Congestive Heart Failure

What is HF?

inability of heart to pump enough blood to meet body's demands

What is systolic dysfunction?

HF with reduced EF ≤40% (HFrEF)

What is diastolic dysfx?

- HF w/ improved EF ≤40% to ≥40%

- HF w/ mildly reduced EF 41-49%

- HF w/ preserved EF ≥50% (HFimpEF, HFmrEF, HFpEF)

What is cor pulmonale (pulmonary heart disease)?

alteration in structure and function of R ventricle caused by primary disorder of respiratory system

What are the classifications of HF based on the NY Heart Association?

- I: no physical limitation

- II: slight physical activity limitation

- III: noticeable limitations of physical activity

- IV: severe limitation of physical activity

What is stage A HF based on the ACC/AHA?

at risk but no symptoms (HTN, CAD, DM, family hx)

What is stage B HF based on the ACC/AHA?

no s/sxs, but decreased EF & showing signs of structural disease (previous MI, LV systolic dysfx, valvular disease)

What is stage C HF based on the ACC/AHA?

structural heart disease w/ HF symptoms (known heart disease, SOB, fatigue, reduced exercise)

What is stage D HF based on the ACC/AHA?

refractrory HF sxs impact activities of daily living and requires intervention (sxs at rest despite therapy)

What are some causes of HF?

- HTN

- ischemia

- viral illness

- toxins

- valve disease

- diabetes

-postpartum

What is the pathophysiology of systolic dysfunction (HFrEF)?

cardiomyocyte loss leading to LV reduced pumping

What is the pathophysiology of diastolic dysfunction (HFrEF)?

structural and cellular alterations leading to LV inability to relax

What are the findings of systolic dysfx?

thinner, elongated cardiomyocytes & fibrosis

What are findings of diastolic dysfx?

cardiomyocyte hypertrophy, inflammation, & fibrosis

What are comorbidities of systolic dysfx?

- MI

- genetic mutation

- myocarditis

- valvular disease

What are comorbidities of diastolic dysfx?

- HTN

- T2DM/obesity

- renal insufficiency

- pulmonary/liver disease

- sleep apnea

What are the adaptive mechanisms of systolic & diastolic dysfx that will lead to HF?

- increased preload

- neurohumoral activation

- RAAS

- vasoconstriction

- fluid retention

- increased oxidative stress

What is cardiac remodeling?

changes that manifest clinically as changes in size, mass, geometry, & function of the heart (scar tissue, fibrosis, inflammation)

What is the consequence of cardiac remodeling?

ventricular dysfunction

How can you detect cardiac remodeling?

- echocardiogram

- ventriculography

- nuclear MRI

What are risk factors for HF?

- Coronary heart disease

- MI

- HTN

- Diabetes

- Smoking

- Valvular heart disease

What are signs of HF?

- elevated JVP

- positive abdominojugular reflex

- rales/crackles or evidence of pleural efusion

- Hepatomegaly

- S3/S4

- ascities

- lower extremity edema

What are the symptoms of HF?

- dyspnea

- mild exercise intolerance ranging to extreme fatigue

- edema

- chest pain

- cough

- orthopnea

- paroxysmal nocturnal dyspnea

- weight gain

- decreased appetite

What is associated with R sided HF?

- congestion of peripheral tissues

-dependant edema/ascites

- Liver/GI congestion

- heart loses ability to move O2-depleted blood to lungs to pick up O2

What is associated with L sided HF?

- decreased CO & pulmonary congestion

- impaired gas exchange and pulmonary edema

- heart loses ability to pump blood to body after its re-oxygenated

How has the approach to a HF pt changed?

used to focus on symptoms like congestion, now focus on progression of LV dysfunction

How is HF diagnosed?

- echocardiogram

- chest radiograph

- ECG

- BNP or NT-proBNP

- CBC/CMP

- myocardial biopsy

What does an echocardiogram do in HF?

- confirms diagnosis

- determine type/severity

- assess structural abnormalities

- provide hemodynamic data

What should you know about BNP?

- naturally rises w/ aging

- may not fall after treatment in diastolic dysfx

- can be elevated in other conditions

- ≥100 pg/mL suggests HF

What are short-term goals of HF treatment?

- reduce preload & reduce afterload

- improve CO

- improve symptoms

What are the long-term goals of HF treatment?

- reduce hospitilizations

- decrease in total costs

- improve satistfaction and quality of life

- improve survival

What is guideline directed medical therapy for HFrEF?

1. RAAS inhibitors: ACE/ARB/ARNi

2. mineralocorticoid receptor antagonists

3. evidence-based BB

4. SGLT2is

What is the neurohormonal response in HF?

1. increased norepinephrine

2. increased angiotensin II

3. increased aldosterone

4. hypertrophy, ischemia, arrhythmia, remodeling, and fibrosis

What is neurohormonal blockage in HF?

BB, ACE/ARB/ARNi & MRA all reduce disease progression

What are the indications for diuretics in HF?

fluid overload and symptomatic relief

What is the primary therapy for RAAS inhibition in HF?

ACEi

What is a secondary option for HF (those who cannot tolerate ACE)?

ARB

What treatment may have better efficacy than an ACE and ARB?

ARNi

When is a beta blocker given in HF?

along with an ACEi or ARB/ARNi to reduce remodeling and mortality

When is an MRA recommended for HF?

persisting symptoms while on an ACEi or ARB

When is an SGLT2i indicated for HF?

with or without type II DM to reduce hospitalizations and adverse cardiac events

What are the evidence-based BB that are shown to improve mortality in HF patients?

- bispoprolol

- carvedilol

- sustained release metoprolol

What is a new medication that slows HR w/out affecting BP, and reduces hospitalization?

Ivabradine

When is ivabradine indicated?

- EF <35%

- sinus rhythm & resting HR ≥70bpm

What medication is indicated for reducing hypertrophy, inflammation, and fibrosis with an EF <45%?

Vericiguat

What is the treatment for HFimpEF?

continue HFrEF management

What is the treatment for HFmrEF

1. RASS

2. MRAs

3. Evidence-based-beta blockers

4. SGLT2i

- Diuretics

What is the treatment for HFpEF?

- Diuretics

- Primary therapy: SGLT2i/MRA

- Secondary: ARNi/ACEi/ARBs/BB

What meds need to be used with caution in HF?

- CCB, TCA, carbamazepine, itraconazole, class I anti-arrhythmics (negative ionotropic activity)

- NSAIDs, glucocorticoids, thiazolidinediones, minoxidil (promote Na+ retention)

- phosphodiesterase inhibitors, beta-2 agonists (arrhythmias)

- TMP-SMX (hyperkalemia)

- metformin (side effects)

What is the treatment of an acute episode of HF?

- Hospitalize

- address possible causes of decompensation

- IV diuresis

- nitrates and vasodilation

- nesiritide recombinant human BNP

What is device based therapy indicated for treatment of advanced heart failure?

- Implantable cardioverter-defibrillator

- Cardiac resynchronization therapy with biventricular pacing

- Combined resynchronization therapy and defibrillator

- Mechanical circulatory support with ventricular assist devices (LVAD/biVAD)

- artificial heart

What is an implantable-cardioverter defibrillator (ICD)?

- indicated to prevent sudden cardiac death if EF ≤35% and life expectancy >1 yr

- detects abnormal rhythm and delivers shock

What is cardiac resynchronization therapy (CRT)?

indicated in dyssynchronous ventricular activity and/or QRS prolongation by sending signals to R & L ventricles (can use w/ ICD)

What are ventricular assist devices (VAD)?

- indicated in advanced HF refractory to optimal medical therapies by offering mechanical circulatory support

- may include pumping for LV (LVAD) only or both ventricles (BiVAD)

What is an artificial heart?

- indicated in advanced HF refractory to VAD

- completely replaces heart function

- works as bridge to transplant