Lecture 8 - Heart Failure with Reduced Ejection Fraction

What is HFrEF defined as?

Heart failure with a reduction in ejection fraction <49%

Thin-walled stretched and dilated ventricles — Pumping issue!

What is the most common cause of HFrEF?

Tissue death due to coronary artery disease (prior infarction or long-term ischemia)

What are the clinical manifestations of HFrEF?

• Dyspnea

• Fatigue (limited exercise tolerance)

• Fluid retention

What population is HFrEF more prevalent in?

White males

What is the pathophysiology of HFrEF?

• The left ventricle enlarges, weakens and thins

• LVEDP increases

• Decreased cardiac output leads to renal hypoperfusion

What does dilated ventricular wall stress cause?

Increase in atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) and NT-Pro-BNP

What does an increase in ANP, BNP, and NT-Pro-BNP cause in HFrEF patients?

High circulating amounts result in sodium retention and increase in systemic vascular resistance and pulmonary pressures

What can increased LVEDP lead to?

Ventricular arrhythmias

What may develop due to chronic inflammation in HFrEF?

Anemia

What are the most common symptoms of HFrEF?

Dyspnea and fatigue

How do we classify heart failure symptoms?

Class I: asymptomatic

Class II: symptomatic with moderate activity

Class III: symptomatic with mild activity

Class IV: symptomatic at rest

What are exam findings of HFrEF

• Cardiac cachexia (early satiety, nausea)

• S3 gallop with JVD is poor prognosis

• Diaphoresis, pallor, clod limbs, peripheral cyanosis, venous distension, tachycardia

• Systolic murmur

• Crackles, pitting edema, anasarca, JVD, HJR

What is the diagnosis of HFrEF?

1. Reduced LVEF <40%

2. Signs and symptoms of heart failure resting, ECHO evidence of left ventricular systolic dysfunction, moderate/severe ventricular distension, or moderate/severe valvular disease

3. Evidence of spontaneous or provokable increased LVEDP or abnormal hemodynamis on testing

Describe HFrEF lab testing

• CBC

• CMP with Magnesium

• BNP or NT-proBNP

• Serum troponins

• Fasting lipid profile

• A1C testing

• TSH

Dsecribe HFrEF Non-invasive Diagnostic Testing

• EKG

• Chest radiography

• TTE

• Cardiac MRI

Describe HFrEF invasive diagnostic testing

• Invasive cardiac catheterization

• Revascularization of tissues with viable myocardium

• Endomyocardial biopsy

• Genetic testing for patient with FHx of SCD

What is the gold standard for hemodynamic assessment?

Invasive cardiac catheterization

What is the goal of non-pharmacological treatment for HFrEF?

Reduce morbidity and mortality, improve QoL, limit disease progression, and reduce hospitalizations

What non-pharmalogical treatment is recommended for HFrEF?

• Monitor daily weights and blood pressures

• Exercise, alcohol and tobacco cessation, weight loss

• Low sodium diet (DASH or Mediterranean diet)

How do we treat arrhythmia?

• Rhythm control - invasive strategies

• Rate control is important (60-100)

• Beta blockers

• Digoxin (hypotensive patients)

What medications are contraindicated for arrythmias in patients with HFrEF?

Nondihydropyridine calcium channel blockers as they may exacerbate heart failure in HFrEF

What is the focus of pharmacological HFrEF treatment?

Treating afterload and volume overload

What pharmacological therapies are uesd for HFrEF?

• Beta blockers

• ACE-I

• ARBs

• ARNI

• Loop and thiazide diuretics

• MRAs

• SGLT2i

How long do we have to wait when switching a patient from ACE-I to ARBs (or ANRIs)?

36 hours

What is a contraindication to starting an ARB?

Development of angioedema

What drugs do we avoid in HFrEF?

• NSAIDs can lead to renal failure

• Non-Dihydropyridine calcium channel blockers can worsen HFrEF

• Chemotherapeutic agents

• Polypharmacy

What patients are a candidate for a cardiac defibrillator?

Patients with a reduced ejection fraction of <35% despite optimized goal directed medical therapy (GDMT) for 90 days

What patients would benefit from cardiac resynchronization therapy (CRT)?

Patients with intraventricular conduction delay or a high degree heart block

How are CRT devices programmed?

To synchronize depolarization of the left and right ventricles to reduce heart failure exacerbation risks and improve patient symptoms

When can a left ventricular assist device (LVAD) also be used?

During the recovery phase of a patient with myocarditis or post-partum cardiomyopathy

What are LVAD patients required to do?

Anticoagulation with warfarin and wear an external power supply to power the device