metoprolol succinate 50 mg daily

      • Symptomatic (e.g. dyspnea): Chlorthalidone 25 mg daily

      • Start statin if patient qualifies

    • Atrial fibrillation at any EF

      • Aspirin 81 mg + anticoagulation per CHA2DS2-VAsc

      • Metoprolol succinate 50 mg daily

  • Heart failure with reduced ejection fraction (HFrEF)

    • Hypervolemia

      • Fluid restrict to 1.5 L daily to correct hypervolemia, hyponatremia

      • Hypervolemia refractory to fluid restriction: Stop chlorthalidone, start bumetanide 1 mg daily and titrate to 2 mg daily

    • Ferritin < 100 ng/mol

      • Administer 1000 mg IV iron ferric carboxymaltose bolus

      • Schedule follow-up at 6, 12, 24, and 36 weeks to monitor anemia

    • LVEF < 30% with GFR > 30 mL/min

      • Start spironolactone 12.5 mg daily and double dose every 4 weeks to 50 mg daily while monitoring for hyperkalemia

      • Persistent symptoms despite spironolactone: Consider digoxin 0.125 mg daily

    • LVEF < 30% and fatigue, palpitation, dyspnea, or anginal pain provoked by moderate exertion: Consult cardiology for defibrillator placement

  • Additional considerations

    • Consider transition of ACE to Entresto (valsartan + sacubitril) in patients with HFrEF class II-III to improve outcomes

    • African American with uncontrolled HTN on ACE/beta-blocker: Consider isosorbide dinitrate/hydralazine (Bidil) 1 tablet TID

    • Angina/chest pain present: Obtain stress test (may require catheterization)

  • Follow up as outpatient within 7 days after hospital discharge to reduce readmission rate

Notes

Non-hypertensive Causes of Heart Failure

  • Cardiac: Pericardial constriction, primary valvular disease, atrial myxoma

  • Infiltrative disorders: Amyloidosis, sarcoidosis

  • Storage disorders: Hemochromatosis

NYHA Stages of Heart Failure

  1. No limitation of physical activity

  2. Light limitation of physical activity: Ordinary activity causes fatigue, palpitations, or dyspnea

  3. Marked limitation: Less than ordinary activity causes fatigue, palpitations, or dyspnea

  4. Unable to engage in physical activity without symptoms, or symptoms that occur at rest

HFpEF

  • Definition: EF > 50% with s/sx of HF (diagnosis of exclusion)

  • Pathophysiology

    • Reduced ventricular compliance reduces ventricular filling during diastole

    • Most commonly associated with LV hypertrophy

  • Treatment

    • Controlling hypertension improves prognosis

    • Beta-blockers reduce heart rate and improve ventricular filling

HFrEF

  • Medications that improve mortality

    • Beta-blockers

      • Approved agents: Metoprolol succinate, carvedilol (Coreg), bisoprolol

      • Start in all patients when euvolemic and stable

      • Contraindications: Hemodynamic instability, bradycardia, severe asthma

    • Aldosterone antagonists (e.g. eplerenone, spironolactone) in patients with EF < 35% and symptomatic HF (survival advantage observed within 30 days)

    • Vasodilators: Hydralazine, isosorbide dinitrate

  • Additional medications

    • Diuretics and digoxin: Improve symptoms, but do not decrease mortality

    • Amlodipine may help control blood pressure, but does affect HF outcomes

    • Verapamil: Negative inotropic effect worsens heart failure

  • Statins do not improve outcomes for patients who do not otherwise meet criteria for lipid-lowering therapy, see CORONA, GISSI-HF trials

BNP

  • Volume expansion → increased ventricular pressure → ventricular dysfunction → BNP release

  • Renally cleared, i.e. ↓ Cr clearance = ↑ BNP

  • BNP > 400

    • LR = 19 for heart failure

    • Does not necessarily indicate acute exacerbation

  • HF exacerbation: BNP at admission is correlated with inpatient mortality