Heart Failure

A clinical syndrome caused by structural and/or functional cardiac disease that produces decreased cardiac output, increased intracardiac filling pressures, and pulmonary or systemic congestion

Heart failure

Objective evidence of spontaneously or provokably increased _______ ________ such as elevated natriuretic peptides, abnormal diastolic imaging, or invasive hemodynamic evidence is needed to diagnose HF when LVEF is greater than 40%

Filling pressure

Major causes and risk factors are CAD or prior MI, hypertension, diabetes, obesity, valvular disease, cardiomyopathy, arrhythmias, and cardiotoxins

Heart failure

Myocardial injury or pressure/volume overload leads to impaired contraction and/or relaxation leads to decreased cardiac output leads to activation of SNS, RAAS, aldosterone, and ADH leads to vasoconstriction plus sodium/water retention leads to increased preload and afterload leads to hypertrophy, fibrosis, and remodeling

Heart failure

_________ ________ stimulates BNP release as a compensatory response

Ventricular stretch

Compensatory response that promotes natriuresis, diuresis, and vasodilation

BNP

Findings that support this are fatigue, weakness, exercise intolerance, cool extremities, confusion, and renal hypoperfusion

Heart failure

Findings that support this are dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, crackles, cough, and hypoxemia

Left-sided heart failure

Findings that support this are JVD, peripheral edema, hepatomegaly, ascites, rapid weight gain, and early satiety

Right-sided heart failure

Provides information on LVEF, valve structure/function, chamber structure, wall-motion abnormalities, and clues to elevated filling pressure

ECG

This supports heart failure diagnosis and prognosis; may be higher with age, CKD, and atrial fibrillation; may be lower than expected in obesity

BNP

During a heart failure workup, this assesses rhythm, ischemia, evidence of prior MI, QRS width and conduction abnormalities

ECG

In heart failure, this can identify pulmonary congestion or suggest an alternative pulmonary diagnosis

Chest radiography

What baseline lab tests should be considered in heart failure?

CBC, BMP, K+, SCr/eGFR, glucose or A1c, lipids, liver tests, TSH, iron studies

Potential _________ heart failure etiologies are ischemia, toxins, arrhythmias, valvular disease, infiltrative disease, and other causes suggested by the presentation

Reversible

LVEF less than 40%; treat with four-pillar guideline-directed medical therapy

HFrEF

Previous LVEF less than 40% but follow-up LVEF greater than 40%; improvement does not mean cure; continue HFrEF GDMT even if asymptomatic, generally indefinitely, to prevent relapse

HFimpEF

LVEF 41-49% plus evidence of elevated filling pressures; SGLT2 inhibitor has the strongest recommendation

HFmrEF

LVEF greater than 50% plus elevated filling pressures; SGLT2 inhibitor; diuresis for congestion; aggressive control of comorbidities

HFpEF

Severe heart failure symptoms despite optimized therapy; should trigger specialty referral and consideration of advanced therapies

Advanced heart failure

At risk; risk factors are present, but there are no symptoms, structural disease, or biomarker abnormalities; focus is to prevent heart failure

Stage A

Pre-HF; no symptoms, but structural/functional disease, high filling pressures, or abnormal biomarkers are present; focus is to prevent symptomatic heart failure

Stage B

Current or prior heart failure symptoms with structural heart disease; focus is GDMT with or without diuresis

Stage C

Severe symptoms or recurrent admissions despite optimized therapy; focus is specialty care, LVAD/transplant evaluation, and supportive care

Stage D

Heart failure with no limitation

Class I

Heart failure where ordinary activity causes symptoms

Class II

Heart failure where less-than-ordinary activity causes symptoms

Class III

Heart failure where there are symptoms at rest

Class IV

NYHA _____ is dynamic and may improve or worsen with heart failure symptoms

Class

ACC/AHA heart failure ______ generally does not move backward

Stage

Recommended interventions are control hypertension, diabetes, obesity, dyslipidemia, CAD; smoking cessation; regular physical activity; healthy weight; avoid cardiotoxic drugs/substances

Stage A

In selected Stage A patients with T2DM and a high CV risk, use an _______ _______ to reduce heart failure hospitalization risk

SGLT2 inhibitor

What main therapy is recommended for stage B HF with LVEF below 40%?

ACE inhibitor

After MI/ACS with LVEF below 40%, patient should be given a _____ _________

Beta blocker

Which medications should be avoided in Stage B heart failure with reduced EF?

Thiazolidinediones, diltiazem, and verapamil

Should be avoided in heart failure because of fluid retention/HF risk

Thiazolidinediones

Should be avoided in heart failure because of negative inotropy

Diltiazem and verapamil

What are the four foundational pillars for symptomatic HFrEF?

ARNI, Beta-blocker, MRA, and SGLT2 inhibitor

Additional treatment for Stage C HFrEF when congested

Loop diuretic

For HFrEf therapy, there is no required pillar order and start ____ doses early

Low

For HFrEF, defer ______ _______ initiation or aggressive titration until compensated

Beta blocker

HFrEF; MRAs and SGLT2 inhibitors generally have less ______ ______-lowering effect

Blood pressure

For HFrEF, a mild initial _______ decline does not automatically require treatment discontinuation

eGFR

What is the preferred RAAS inhibitor in NYHA II-III HFrEF?

ARNI

What medications are in Entresto?

Sacubitril and valsartan

In HFrEF, these decrease angiotensin II and aldosterone and increase bradykinin which results in less vasoconstriction and remodeling but more cough/angioedema risk; they reduce morbidity and mortality when an ARNI cannot be used

ACE inhibitors

What is the target dose of enalapril in HFrEF?

10 mg twice daily

What is the target dose for lisinopril in HFrEF?

20-40 mg once daily

Major adverse effects are hyperkalemia, increased SCr or AKI, hypotension, dry cough, and angioedema

ACE inhibitors

Should be avoided with pregnancy, prior angioedema, concomitant ARNI, bilateral renal artery stenosis, and significant hyperkalemia

ACE inhibitors

How often should BP/BMP be checked for ACE inhibitor after starting or titrating?

1-2 weeks

How often should BP/BMP be checked for ACE inhibitor once stable?

Every 3-6 months

For RAAS inhibitors, a stable increase in SCr of up to approximately ______ may be acceptable

30%

For heart failure, this medication blocks the angiotensin II AT1 receptor and produces renal, potassium, and BP effects similar to ACE inhibitors; cause less cough but still carry some angioedema risk

ARBs

What is the target dose of losartan in HFrEF?

50-100 mg once daily

Inhibits neprilysin, increasing natriuretic peptides and promoting natriuresis

Sacubitril

What starting dose of sacubitril/valsartan is used in an ACEI/ARB-naive patient, low-BP patient, or patient with major renal impairment?

24/26 mg twice daily

What sacubitril/valsartan dose is used when transitioning from a substantial ACEI/ARB dose?

49/51 mg twice daily

What is the target sacubitril/valsartan dose for heart failure?

97/103 mg twice daily

How often should sacubitril/valsartan dose be titrated?

Every 2-4 weeks

When transitioning from an ACE inhibitor to an ARNI, stop the ACE inhibitor and wait ____ ________ before starting the ARNI to reduce angioedema risk

36 hours

Should be avoided with prior ACEI/ARB-associated angioedema, pregnancy, concomitant ACEI or separate ARB, and severe hepatic impairment

Entresto

Adverse effects include hypertension, hyperkalemia, renal dysfunction, and angioedema

Entresto

For Entresto, check BP, potassium, and renal function at baseline and approximately ____ _________ after initiation or titration

1-2 weeks

Which beta-blockers have proven mortality benefit in HFrEF?

Carvedilol, metoprolol succinate, bisoprolol

What is the starting dose for carvedilol?

3.125 mg twice daily

What is the target dose for carvedilol?

25 mg twice daily

What is the target dose for carvedilol if body weight is greater than 85 kg?

50 mg twice daily

What is the starting dose for metoprolol succinate NYHA III-IV?

12.5 mg daily

What is hte starting dose for metoprolol succinate for NYHA II?

25 mg daily

What is the target dose for metoprolol succinate?

200 mg daily

What is the starting dose for bisoprolol?

1.25 mg daily

What is the target dose for bisoprolol?

5-10 mg daily

Block chronic catecholamine toxicity, thereby decreasing heart rate, arrhtyhmias, myocardial oxygen demand, and remodeling

Beta-blockers

Four GDMT HFrEF pillars all decrease ________

Mortality

Initiate beta blocker for HFrEF only when the patient is clinically stable and not markedly volume _________

Overloaded

For beta blockers for HFrEF, titrate about every ___ _______ and never stop abruptly

2 weeks

Major adverse effects are bradycardia, hypotension, fatigue, AV block, dizziness, temporary fluid retention, bronchospasm, and masking of hypoglycemia symptoms

Beta-blockers

Blocks Beta-1, Beta-2, and Alpha-1; produces more vasodilation and orthostasis; has respiratory/bronchospasm concerns from beta-2 blockade; take with food

Carvedilol

HR, BP, weight, edema, dizziness, fatigue, AV block when relevant should be monitored with _____ ________- therapy

Beta-blocker

Which steroidal MRAs are used in HFrEF?

Spironolactone and eplerenone

What are the two key parameters for initiating an MRA in HFrEF NYHA II-IV?

eGFR > 30 and Potassium < 5.0

Adverse effects are hyperkalemia, increased SCr/renal dysfunction, and hypotension

MRAs

Adverse effects include gynecomastia, breast tenderness, menstrual effects, sexual dysfunction

Spironolactone

MRA with fewer endocrine effects but more CYP3A4 interaction concerns

Eplerenone

What is the required MRA monitoring schedule?

Baseline, day 3, week, 1 monthly for 3 months, every 3 months

Do not initiate a MRA if potassium is greater than ____ mEq/L or eGFR is below 30 mL/min/1.73 m²

5.0

Discontinue MRA if potassium cannot be maintained below ____ mEq/L

5.5

Potassium supplements, potassium-containing salt substitutes, NSAIDs, trimethoprim, ACEI, ARB, or ARNI, and other potassium-raising drugs should be considered before initiating a patient on an _____

MRA

Which SGLT2 inhibitors are used in heart failure?

Dapagliflozin and empagliflozin

Recommended for symptomatic chronic HFrEF with or without diabetes

SGLT2 inhibitors

Act via glucosuria plus osmotic diuresis/mild natriuresis; HF benefits extend beyond glucose lowering

SGLT2 inhibitors

Adverse effects include genital mycotic infections, increased urination, volume depletion/hypotension, early, usually transient eGFR dip, rare euglycemic DKA, rare Fournier gangrene, hypoglycemia mainly with insulin or sulfonylureas

SGLT2 inhibitors

How often should volume, BP, renal function, and diuretic need be assessed in high risk patient after starting SGLT2 inhibitor?

1-2 weeks

How often should renal function be checked with a stable patient on SGLT2 inhibitor?

3-6 months

What infection-related counseling should be given for an SGLT2 inhibitor?

Maintain genital hygiene and report itching, discharge, dysuria, fever, or severe perineal pain

Should be held during severe acute illness, prolonged fasting, or major surgery

SGLT2 inhibitors

Rare side effect of SGLT2 inhibitors; symptoms are nausea, vomiting, abdominal pain, rapid breathing, or severe malaise even if glucose is not markedly elevated; seek urgent evaluation

Euglycemic DKA

Used for fluid retention and congestion in HF; improve dyspnea, edema, and exercise tolerance; have no established mortality benefit

Loop diuretics