Heart failure
Posted by dkwinter

See also:

 

Classification

  • NYHA functional classes
  • Etiology
  • Stage in development & progression
  • Left ventricular ejection fraction (LVEF)
    • HFrEF (LVEF <=40%
    • HFmrEF (LVEF 41-49%)
    • HFpEF (LVEF >=50%)
    • HFimpEF (pt had HFrEF but improved by >=10%)

Tx, depends on LVEF

  • HFrEF (2021 guidelines)
    • All patients ("standard therapy" start all 4 at low doses then increase to target at 3-6 months) 
      • ACE-I, ARB (candesartan & valsartan have best evidence in HF) or ARNI (angiotensin receptor/neprilysin inhibitor→Sacubitril/valsartan)
      • Beta-blocker (specifically bisoprolol, carvedilol, LA metoprolol)
      • MRA (e.g. spironolactone; minimal effect on BP)
      • SGLT2i (empagliflozin up to 10 mg daily; minimal effect on BP)
    • Special considerations
      • If high K: switch ACE-I to ARNI
      • If low BP: MRA and SGLT2i are still ok
    • ​Individualized therapies
      • Ivabradine (Sinus rhythm AND HR <70)
      • Digoxin (AF with suboptimal rate control; Persistent HF sx despite optimized standard therapy)
      • Hydralazine + nitrate (Black on optimal standard therapy; Unable to tolerate ARNI/ACE-I/ARB)
      • Loop diuretic (Titrated to minimum effective dose to maintain euvolemia)
      • Vericiguat (Recent HF hospitalization)
      • Intravenous iron
  • HFmfEF
    • ACE-I, ARB
    • Beta-blocker
    • MRA
    • SGLT2i ("flozin")
  • HFpEF
    • SGLT2i ("flozin")

Meds to deprescribe when diagnosed with heart failure

  • NSAIDs/COX-2 inhibitors
  • Diltiazem, nifedipine, verapamil (all have negative inotropic effects)
  • Diabetes medications (glitazones, saxagliptin--sitagliptin is ok

If hypotensive on new HF regimen then discontinue if taking:

  • Thiazides
  • Amlodipine

 

Hx
     Cough that is exacerbated by lying down at night
     Cough is improved by propping up on pillows
     Exertional dyspnea

Workup
     CBC
     CXR
     ECG
     Echocardiography
     PFTs
     BNP

CHF, unspecified
     Etiologies
          Myocarditis (the most likely precipitant in young patient with acute-onset sx and limited risk factors)
     Tx
          Diuretic

CHF without preserved EF (left heart failure/systolic heart failure)
     Sx
          Pulmonary edema
          Shortness of breath
          Paroxysmal nocturnal dyspnea
          Dyspnea on exertion
          Bilateral pleural effusions
          Third heart sound
          Cardiomegaly
     Complications
          Diastolic dysfunction
          Right heart failure
     

         

CHF with diastolic dysfunction (impaired ventricular relaxation)     
     Ddx
          Constictive pericarditis also causes impaired filling
     Sx
          Pulmonary edema
     Tx (rapid)
          Rapidly reduce preload with
               Nitroglycerin (IV, SL, or topical)
     Tx (mainstay)
          Loop diuretics
          Beta-blocker
          ACE inhibitor or ARB
          Aldosterone antagonist

CHF with preserved EF (right heart failure)
     Sx
     PE


CHF, with pulmonary hypertension, RV hypertropy, and RV failure (right heart failure/Cor pulmonale)
     Etiologies
          COPD (the most common cause)
          Pneumoconiosis
          Pulmonary fibrosis
          Kyphoscoliosis
          Primary pulmonary hypertension
          Repeated episodes of pulmonary embolism
     Sx
          No evidence of pulmonary congestion
          Jugular venous distention
          Ascites
          Lower extremity edema
          Hepatosplenomegaly
          Hepatojugular reflux
          

 

Selected slides from the FMF presentation (2022):

Heart Failure Medications Demystified: Simplified, patient-centered approach
Presented by / Présentée par : Ricky Turgeon