Chronic heart failure resident survival guide

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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

There are several goals in the chronic management of systolic heart failure. One goal of therapy is to improve the patient's symptoms, exercise tolerance and quality of life. Diuretics, along with regular assessment of the patient's weight, minimizes fluid accumulation and the accompanying symptoms of dyspnea and orthopnea. Another goal is to reduce hospitalization and mortality. To achieve the second goal, patients with chronic heart failure should be administered an ACE inhibitor (or ARB if they are ACE intolerant) and a beta blocker. If the patient remains symptomatic, additional therapy may include an aldosterone antagonist.

Goals of Therapy

Goals Therapeutic intervention
To alleviate symptoms and signs Diuretics, morphine (no mortality benefit)
To reduce mortality ACE inhibitors[1][2], ARBs, beta blockers[3], aldosterone antagonists[4], hydralazine plus isosorbide dinitrate[5], Omega-3 fatty acid[6][7], CRT[8], ICD[9]
To reduce hospitalization Digoxin[10], ARBs (in HFpEF)[11]

Classification

Based on the Stage of Heart Failure

ACCF/AHA Stages Description
A At high risk for heart failure (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

Based on the Severity of Congestive Heart Failure

NYHA
classification
Description
I No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (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

NYHA - New York Heart Association

Causes

Life Threatening Causes

Chronic heart failure is life threatening and should be treated as such irrespective of the underlying cause.

Common Causes

Complete Diagnostic Approach

The algorithm below describes the diagnostic approach to a patient with chronic heart failure.[12][13][14]

Abbreviations: ARDS: Acute respiratory distress syndrome; BNP: B-type natriuretic peptide; BUN: Blood urea nitrogen; CAD: Coronary artery disease; CBC: Complete blood count; CCB: Calcium channel blocker; CT: Computed tomography; CXR: Chest x-ray; DM: Diabetes mellitus; EKG: Electrocardiogram; HTN: Hypertension; LVEF: Left ventricular ejection fraction; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; MRI: Magnetic resonance imaging; NT-pro BNP: N-terminal pro-brain natriuretic peptide; OCPs: Oral contraceptive pills; PAWP: Pulmonary artery wedge pressure TSH: Thyroid stimulating hormone


 
 
 
 
Characterize the symptoms:

Symptoms of fluid accumulation:
Dyspnea

❑ At rest
❑ Exertional

Paroxysmal nocturnal dyspnea
Orthopnea
Cough
Peripheral edema
Ascites
Symptoms of reduced cardiac output:
Fatigue
Oliguria
Dizziness
Altered mental status
Cyanosis
Abdominal pain (may be suggestive of mesenteric ischemia)
Symptoms suggestive of precipitating events:
Chest pain (if myocardial ischemia is present)
Palpitation (suggestive of arrhythmias)
Fever (suggestive of sepsis)
Nonspecific symptoms:
Anorexia
Bloating
Nausea
Weight loss
Obtain a detailed history:
Past medical history:

Atrial fibrillation
Cardiomyopathy
Diabetes mellitus
Hypertension
Myocarditis
Previous myocardial infarction
Prior heart failure
Sleep apnea
Thyroid disease
Valvular heart disease

Medication history:

❑ Noncompliance with medications
❑ Intake of the following drugs:
Alcohol
Beta blockers
Calcium channel blockers
Chemotherapy drugs - anthracyclines
NSAIDs
Thiazolidinedione

Family history:

❑ History of dilated cardiomyopathy
Radiation to the chest
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

General appearance:
❑ Ill-looking
❑ In respiratory distress
❑ Usually in upright sitting position
Vitals:
Temperature

Fever (suggestive of underlying infection)

Pulse

Tachycardia
Narrow pulse pressure (<25 mmHg)

Blood pressure

Hypotension (suggestive of circulatory collapse)
Hypertension

Respiration

Tachypnea (commonest symptom)

Pulse oximetry
Assess weight:

❑ Subtract 'dry weight' from value to assess edema

Skin:
Cool and clammy, in hypoperfusion or cardiogenic shock
Cyanosis, in severe hypoxemia
Anasarca
Neck examination:
Jugular vein distention
Respiratory examination:
Tachypnea
Wheeze (suggestive of cardiac asthma)
❑ Dullness at lung bases, suggestive of pleural effusion
Crackles/crepitations/rales
Cardiovascular examination:
❑ Displaced apex beat (suggestive of enlarged left ventricle)
Parasternal heave (when right ventricular pressure is increased)
S3 (typical) or S4 or both
❑ New or changed murmur (suggestive of an underlying valvular heart diseases)

Mitral regurgitation - Holosystolic murmur
Aortic regurgitation - Decrescendo diastolic murmur
Aortic stenosis - Crescendo-decrescendo systolic ejection murmur with ejection click

Abdominal examination:
Hepatojugular reflux
Hepatomegaly
Ascites
Extremity examination:
Pedal edema
Neurological examination:
Altered mental status

Syncope (suggestive of aortic stenosis or pulmonary embolism)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

Routine (Class I, level of evidence C)

CBC (rule out anemia)
Troponin
❑ Elevated in myocardial ischemia and acute cardiogenic pulmonary edema
Troponin T ≥0.1 ng/mL (associated with poor survival)[15]
Electrolytes
❑ Dilutional hyponatremia (with the presence of edema)
Serum calcium
Serum magnesium
BUN, creatinine
Urinalysis
Fasting blood sugar
Fasting lipid profile
Liver function tests
TSH

BNP or NT-pro BNP
Heart failure is unlikely if:[13][16]

BNP ≤ 35 pg/mL
❑ NT-pro BNP ≤ 125 pg/mL

Chest X-ray (Class I, level of evidence C)

Cardiomegaly (cardiothoracic ratio >50%)
❑ Cardiogenic pulmonary edema
Kerley B lines
Peribronchial cuffing
❑ Cephalization
Chest X-ray findings in a patient with acute heart failure

EKG

Low QRS voltage
Arrhythmia (usually atrial fibrillation)
Poor R wave progression (suggestive of a prior MI)
Left ventricular hypertrophy (consistent with a history of hypertension)
Left bundle branch block (LBBB)
Left atrial enlargement
❑ Non-specific ST segment and T wave changes

❑ 2-D echocardiography with doppler
(Class I, level of evidence C)

❑ Ventricular size, function, wall thickness, wall motion, and valve function

Radionuclide ventriculography or MRI

❑ To assess LVEF and volume when echocardiography is inadequate
❑ To assess myocardial infiltrative processes or scar burden (MRI)

Coronary angiography (in settings of ischemia)
Pulmonary artery catheterization - in respiratory distress or shock
Additional tests to rule out other etiologies:


ANA, rheumatoid factor (for rheumatologic diseases)
❑ Diagnostic tests for hemochromatosis, pheochromocytoma
Endomyocardial biopsy (when myocarditis is suspected)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnoses:

Alternative diagnosesFeatures
COPDDyspnea, cough, sputum, history of smoking
Spirometry reveals obstructive pattern
PneumoniaFever, cough, sputum
❑ CXR - consolidation
Liver cirrhosisJaundice, fatigue, peripheral edema, coagulopathy
❑ Abnormal liver function tests
Liver biopsy confirms the underlying cause
Pulmonary embolismPleuritic chest pain, cough, S4
❑ Risk factors - trauma, immobilization, smoking, OCPs
❑ CT pulmonary angiography - clot in pulmonary artery
Peripartum cardiomyopathy Dyspnea, orthopnea, PND
Pregnancy
❑ Absence of heart disease prior to onset of heart failure
Echocardiography confirms left ventricular enlargement and systolic dysfunction
Nephrotic syndrome Dyspnea, fatigue, peripheral edema
Urinalysis reveals proteinuria > 3.5g/24 hours
 


Treatment

 
 
 
 
Consider admission:[17]

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 hemodynamic and volume status

Congestion at rest
e.g., orthopnea, ↑JVP, rales, S3, pedal edema

❑ Low perfusion at rest
e.g., narrow pulse pressure, cool extremities, hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify the patient based on the
left ventricular ejection fraction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Systolic heart failure
LVEF ≤ 40%
 
Diastolic heart failure
LVEF ≥ 50%
 
 
 
 
 
 
 
 
 
 
 
First step: Diuresis





 
 
 
 
 
 
 
 
 
 
 
 
Second step: ACE Inhibition and Angiotensin Receptor Blockade





 
 
 
 
 
 
 
 
 
 
 
Third step: Beta blockers





 
 
 
 
 
 
 
 
 
 
Fourth step: Aldosterone Antagonism





 
 
 
 
 
 
 
 
 
 
Fifth step: The Combination of Hydralazine and a Nitrate





 
 
 
 
 
 
 
 
 
 
Sixth step: Digoxin





 


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) [18] [19]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 


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.[20]
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

  • Ensure 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.
  • 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.[21][22][23][24][25][26][27]
  • Make sure your patient is on DVT prophylaxis unless contraindicated.[28][29]
  • 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 .[30][31]

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: [13]

  • 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

Don'ts

References

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