Heart Failure (Outpatient)

Definition

  • Inability of the heart to provide adequate blood flow to organs, either because of an impairment of filling of the heart, or an impairment of the ejection of blood from the heart

Diagnosis

  • History
    • Dyspnea on exertion
    • Paroxysmal Nocturnal Dyspnea (PND – wake up from sleep gasping for air)
    • Orthopnea (Shortness of breath worsens while lying flat on back)
  • Physical Exam
    • Jugular Venous Distension
    • S3, S4
    • Pulmonary crackles
    • Hepatojugular reflex
    • Ascites
    • Lower extremity edema
  • Laboratory
    • BNP or NT-proBNP: This is a marker released from the ventricle in response to increased stretch
      • May be falsely normal in obese patients
  • Imaging
    • Chest X-Ray: Cardiomegaly, pleural effusions, pulmonary edema
    • Echocardiogram: Ejection Fraction (EF), wall-motion abnormalities, chamber dilation, hypertrophy, etc.

Classifications

New York Heart Association (NYHA) Classification System (1)

  • Class I: No limitations of physical activity
  • Class II: Slight limitation in physical activity due to fatigue, palpitation, dyspnea, or anginal pain with ordinary activity.
  • Class III: Marked limitation in physical activity due to fatigue, palpitation, dyspnea, or anginal pain with less-than-ordinary activity.
  • Class IV: Inability to do any physical activity without discomfort. May have symptoms at rest.

Heart Failure Staging (2)

  • Stage A: Have risk factors for development of heart failure
  • Stage B: Structural/functional cardiac abnormalities, but no symptoms
  • Stage C: Symptomatic heart failure
  • Stage D: Severely symptomatic heart failure

Approach

Heart Failure with reduced Ejection Fraction (HFrEF) (Systolic Dysfunction)

  • LVEF < 40% (3)
  • Etiologies/Workup
    • Ischemia
      • Stress test vs coronary angiogram depending on patient’s risk factors
    • Alcohol
      • History
    • Myocarditis
      • Echocardiogram and Cardiac Magnetic Resonance Imaging (CMR) +/- endocardial biopsy depending on patient’s risk factors
    • Valvular disease (e.g. aortic stenosis)
      • Echocardiogram
    • Stress-induced Cardiomyopathy (Takotsubo Cardiomyopathy)
      • Pathophysiology likely related to catecholamine-induced myocardial changes
      • EKG changes may mimic STEMI, troponin will be elevated
      • Echocardiogram shows “octopus trap” (which is the English translation of “takotsubo”), that is, apical ballooning of the left ventricle during systole
      • Treat with therapy discussed below, improvement is usually rapid and full
    • Idiopathic
  • Guideline-Directed Medical Therapy
    • ACE-Inhibitor/ARB (4)
    • Beta-Blocker: Carvedilol, metoprolol associated with decreased mortality (5)
    • Statin: Mixed evidence. A large randomized controlled trial (CORONA) in 2007 did not show clinical benefit (6)
      • If another indication for statin (hyperlipidemia, increased 10-year ASCVD risk, initiate statin as appropriate)
    • Mineralocorticoid receptor inhibitor (e.g. spironolactone)
      • Indication: NYHA II-IV, LVEF ≤ 35%, baseline serum potassium <5 mEq/L, and CrCl ≥ 30 mL/min who are otherwise on maximal tolerated therapy (7)
      • Indication: LVEF ≤ 40% in patients with recent STEMI and either heart failure symptoms or diabetes mellitus who are otherwise on maximal tolerated therapy (8)
    • Hydralazine/Isosorbide dinitrate
      • Indication: NYHA III-IV in black patients otherwise optimized on medical therapy (7)
  • Cardiac Resynchronization Therapy (CRT)
    • Indication: NYHA II-IV, LVEF ≤ 35%, and LBBB with QRS ≥ 150 ms (7) in patients optimized on maximal tolerated medical therapy
  • Implantable Cardiac Defibrillator (ICD)
    • Indication: NYHA II-IV, LVEF ≤ 35%, ≥1 year life expectancy, ≥40 days post-MI and ≥3 months post-revascularization (7, 9) in patients otherwise optimized on maximal tolerated medical therapy
  • Loop diuretic for symptom (shortness of breath, edema) control

Heart Failure with mid-range Ejection Fraction (HFmrEF)

  • LVEF 40-50% (3)
  • Management similar to HFpEF

Heart Failure with preserved Ejection Fraction (HFpEF) (Diastolic Dysfunction)

  • LVEF > 50% (3)
  • Etiologies/Workup
    • Ischemia
      • Stress test vs coronary angiogram depending on patient’s risk factors
    • Chronic Hypertension
      • Echocardiogram will show ventricular hypertrophy
    • Restrictive Cardiomyopathy
      • Primary/Idiopathic or secondary to amyloidosis, sarcoidosis, hemochromatosis, hypereosinophilic syndrome (HES), or radiation
      • Elevated BNP
      • Right Heart Cath: Simultaneous right and left ventricular systolic pressure rise and fall with respiration
      • CMR (Cardiac MRI): Will not show cardiac thickening. Utility in better characterizing those with high suspicion of restrictive cardiomyopathy based off of echocardiogram findings and differentiating it from constrictive pericarditis
    • Constrictive Pericarditis
      • Clinical sequela of acute pericarditis
      • Low BNP
      • Echocardiography can diagnose
      • Right Heat Cath: Displays ventricular interdependence: right ventricular systolic pressure rises during inspiration coupled with a simultaneous decrease in left ventricular systolic pressure (this is also what causes pulsus paradoxus)
    • Valvular disease (e.g. mitral stenosis)
      • Echocardiogram to diagnose
  • Management
    • Loop diuretics for symptom (shortness of breath, edema) control
    • Treat underlying pathology

References

  1. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels, 9th ed, Little, Brown & Co, Boston 1994. p.253.
  2. Ammar, K., Khawaja Afzal Ammar From the Division of Cardiovascular Diseases (K.A.A., Jacobsen, S., Steven J. Jacobsen From the Division of Cardiovascular Diseases (K.A.A., Mahoney, D., Douglas W. Mahoney From the Division of Cardiovascular Diseases (K.A.A., . . . Ammar, C. (2007, March 12). Prevalence and Prognostic Significance of Heart Failure Stages. Retrieved January 06, 2021, from https://www.ahajournals.org/doi/10.1161/circulationaha.106.666818
  3. Hajouli, S. (2020, August 10). Heart Failure And Ejection Fraction. Retrieved January 06, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK553115/
  4. Rekha Garg, M. (1995, May 10). Overview of Randomized Trials of Angiotensin-Converting Enzyme Inhibitors on Mortality and Morbidity in Patients With Heart Failure. Retrieved January 06, 2021, from https://jamanetwork.com/journals/jama/article-abstract/388358
  5. JoAnne Micale Foody, M. (2002, February 20). β-Blocker Therapy in Heart Failure. Retrieved January 06, 2021, from https://jamanetwork.com/journals/jama/fullarticle/194661
  6. Kjekshus, J., Al., E., Group*, F., Author AffiliationsAffiliations for authors are listed in the Appendix.Address reprint requests to Dr. Kjekshus at the Department of Cardiology, Masoudi, F., F. P. Polack and Others, . . . M. C. Castells and E. J. Phillips. (2007, November 29). Rosuvastatin in Older Patients with Systolic Heart Failure: NEJM. Retrieved January 06, 2021, from https://www.nejm.org/doi/full/10.1056/NEJMoa0706201
  7. Yancy, C., Clyde W. Yancy Search for more papers by this author, Jessup, M., Mariell Jessup Search for more papers by this author, Bozkurt, B., *, B., . . . Al., E. (2017, April 28). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Retrieved January 06, 2021, from https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000509
  8. Pitt, B., Al., E., for the Eplerenone Post–Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators*, Author AffiliationsFrom the University of Michigan, Jessup, M., Others, C.-W. T. and, Others, Y. M. B.-O. and, Others, M. G. T. and, Others, D. M. and, Others, G. W. and, & E. G. Levin and Others. (2003, April 3). Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction: Nejm. New England Journal of Medicine. Retrieved October 12, 2021, from https://www.nejm.org/doi/full/10.1056/nejmoa030207. 
  9. Al-Khatib, S., Stevenson, W., Ackerman, M., Bryant, W., Callans, D., Curtis, A., . . . Page, R. (2018, August 16). 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Retrieved January 06, 2021, from https://www.sciencedirect.com/science/article/pii/S0735109717413064?via=ihub

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