Heart Failure for the Internist

Phil Camp and Paul AndreR3s UNM IM

Goals

• Be able to diagnose HF• Recognize other possible diagnoses on the

differential• Understand treatment goals of ADHF• Understand GDMT in the treatment of HF

Outline of lecture

• Most patient care is initiated by ED call, will start there

• Continue with admission orders and care while patient is in ADHF

• GDMT• Discharge and follow up

Heart Failure: Diagnosis

• HF is a clinical diagnosis• Objective data can help differentiate HFpEF

from HFrEF, along with ADHF from other diagnoses

• Diagnosis is made with Framingham Criteria for Heart Failure– Need 2 major OR 1 major and 1 minor

Major Criteria

• PND or orthopnea• JVD; increased venous pressure >16 cm H2O• Rales• Cardiomegaly on CXR• Acute pulmonary edema on CXR• S3 gallup• Hepatojugalar reflux• Weight loss of 4.5 kg in 5 days of presumed HF

treatment

Minor Criteria

• Bilateral LE edema• Nocturnal cough• Dyspnea on ordinary exertion• Hepatomegaly• Pleural effusion on CXR• Tachycardia > 120 bpm• Weight loss > 4.5 kg in five days

Common ED calls

• “This guy has a history of HFpEF and is short of breath…”

• “This lady with ESRD on HD has a BNP of >30000…”

• “This guy is in ADHF… his HR is 155 in Afib with RVR…”

BNP: Why it matters and why it doesn’t

• BNP reflects wall tension• Wall tension = radius x pressure

wall thicknessHFrEF = thin walls; dilated LV radius = high BNPHFpEF = thick walls; nml LV radius = low BNPOther factors effecting BNP interpretation: Age,

weight, renal functionBNP is metabolized by kidney -> don’t present a BNP

without giving a GFR (creatinine)

ADHF: Initial evaluation

• Quick chart biopsy– Previous cardiac studies; especially EF evaluations,

cath reports, and BNPs– Recent HF clinic notes and DC summaries; DRY

WEIGHT/Last HF weight on discharge, medications, reason for previous admission

• Thorough history and physical– Precipitating event?– JVD? S3? crackles? LE edema? Orthopnea?

Causes of Decompensation

• Every admission of ADHF needs a reason for why they are in ADHF

• Common precipitants– MY HEARTS DIE

Precipitants of ADHF

• MY HEARTS DIE– MYocardial ischemia– Hypertension (uncontrolled) or Hypoxia (OSA)– Endocrine (DM, hypo/hyperthyroid)– Arrhythmias (afib, brady and tachy) or Anemia– Reduction in therapy (nonadherence) or Renal insufficiency– Too much Na and fluid– Second CV disorder (endocarditis,myocarditis, dissection)– Drugs (neg inotropes, toxins, Na retaining meds)– Infections (sepsis, PNA)– Embolism (PE)

Hemodynamic Profiles: What are they and why do they matter?

• 4 hemodynamic profiles– Warm or cold: narrow pulse pressure, cool skin,

hypotension, CI <2.2– Wet or dry: orthopnea, JVD, rales, S3, edema,

PCWP >18• Cold patients must be warmed up before they

can be dried out

ED HF dispositions• ADHF due to medication/diet noncompliance

– Admit to Cards• ADHF due to inadequate/improper medical therapy

– Admit to Cards• ADHF due to cardiac decompensation

– Admit to Cards– Cardiogenic shock -> typically MICU

• ADHF due to acute illness, toxic ingestion requiring treatment, endocrine issues– Admit to medicine

• FLUID OVERLOAD in someone who is ESRD on HD– Admit to medicine

• Family Medicine admits their own ADHF

HFpEF? HFrEF?

• EF >50% -> HFpEF (preserved EF)• EF 40-49% -> HFpEF borderline• EF previously <40%, now >40% -> HFpEF

improved• EF <40% -> HFrEF (reduced EF)Why it matters:

Most studies divide patients into either HFpEF or HFrEF

AHA/ACCF guidelines vary by HFpEF and HFrEF

HFpEF masqueraders

• Cardiac– Think outside-in anatomically– Pericardium, epicardium, myocardium, electrical disease,

valvular disease, vascular disease• Noncardiac– Obesity, deconditioning, anemia, hypothyroidism– Neuromuscular disease– Pulmonary: OSA, COPD– Renal Artery stenosis– High output heart failure: anemia, sepsis, AV shunt,

hyperthyroid

AHA/ACCF HF Stages

• Stage A: high risk for HF; no structural disease or symptoms of HF

• Stage B: Structural heart disease; no signs or symptoms of HF

• Stage C: Structural heart disease; prior or current symptoms of HF

• Stage D: Refractory HF requiring specialized interventions

NYHA Functional Classes

• I – No limitations of physical activity• II – Slight limitation of physical activity– Comfortable at rest. Ordinary activity results in

symptoms• III – Marked limitation of physical activity– Comfortable at rest. Less than ordinary activity

results in symptoms• IV – Unable to carry on physical activity

without symptoms or symptoms at rest

Questions?

• Diagnose HF?• Classify/stage HF?• Evaluate DDx?

Admission Orders• HF power plan

– Fluid restriction: 2 L– If hyponatremic: 1.5 L

• Beta blocker at ½ normal dose– Safe to start/resume when dry– Hold if cold – start dobutamine/milrinone

• Diuresis with IV loop diuretic– Pick your poison. If no response after 6 hrs, double or try another loop.

If no response, change to gtt, add metolazone/chlorothiazide• If AKI; hold ACEi/ARB

– Start Nitrate/hydralazine combo for afterload reduction• As always, treat underlying cause of decompensation

Daily Goals/Common Pitfalls of Managment

• Don’t be scared with aggressive diuresis• Vascular refill rapid 1st 24 hrs of diuresis• Continue on IV diuretics until dry• If AKI, hold diuresis. Don’t give fluids.• Hydralazine can be rapidly titrated after each

dose if tolerated

What to look for on prerounds?

• Chart review– Labs: Cr, K, Na– Vitals: Orthostatic? Weight? I/Os?– Review tele: particularly in the paper chart

• Physical exam– Wet or dry– Cold or warm

HFpEF Treatment Guidelines

• HHAARDN – 5 guideline treatments + 2• H – HTN; treat to guideline goals• H – HTN drug choices; ACEi/ARB or Beta blocker• A – Afib; Control by guidelines• A – Aldosterone antagonist; Spironolactone

decreases hospitalization and reduces mortality• R – Revascularize; if ischemic• D – Diuretic; if wet, diuresis• N – n3 PUFA; n3 polyunsaturated fatty acids

HFrEF Treatment Guidelines

• Medications– ACEi/ARB– Beta blocker– Diuretic– Nitrate/hydralazine– Aldosterone antagonist– Digoxin– n3 PUFA

ACEi• Class 1, LOE A• Contraindication – angioedema, pregnancy/plan for pregnancy• Caution – Cr >3.0, bilateral RAS, K >5, hypotension (SBP <80)• Enalapril• Captopril• Lisinopril• Ramapril• Quinapril• Fosinopril• Perindopril• Trandolapril

ARB

• ACEi intolerant patients, Class 1, LOE A• Candesartan• Losartan• Valsartan

Beta Blocker

• Class 1, LOE A• ADHF safe dose – ½ home dose• Start new when on oral diuretic• Carvedilol• Metoprolol succinate• Bisoprolol

Diuretic

• Furosemide• Bumetanide• Torsemide• Metolazone• Chlorothiazide• Know patient’s dry weight, get daily weights

on home scale and instruct on diuretic use based on weight

Nitrate and hydralazine

• Recommended in African Americans with NYHA class III-IV on optimal medical therapy. Class 1, LOE A

• Can’t tolerate ACEi/ARB. Class IIa, LOE B• Nitrate mean daily dose 136 mg• Hydralazine mean daily dose 270 mg

Aldosterone antagonist

• Recommended in NYHA class II-IV: EF<35%; Cr <2.5 in men, <2.0 in women; K<5, GFR>30. Class I, LOE A

• Monitoring: Chem7 day 3, 7; Wk 2, 3; Month 1 and every 3 months after

• Spironolactone• Eplerenone

Digoxin

• Can be beneficial to reduce HF hospitalizations unless contraindicated. Class IIa, LOE B

• Goal serum level 0.5 – 0.9

n3 PUFA

• Reasonable to use as adjunct in NYHA class II-IV to reduce mortality and hospitalizations. Class IIa, LOE B.

• Dose 1200 TID

ARNi

• No current recommendations at this time• LCZ696 (Entresto)– Combination pill of valsartan and sacubitril– Superior to enalapril by PARADIGM trial

Medications to be aware of

• Statins – no benefit in HF; OK to give for other indications

• Nebivolol – No benefit by SENIORS trial• Non-dihydropyridine calcium channel blockers

– EF<40%, Class III, LOE C, MAY CAUSE HARM• Amlodipine OK

Devices

• ICD – implantable cardioverter defibrillator– EF <35%, >40 days post MI, NYHA class II or III on GDMT

with >1yr estimated survival. Class I, LOE A.– EF <30%, >40 days post MI, NYHA class I on GDMT with

>1yr estimated survival. Class I, LOE B.• CRT – cardiac resynchronization therapy– EF <35%, SR, LBBB with QRS >150 ms, NYHA class II-IV

on GDMT. Class I, LOE A for NYHA III/IV, LOE B for NYHA class II• Look at the EKG for rhythm, QRS duration and morphology• Evaluate patient for NYHA class, GDMT, and EF

Stage D HF

• Definition• Goals

– Control symptoms with GDMT– Improve quality of life– Reduce admissions– Establish end of life goals

• Therapeutic options– LVAD, heart transplant– Inotropic support– Fluid restrict 1.5-2 Liter/day is reasonable– Palliative care and hospice

Discharge

• Day of discharge:– BNP, H/H, dry weight– Cards: DC summary dictated on day of DC– Med rec with indications for all meds given– All GDMT medications must be listed• Need reasons patients not DC’d with ACEi/ARB or Beta

blocker

• Follow up:– 1 week with HF clinic, PCP

Questions?

• Know treatment goals of ADHF?• Know GDMT for HFpEF and HFrEF?• Aware of stage D HF as unique?• Discharge requirements?

• Always ACEI 1st (all BB studies done on ACEI)• Class I & III (goes for any guidelines on boards)