Post on 25-May-2020
Update in
Congestive
Hear FailureDRAGOS VESBIANU MD
Case
58 yo AAM c/o shortness of breath for 3 weeks. Used
to walk one mile per day and now he has noticed
that he gets short of breath after 2 blocks. He also has a hard time climbing steps. Denies cough and
has occasional wheezing. He usually sleeps on 2
pillows because of back problems. Has gained 10 lbs
in the last month, but it’s not unusual for his weight to
fluctuate.
Case
PMH: HTN, DM 2, HLD, COPD
Meds: Lipitor, HCTZ, Metformin, Lantus, Advair,
Albuterol BID
Physical exam:
Comfortable, not SOB at rest
Bilateral wheezing and rales lower lungs
S1, S2, RRR
+1 b/l LE pitting edema
Symptoms in HF
Common Symptoms:
-dyspnea
-edema
-fatigue
-wheezing
Subtle symptoms:
-abdominal pain, nausea, anorexia
-confusion
-lethargy
• After detailed history; Initial laboratory evaluation:
• CBC, urinalysis, CMP (including calcium and magnesium),
fasting lipid profile, TSH, iron panel,
• Serial monitoring, when indicated, should include serum
electrolytes and renal function, BNP, +/-CE
• A 12-lead ECG should be performed initially on all patients
presenting with HF.
• Chest X-ray in all patients with new onset HF.
• Echocardiogram in all patients with new dx of HF (MUGA in some)
• Repeat echo usually for a significant change in clinical status
or for consideration of changes after therapy or to evaluate
for device therapy.
• Noninvasive stress imaging or cardiac cath is reasonable in HF
and suspected CAD
Initial Workup of Stage C HF
Role of BNP in chronic HF
•BNP and NT-proBNP are sensitive (92-93%) and can
help rule out heart failure
•BNP has prognostic value and can be used for risk
stratification
•BNP guided therapy may play a role especially in
hospitalized patients.
Case
You start the patient on Lasix 40 mg BID. He calls
in 5 days to let you know he is doing much better.
You check an Echocardiogram that shows, LVH, bilateral atrial enlargement, EF of 30%
What do you do next?
Definition of Heart Failure
Classification Ejection
Fraction
Description
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
≤40% Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
≥50% Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
Classification of Heart Failure
ACCF/AHA Stages of HF NYHA Functional Classification
A At high risk for HF but without structural
heart disease or symptoms of HF.
None
B Structural heart disease but without signs
or symptoms of HF.
I No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
C Structural heart disease with prior or
current symptoms of HF.
I No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
II Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
III Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
IV Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
D Refractory HF requiring specialized
interventions.
Pharmacological Treatment for
Stage C HFrEFTequila shot vs Penicillin shot
Diuretics are recommended in patients with HFrEF who have evidence of fluid retention, unless contraindicated, to improve symptoms.
ACE inhibitors are recommended in patients with HFrEF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality.
ARBs are recommended in patients with HFrEF with current or prior symptoms who are ACE inhibitor-intolerant, unless contraindicated, to reduce morbidity and mortality.
I IIa IIb III
I IIa IIb III
I IIa IIb III
Pharmacological Treatment for
Stage C HFrEF (cont.)
Tequila shot vs Penicillin shot
Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful for patients with HFrEF.
Use of 1 of the 3 beta blockers proven to reduce mortality (i.e., bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality.
I IIa IIb III
I IIa IIb III
Harm
Neprilysin as a Therapeutic Target
Inactive
fragments
Neprilysin
Natriuretic peptides
Adrenomedullin
Bradykinin
Substance P
(angiotensin II)
• Neprilysin breaks down endogenous
vasoactive peptides, including the natriuretic
peptides
• Inhibition of neprilysin potentiates the action
of those peptides
• Because angiotensin II is also a substrate
for neprilysin, neprilysin inhibitors must be
co-administered with a RAAS blocker
• The combination of a neprilysin inhibitor and
an ACEI is associated with unacceptably high
rates of angioedema
Corti R et al. Circulation. 2001;104:1856-1862.
Sacubitril/Valsartan (LCZ696): Angiotensin Receptor–Neprilysin Inhibitor (ARNI)
1. McMurray JJ et al. N Engl J Med. 2014;371:993-1004
PARADIGM-HF: CV Death or HF Hospitalization (Primary Endpoint)
SHIFT Trial Primary Composite Endpoint:
CV Death or Hospitalization for Worsening HF
Swedberg K et al. Lancet. 2010;376:875-885.
COR LOE Recommendation
I B-R ACEI or ARB or ARNI in conjunction with β blockers + MRA
(where appropriate) is recommended for patients with chronic
HFrEF to reduce morbidity and mortality
I B-R In patients with chronic, symptomatic HFrEF NYHA class II or III
who tolerate an ACEI or ARB, replacement by an ARNI is
recommended to further reduce morbidity and mortality
III B-R ARNI should NOT be administered concomitantly with ACEI or
within 36 hours of last ACEI dose
III C-EO ARNI should NOT be administered to patients with a history of
angioedema
1. Yancy CW et al. J Am Coll Cardiol. 2016;68:1476-1488.
2016 ACC/AHA/HFSA Focused Update on New Pharmacological
Therapy for Heart Failure: An Update of the 2013 ACCF/AHA
Guideline for the Management of Heart Failure
COR LOE Recommendations
IIa B-R Ivabradine can be beneficial to reduce HF hospitalization for
patients with symptomatic (NYHA class II-III), stable, chronic
HFrEF (LVEF ≤35%) who are receiving GDMT, including a β
blocker at maximally tolerated dose, and who are in sinus
rhythm with a heart rate ≥70 bpm at rest
Pharmacological Treatment for
Stage C HFrEF (cont.)
Aldosterone receptor antagonists [or mineralocorticoid receptor antagonists (MRA)] are recommended in patients with NYHA class II-IV and who have LVEF of 35% or less, unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in women (or estimated glomerular filtration rate >30 mL/min/1.73m2) and potassium should be less than 5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency.
I IIa IIb III
Pharmacological Treatment for
Stage C HFrEF (cont.)
Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of 40% or less who develop symptoms of HF or who have a history of diabetes mellitus, unless contraindicated.
Inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency when serum creatinine greater than 2.5 mg/dL in men or greater than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73m2), and/or potassium above 5.0 mEq/L.
I IIa IIb III
I IIa IIb III
Harm
Pharmacological Treatment for
Stage C HFrEF (cont.)
The combination of hydralazine and isosorbide dinitrate is recommended to reduce morbidity and mortality for patients self-described as African Americans with NYHA class III–IV HFrEF receiving optimal therapy with ACE inhibitors and beta blockers, unless contraindicated.
A combination of hydralazine and isosorbide dinitrate can be useful to reduce morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated.
I IIa IIb III
I IIa IIb III
Medical Therapy for Stage C HFrEF:
Magnitude of Benefit Demonstrated in
RCTs
GDMTRR Reduction
in Mortality
NNT for Mortality
Reduction
(Standardized to 36 mo)
RR Reduction
in HF
Hospitalizations
ACE inhibitor or
ARB17% 26 31%
Beta blocker 34% 9 41%
Aldosterone
antagonist30% 6 35%
Hydralazine/nitrate 43% 7 33%
Case
Your guy had a few “no shows” in the clinic and you
get a call from your hospitalist colleagues that he
got admitted for CHF exacerbation. He presented to the hospital with shortness of breath and 30 lbs
weight gain. BP is 160/96, HR is 93, sat 90% on RA.
Positive JVDs, crackles bilaterally. BNP is 2000. Now
on Coreg 6.25 mg, Lisinopril 10 mg and
Spironolactone 25 mg
How should approach his CHF exacerbation.
Triggers for acute
decompensation
Non compliance with medications
Non compliance with diet
Poorly controlled HTN
Ischemia/ACS
Afib
Infections (demand ischemia)
PE
Worsening renal function
Management of acute
decompensation
Volume control
Afterload and preload reduction
Positive pressure ventilation
Initiation of neuro-hormonal drugs
Morphine use
Implantable Cardiac Defibrillators (ICD)
• Sustained ventricular tachycardia is associated with sudden cardiac death in HF.
• About one-third of mortality in HF is due to sudden cardiac death.
• ICDs for primary prevention have been shown to improve survival in selected patients with HF
Indications for ICD Therapy
• ICD therapy is recommended for primary prevention of
SCD in selected patients with HFrEF at least 40 days post-
MI with LVEF ≤35%, and NYHA class II or III symptoms on
chronic GDMT, who are expected to live ≥1 year
• ICD therapy is recommended for primary prevention of
SCD in selected patients with HFrEF at least 40 days post-
MI with LVEF ≤30%, and NYHA class I symptoms while
receiving GDMT, who are expected to live ≥1 year
• ** ICDs do not improve symptoms; most patients
should be on GDMT; should have an expected life-
expectancy of at least 1 year
2013 ACCF/AHA Guideline for the Management of Heart Failure
Cardiac Resynchronization Pacing:
Consequences of a Prolonged QRS
Delayed Ventricular
ActivationDelayed lateral wall contraction
Disorganized ventricular contraction
Decreased pumping efficiency
Reduction in diastolic filling
times
Prolongation of the duration
of mitral regurgitation
Sinus
node
AV
node
Conduction
block
• Intraventricular Activation
• Organized ventricular activation
sequence
• Coordinated septal and freewall
contraction
• Improved pumping efficiency
Mechanism:
Ventricular Resynchronization
Sinus
node
AV
node
Stimulation
therapy
Conduction
block
Device Therapy for Stage C HFrEF
ICD therapy is recommended for primary prevention of
SCD to reduce total mortality in selected patients with
nonischemic DCM or ischemic heart disease at least 40
days post-MI with LVEF of 35% or less, and NYHA class II or III
symptoms on chronic GDMT, who have reasonable
expectation of meaningful survival for more than 1 year.
CRT is indicated for patients who have LVEF of 35% or less,
sinus rhythm, left bundle-branch block (LBBB) with a QRS
duration of 150 ms or greater, and NYHA class II, III, or
ambulatory IV symptoms on GDMT.
I IIa IIb III
I IIa IIb III
NYHA Class III/IV
I IIa IIb III
NYHA Class II
STAGE AAt high risk for HF but
without structural heart
disease or symptoms of HF
STAGE BStructural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
STAGE CStructural heart disease
with prior or current
symptoms of HF
THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality
Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists
Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin
In selected patients· CRT· ICD· Revascularization or valvular
surgery as appropriate
STAGE DRefractory HF
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
remodeling
Drugs
· ACEI or ARB as
appropriate
· Beta blockers as
appropriate
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital
readmissions· Establish patient’s end-
of-life goals
Options· Advanced care
measures· Heart transplant· Chronic inotropes· Temporary or permanent
MCS· Experimental surgery or
drugs· Palliative care and
hospice· ICD deactivation
Refractory symptoms of HF at rest, despite GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Development of
symptoms of HFStructural heart
disease
• Trials have not shown
significant mortality or morbidity
benefit with use of ACEI/ARB
specifically in HFpEF
• No trials showing definite
benefit of Beta blockers,
sildenafil
• TOPCAT trial: Randomized-
double blind trial of
spironolactone (15-45 mg) vs.
placebo in HFpEF patients
(LVEF >45%) with
• Prior HF hospitalization or
• BNP > 100 pg/ml
HFpEF