Chronic heart failure resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Chronic Heart Failure Resident Survival Guide Microchapters
Overview
Classification
Causes
Diagnosis
Treatment Diuretic Therapy Medications
Do's
Don'ts

Overview

Heart failure is a complex syndrome whereby there is inadequate output of the heart to meet the metabolic demands of the body. Heart failure is a clinical syndrome characterized by symptoms of dyspnea, edema and fatigue and signs such as rales on physical examination. There can be two forms of presentation namely:

• Heart failure with preserved ejection fraction (HFpEF) - This is otherwise called diastolic HF. It is characterized with an ejection fraction ≥ 50%.
• Heart failure with reduced ejection fraction (HFrEF) - This is also called systolic HF. It is characterized with an ejection fraction of ≤ 40%.

Advanced heart failure refers to severe symptoms of heart failure with dyspnea and/or fatigue at rest or with minimal exertion (NYHA class III or IV). These parameters assist in identifying patients with advanced heart failure:

• Repeated (≥2) hospitalizations or ED visits for HF in the past year
• Progressive deterioration in renal function (eg, rise in BUN and creatinine)
• Weight loss without other cause (eg, cardiac cachexia)
• Intolerance to ACE inhibitors due to hypotension and/or worsening renal function
• Intolerance to beta blockers due to worsening HF or hypotension
• Frequent systolic blood pressure <90 mm Hg
• Persistent dyspnea with dressing or bathing requiring rest
• Inability to walk 1 block on the level ground due to dyspnea or fatigue
• Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose over 160 mg/d and/or use of supplemental metolazone therapy
• Progressive decline in serum sodium, usually to < 133 mEq/L
• Frequent ICD shocks

Guideline-directed medical therapy (GDMT) - This is a term which represents the optimal medical therapy in the management of heart failure as defined by ACCF/AHA. These are primarily the class 1 recommendations. It involves the use of ACE inhibitors or (ARBs), beta blockers, aldosterone antagonists, and hydralazine/nitrate medications.

Goals of Therapy

Goals	Therapeutic intervention
To alleviate symptoms and signs	Diuretics, morphine (no mortality benefit)
To reduce mortality	ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, hydralazine plus isosorbide dinitrate, Omega-3 fatty acid, CRT, ICD
To reduce hospitalization	Digoxin, ARBs (in HFpEF)
Treat underlying cardiovascular disease

Classification

ACCF/AHA Stages of Heart Failure

Stage of Heart Failure	Description
A	At high risk for HF but without structural heart disease or symptoms of HF.
B	Structural heart disease but without signs or symptoms of HF.
C	Structural heart disease with prior or current symptoms of HF.
D	Refractory HF requiring specialized interventions.

ACCF - American College of Cardiology Foundation; AHA - American Heart Association.

New York Heart Association (NYHA)

Stage of Heart Failure	Description
I	No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
II	Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.
III	Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.
IV	Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

Causes

Life Threatening Causes

Acute decompensated heart failure is a life-threatening condition and must be treated as such irrespective of the causes. Life-threatening conditions can result in death or permanent disability within 24 hours if left untreated.

• Accelerated hypertension
• Acute kidney injury
• Acute myocardial ischemia
• Acute or progressive valvular disease (e.g. acute mitral regurgitation)
• Acute or subacute valve disease endocarditis
• Aortic dissection
• Cardiac arrhythmias, especially ventricular arrhythmias
• Cardiotoxic agents (e.g. alcohol, cocaine, and certain chemotherapy drugs)
• Diabetic emergencies (e.g. ketoacidosis)
• Pulmonary embolus
• Severe anemia (e.g. acute hemolysis or blood loss)
• Systemic inflammatory response syndrome
• Thyrotoxicosis

Common Causes

• Cardiotoxic drugs (e.g. NSAIDs, thiazolidinedione, and certain chemotherapy drugs)
• Concurrent infections e.g., pneumonia, viral illnesses
• Electrolyte imbalances
• Excessive alcohol or illicit drug use (e.g. cocaine)
• Medication noncompliance
• Myocardial ischemia or infarction
• Noncompliance with dietary restrictions (e.g., sodium and fluid restriction)
• Progressive valvular disease (e.g. mitral regurgitation)
• Pulmonary embolus
• Uncontrolled arrhythmias
• Uncontrolled hypertension
• Endocrine abnormalities - diabetes mellitus, thyroid disorders (hyperthyroidism, hypothyroidism)

Diagnosis

The algorithm below describes the diagnostic approach to a patient with chronic heart failure.

Characterize the symptoms: ❑ Cardiac ❑ Chest pain ❑ Cough ❑ Dyspnea at rest ❑ Exertional dyspnea ❑ Orthopnea ❑ Palpitation ❑ Paroxysmal nocturnal dyspnea ❑ Peripheral edema ❑ Extracardiac ❑ Anorexia ❑ Bloating ❑ Fatigue ❑ Nausea ❑ Oliguria ❑ Weight loss Obtain a detailed history: ❑ Medications: ❑ Alcohol ❑ Beta blockers ❑ Calcium channel blockers ❑ Chemotherapy drugs - anthracyclines ❑ NSAIDs ❑ Thiazolidinedione ❑ Past medical history ❑ Arrhythmias ❑ Cardiomyopathy ❑ Diabetes mellitus ❑ Hypertension ❑ Obesity ❑ Previous myocardial infarction ❑ Sleep apnea ❑ Thyroid disease ❑ Valvular heart disease ❑ Family history ❑ History of dilated cardiomyopathy ❑ Radiation to the chest

Examine the patient: ❑ General examination: ❑ Pulse rate - ↑ ❑ Blood pressure - ↑ or ↓ ❑ Respiratory rate - ↑ ❑ Weight ❑ Head/neck examination: ❑ ↑ JVP ❑ Cardiovascular examination: ❑ Wheeze (cardiac asthma) ❑ S3 or S4 or both ❑ New or changed murmur ❑ Respiratory examination ❑ Crackles/crepitations/rales ❑ Abdominal examination: ❑ Hepatomegaly ❑ Ascites ❑ Neurological examination: ❑ Altered mental status ❑ Extremity examination: ❑ Pedal edema Consider close differential diagnoses: ❑ Acute asthma ❑ Acute respiratory distress syndrome ❑ Cardiac tamponade ❑ Pneumonia ❑ Pulmonary embolism

Initial stabilization: ❑ Assess airway, pulse oximetry ❑ Nurse 45 degrees upright ❑ Give oxygen, if Sa02 ↓90% by non-rebreather face masks ❑ Continuous cardiac monitoring ❑ Intravenous access ❑ Monitor vitals - Pulse, BP ❑ Monitor urine output ❑ Order ❑ Chest x ray ❑ Cardiomegaly ❑ Pulmonary edema ❑ Kerley B lines ❑ EKG ❑ Evidence of ischemia ❑ Infarction ❑ Arrythmia ❑ Left ventricular hypertrophy ❑ 2-D echocardiography with doppler ❑ Ventricular size, function, wall thickness, wall motion, and valve function ❑ Measure BNP or NT-pro BNP ❑ Heart failure is unlikely if:: In acute onset cases ❑ BNP ≤ 100 pg/mL ❑ NT-pro BNP ≤ 300 pg/mL In non-acute cases ❑ BNP ≤ 35 pg/mL ❑ NT-pro BNP ≤ 125 pg/mL

Order laboratory tests: ❑ CBC ❑ Troponin ❑ Electrolytes - ↓Na ❑ serum calcium ❑ serum magnesium ❑ BUN, creatinine - ↑ ❑ Arterial blood gas ❑ Fasting blood sugar ❑ Liver function tests Other additional laboratory tests: ❑ TSH ❑ Urinalysis ❑ ANA, rheumatoid factor ❑ Diagnostic tests for hemochromatosis, pheochromocytoma ❑ Radionuclide ventriculography or MRI ❑ Coronary angiography ❑ Endomyocardial biopsy ❑ Pulmonary artery catheterization - in respiratory distress or shock

Treatment

Consider admission: ❑ Hypotension and/or cardiogenic shock ❑ Poor end-organ perfusion - worsening renal function, cold clammy extremities, altered mental status ❑ Hypoxemia - Sa02 ↓90% ❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension ❑ Presence of an acute coronary syndrome

❑ Assess functional capacity using NYHA ❑ Assess volume status

Fluid retention

No fluid retention

Diuretic therapy

ACE inhibitors AND Beta blockers

Intolerant to ACE-I

Cough

Renal insufficiency or angioedema

ARBs

Hydralazine/isosorbide dinitrate

Persistent symptoms?

Yes

No

Add: ❑ Aldosterone or eplerenone if: ❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women ❑ Estimated glomerular filtration rate >30 mL/min/1.73 m2 ❑ Serum potassium ≤ 5.0 mEq/L ❑ NYHA class II–IV HF with LVEF ≤ 35% OR ❑ Hydralazine/isosorbide dinitrate ❑ African Americans with NYHA class III–IV HFrEF on GDMT OR ❑ ARBs

Persistent symptoms?

Add digoxin

Persistent symptoms?

Yes

No

❑ LVEF ≤ 35% ❑ Sinus rhythm or LBBB ❑ NYHA III - IV

LVEF ≤ 35%?

Yes

No

Yes

No

Cardiac resynchronization therapy (CRT) ± Implantable cardioverter defibrillator (ICD)

Implantable cardioverter defibrillator ❑ As primary prevention of sudden cardiac death in: ❑ Post MI with LVEF ≤ 35%, NYHA II or III on chronic GDMT ❑ Post MI with LVEF ≤ 30%, NYHA I on chronic GDMT

Continue GDMT

Persistent symptoms (Advanced heart failure)

IV inotropes or vasodilators

Mechanical circulatory support (MCS): Intra-aortic balloon pump LVAD - as bridge to recovery, transplant, or as definitive therapy ❑ General indications: ❑ LVEF ≤ 25% ❑ NYHA III or IV on chronic GDMT ❑ Predicted 1-2 year mortality

Cardiac transplantation

Diuretic Therapy

Evidence of volume overload

❑ Low sodium diet (<2 g daily) ❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L ❑ Commence IV diuretics ❑ Frusemide 40 mg, or ❑ Torsemide 20 mg, or ❑ Bumetanide 1 mg Contraindications ❑ Hypotension and cardiogenic shock Note - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)

Symptomatic improvement?

Yes

No

Maintain current IV diuretic dose

Double IV diuretic dose and titrate according to patient's response or when the maximum dose is reached

No symptomatic improvement

Add ❑ Another diuretic e.g., IV chlorothiazide or oral metolazone or ❑ An aldosterone antagonist e.g., spironolactone or eplerenone, in post MI patients

Adjuvants to diuretics ❑ Low dose dopamine to preserve renal function and renal blood flow ❑ IV nitroprusside, nitroglycerin, or nesiritide for hemodynamically stable patients to relieve dyspnea ❑ Vasopressin antagonists (e.g. tolvaptan; start with 15mg orally daily)

No symptomatic improvement (refractory edema)

Ultrafiltration or dialysis

General measures ❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts ❑ Convert all IV diuretic to oral ❑ Daily serum electrolytes, urea & creatinine ❑ DVT prophylaxis

Commonly Prescribed Medications

Drug Class	Drug	Daily doses, maximum daily dose
Loop diuretics	Furosemide	20 to 40 mg once or twice, 600 mg max daily dose In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.
	Bumetanide	0.5 to 1.0 mg once or twice, 10 mg
	Torsemide	10 to 20 mg once, 200 mg
Thiazide diuretics	Chlorothiazide	250 to 500 mg once or twice, 1000 mg
	Hydrochlorothiazide	25 mg once or twice, 200 mg
	Metolazone	2.5 mg once, 20 mg
K+- sparing diuretic	Amiloride	5 mg once, 20 mg
	Spironolactone	12.5 to 25.0 mg once, 50 mg
	Triamterene	50 to 75 mg twice, 200 mg
ACE inhibitors	Enalapril	2.5 mg twice, 10 to 20 mg twice
	Lisinopril	2.5 to 5 mg once, 20 to 40 mg once
	Ramipril	1.25 to 2.5 mg once, 10 mg once
ARBs	Candesartan	4 to 8 mg once, 32 mg once
	Losartan	25 to 50 mg once, 50 to 150 mg once
	Valsartan	20 to 40 mg twice, 160 mg twice
Beta blockers	Bisoprolol	1.25 mg once, 10 mg once
	Carvedilol	3.125 mg twice, 50 mg twice
	Metoprolol succinate	12.5 to 25.0 mg once, 200 mg once
Aldosterone antagonists	Spironolactone	12.5 to 25.0 mg once, 25 mg once or twice
	Eplerenone	25 mg once, 50 mg once
Inotropes	Dopamine	5 to 10 mcg/kg/min
	Dobutamine	2.5 to 5 mcg/kg/min
	Milrinone	0.125 to 0.75 mcg/kg/min
Vasodilators	Nitroglycerin	5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated, max is 400mcg/min
	Nitroprusside	5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated, max is 400mcg/min
	Nesiritide	2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion, maximum of 0.03 mcg/kg/minute
Hydralazine and isosorbide dinitrate	Fixed-dose combination	37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
	Individual doses	Hydralazine: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses Isosorbide dinitrate: 20 to 30 mg 3 or 4 times daily, 120 mg daily in divided doses
Digoxin		0.125 to 0.25 mg daily

Do's

• Order an echocardiogram as soon as possible if no recent one available or if the patient's clinical status is deteriorating.
• Digitalis decreases hospitalization but not mortality. It can be beneficial in symptomatic patients with low EF.
• Make sure your patient is on DVT prophylaxis unless contraindicated.
• Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
• Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .

Don'ts

• Avoid the use of NSAIDs, sympathomimetics, tricyclic antidepressants, class I and III antiarrhythmics (except amiodarone), and nondihydropyridine calcium channel blockers (diltiazem, verapamil.
• Don't Use parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion.
• Don't combine an ACEI, ARB, and aldosterone antagonist in patients with HFrEF unless otherwise indicated as this combination carries a risk of renal functions worsening and hyperkalemia.
• Avoid using statins solely for heart failure. It adds no benefit.

References

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