Heart failure Tsu general

Presentation of ADHF: congestion

• Orthopnea

• Dyspnea

• Rales/crackles

• Elevated JVD

• GI discomfort

• Hepatojugular reflex

• Peripheral edema

*Usually caused by abrupt

increase in SBP

Presentation of ADHF: Hypoperfusion

• Cold extremities

• Fatigue

• Poor appetite

• Worsening renal function

What is BNP

B-type natriuretic peptide → Synthesized and secreted by ventricular myocardium in response to

• Increased wall stress

• Hypertrophy

• Volume overload

Is usually elevated in HF but should not be used in isolation to confirm or exclude

diagnosis of HF

Echocardiogram: HFrEF

systolic dysfunction, < 40% → thin, weak heart muscle

Echocardiogram: HFpEF

Diastolic dysfunction > 50% → thick, still heart muscle

Echocardiogram: HFmrEF

40-50 %

Meds that induce/exacerbate HF:

Negative inotropic agents

• Anti-arrhythmics

•  Beta-blockers

• Calcium channel blockers (non-DHP)

Cardiotoxins

•  Alcohol

• Anthracyclines

Sodium and water retention

• Androgens

• COX-2 inhibitors

• Estrogens

• NSAIDS

• TZDs

Osmotic agents

• Albumin

• Blood products

Forester classification: perfused

Cl > 2.2 → well-perfused → warm

Cl < 2.2 → hypoperfused → cold 

Forester classification: congestion

PCWP > 18 → pulmonary congestion → wet

PCWP < 18 → no pulmonary congestion → dry 

Forester classification:

Dry and warm = no congestion + perfusion = Stage 3

Dry and cold = no congestion + no perfusion = Stage 1

Wet and warm = congestion + perfusion = stage 4

Wet and cold = congestion + no perfusion = stage 2

Treatment for diuresis

Loop IV → total daily dose as 1-2.5 IV dose

Incr bolus dose → must double until adequate urine output then can give more freq

Can add diuretic of different class:

Sequential nephron blockage 

• Commonly thiazide or thiaside-like 

  • PO metolazone 2.5 - 10 mg daily

  • PO HCTZ 12.5-25 mg daily 

  • IV chlorothiazide 500-100 mg once to twice daily

• Acetazolamide

• Vasopressin Antagonists → increases K

• Ultrafiltration → invasive!

Discharge criteria

• Initiation and optimization of chronic therapy

• Causes of HF + barriers to vare

• Volume and BP status

• Renal func and electrolytes

• Management comorbid conditions

• HF education, self-care, emergency plans, adherence

• Palliative or hospice care 

When to follow up after discharge

Follow-up visit with 7-14 days and/or telephone call within 3 days of discharge 

LVEF assessment

ACEI or ARB (or ARNI) at discharge if LVEF < 40%

MRA at discharge if LVEF < 40%

BB at discharge if LVEF < 40%

Treatment for HFrEF < 40%

Improved clinical outcomes 

• ANRI (preferred) or ACEI/ARB

• Beta-blocker

• MRA 

• SGLT2 inhibitor 

Select populations 

• Digoxin

• hydralazine/isosorbide finitrate

• Ivabradine 

• Vericiguat

non-DHP CCB HARMFUL

Treatment for HFpEF > 50% 

Some evidence for clinical benefit (esp. HFmrEF)

• SGLT2 inhibit

• ARNI

Treatment aimed at etiology and disease progression 

• Control HTN, DM, obesity, HR

• Treat CAD and prevent myocardial ischemia 

CAN include non-DHP CCB

Staging NYHA: Stage I

No limitation of physical activity. ordinary physical activity does not cause symptoms of HF

Staging NYHA: Stage II

slight limitation of physical activity. comfortable at rest, but ordinary physical activity results in symptoms of HF

Staging NYHA: Stage III

Marked limitation of physical activity. but less than ordinary physical activity results in symptoms of HF

Staging NYHA: Stage IV

Unable to carry on any physical activity w/o sx of HF or s/x of HF at rest

Stage A:

pt at risk for HF w/o current or previous signs of HF

Stage B:

Pre-HF without current or previous s.x of HF but evidence of one of the following

1. structural heart disease

2. evidence of incr filling pressure

3. risk factors → natriuretic peptides or persistent elevated cardiac troponin

Stage C:

Symptomatic HF: current or previous s/sx of HF

Stage D:

Advanced HF: marked HF s/sx that interfere w/ daily life and recurrent hospitalization

HErEF Stage C treatment

ARNI + BB + MRA + SGLT = GDMT

HErEF Stage C treatment: persistent volume overload

Titrate diuretic agent

HErEF Stage C treatment: persistent symptomatic African American

hydralazine + isosorbide denitrate

HErEF Stage C treatment: resting HR > 70 on max tolerated BB dose in sinus rhythm

Ivabradine

HErEF Stage C treatment: high risk pt on optimal GDMT w/ worsening HF or require IV diuretics

Vericiguat

HFrEF Dcr hospitalization and HF deaths (improved outcomes)

• ARNI, ACEI, ARBS

• BB → metoprolol succinate, carvediolol, bisoprolol

• MRA

• SGLT2 inhibitors 

• Hydralazine and isosorbide dinitrate in african americans

Just hospitalization

• Digoxin 

• Ivabradine 

HFpEF: Dcr hospitalization and HF deaths (improved outcomes)

Dcr hospitalization and HF deaths (improved clinical outcomes)

• SGLT2 inhibitors 

• ARNI

• MRA

• ARBs

Control BP → BB, ACI, ARBs (preferred)

Control AF to reduce symptoms → rate control prefered

• BBs, non-DHP digoxin