Update in

Congestive

Hear FailureDRAGOS VESBIANU MD

Case

58 yo AAM c/o shortness of breath for 3 weeks. Used

to walk one mile per day and now he has noticed

that he gets short of breath after 2 blocks. He also has a hard time climbing steps. Denies cough and

has occasional wheezing. He usually sleeps on 2

pillows because of back problems. Has gained 10 lbs

in the last month, but it’s not unusual for his weight to

fluctuate.

Case

PMH: HTN, DM 2, HLD, COPD

Meds: Lipitor, HCTZ, Metformin, Lantus, Advair,

Albuterol BID

Physical exam:

Comfortable, not SOB at rest

Bilateral wheezing and rales lower lungs

S1, S2, RRR

+1 b/l LE pitting edema

Symptoms in HF

Common Symptoms:

-dyspnea

-edema

-fatigue

-wheezing

Subtle symptoms:

-abdominal pain, nausea, anorexia

-confusion

-lethargy

• After detailed history; Initial laboratory evaluation:

• CBC, urinalysis, CMP (including calcium and magnesium),

fasting lipid profile, TSH, iron panel,

• Serial monitoring, when indicated, should include serum

electrolytes and renal function, BNP, +/-CE

• A 12-lead ECG should be performed initially on all patients

presenting with HF.

• Chest X-ray in all patients with new onset HF.

• Echocardiogram in all patients with new dx of HF (MUGA in some)

• Repeat echo usually for a significant change in clinical status

or for consideration of changes after therapy or to evaluate

for device therapy.

• Noninvasive stress imaging or cardiac cath is reasonable in HF

and suspected CAD

Initial Workup of Stage C HF

Role of BNP in chronic HF

•BNP and NT-proBNP are sensitive (92-93%) and can

help rule out heart failure

•BNP has prognostic value and can be used for risk

stratification

•BNP guided therapy may play a role especially in

hospitalized patients.

Case

You start the patient on Lasix 40 mg BID. He calls

in 5 days to let you know he is doing much better.

You check an Echocardiogram that shows, LVH, bilateral atrial enlargement, EF of 30%

What do you do next?

Definition of Heart Failure

Classification Ejection

Fraction

Description

I. Heart Failure with

Reduced Ejection Fraction

(HFrEF)

≤40% Also referred to as systolic HF. Randomized clinical trials have

mainly enrolled patients with HFrEF and it is only in these patients

that efficacious therapies have been demonstrated to date.

II. Heart Failure with

Preserved Ejection

Fraction (HFpEF)

≥50% Also referred to as diastolic HF. Several different criteria have been

used to further define HFpEF. The diagnosis of HFpEF is

challenging because it is largely one of excluding other potential

noncardiac causes of symptoms suggestive of HF. To date,

efficacious therapies have not been identified.

a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their

characteristics, treatment patterns, and outcomes appear similar to

those of patient with HFpEF.

b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF

previously had HFrEF. These patients with improvement or recovery

in EF may be clinically distinct from those with persistently

preserved or reduced EF. Further research is needed to better

characterize these patients.

Classification of Heart Failure

ACCF/AHA Stages of HF NYHA Functional Classification

A At high risk for HF but without structural

heart disease or symptoms of HF.

None

B Structural heart disease but without signs

or symptoms of HF.

I No limitation of physical activity.

Ordinary physical activity does not cause

symptoms of HF.

C Structural heart disease with prior or

current symptoms of HF.

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.

D Refractory HF requiring specialized

interventions.

Pharmacological Treatment for

Stage C HFrEFTequila shot vs Penicillin shot

Diuretics are recommended in patients with HFrEF who have evidence of fluid retention, unless contraindicated, to improve symptoms.

ACE inhibitors are recommended in patients with HFrEF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality.

ARBs are recommended in patients with HFrEF with current or prior symptoms who are ACE inhibitor-intolerant, unless contraindicated, to reduce morbidity and mortality.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Pharmacological Treatment for

Stage C HFrEF (cont.)

Tequila shot vs Penicillin shot

Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful for patients with HFrEF.

Use of 1 of the 3 beta blockers proven to reduce mortality (i.e., bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce morbidity and mortality.

I IIa IIb III

I IIa IIb III

Harm

Neprilysin as a Therapeutic Target

Inactive

fragments

Neprilysin

Natriuretic peptides

Adrenomedullin

Bradykinin

Substance P

(angiotensin II)

• Neprilysin breaks down endogenous

vasoactive peptides, including the natriuretic

peptides

• Inhibition of neprilysin potentiates the action

of those peptides

• Because angiotensin II is also a substrate

for neprilysin, neprilysin inhibitors must be

co-administered with a RAAS blocker

• The combination of a neprilysin inhibitor and

an ACEI is associated with unacceptably high

rates of angioedema

Corti R et al. Circulation. 2001;104:1856-1862.

Sacubitril/Valsartan (LCZ696): Angiotensin Receptor–Neprilysin Inhibitor (ARNI)

1. McMurray JJ et al. N Engl J Med. 2014;371:993-1004

PARADIGM-HF: CV Death or HF Hospitalization (Primary Endpoint)

SHIFT Trial Primary Composite Endpoint:

CV Death or Hospitalization for Worsening HF

Swedberg K et al. Lancet. 2010;376:875-885.

COR LOE Recommendation

I B-R ACEI or ARB or ARNI in conjunction with β blockers + MRA

(where appropriate) is recommended for patients with chronic

HFrEF to reduce morbidity and mortality

I B-R In patients with chronic, symptomatic HFrEF NYHA class II or III

who tolerate an ACEI or ARB, replacement by an ARNI is

recommended to further reduce morbidity and mortality

III B-R ARNI should NOT be administered concomitantly with ACEI or

within 36 hours of last ACEI dose

III C-EO ARNI should NOT be administered to patients with a history of

angioedema

1. Yancy CW et al. J Am Coll Cardiol. 2016;68:1476-1488.

2016 ACC/AHA/HFSA Focused Update on New Pharmacological

Therapy for Heart Failure: An Update of the 2013 ACCF/AHA

Guideline for the Management of Heart Failure

COR LOE Recommendations

IIa B-R Ivabradine can be beneficial to reduce HF hospitalization for

patients with symptomatic (NYHA class II-III), stable, chronic

HFrEF (LVEF ≤35%) who are receiving GDMT, including a β

blocker at maximally tolerated dose, and who are in sinus

rhythm with a heart rate ≥70 bpm at rest

Pharmacological Treatment for

Stage C HFrEF (cont.)

Aldosterone receptor antagonists [or mineralocorticoid receptor antagonists (MRA)] are recommended in patients with NYHA class II-IV and who have LVEF of 35% or less, unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in women (or estimated glomerular filtration rate >30 mL/min/1.73m2) and potassium should be less than 5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency.

I IIa IIb III

Pharmacological Treatment for

Stage C HFrEF (cont.)

Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of 40% or less who develop symptoms of HF or who have a history of diabetes mellitus, unless contraindicated.

Inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency when serum creatinine greater than 2.5 mg/dL in men or greater than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73m2), and/or potassium above 5.0 mEq/L.

I IIa IIb III

I IIa IIb III

Harm

Pharmacological Treatment for

Stage C HFrEF (cont.)

The combination of hydralazine and isosorbide dinitrate is recommended to reduce morbidity and mortality for patients self-described as African Americans with NYHA class III–IV HFrEF receiving optimal therapy with ACE inhibitors and beta blockers, unless contraindicated.

A combination of hydralazine and isosorbide dinitrate can be useful to reduce morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated.

I IIa IIb III

I IIa IIb III

Medical Therapy for Stage C HFrEF:

Magnitude of Benefit Demonstrated in

RCTs

GDMTRR Reduction

in Mortality

NNT for Mortality

Reduction

(Standardized to 36 mo)

RR Reduction

in HF

Hospitalizations

ACE inhibitor or

ARB17% 26 31%

Beta blocker 34% 9 41%

Aldosterone

antagonist30% 6 35%

Hydralazine/nitrate 43% 7 33%

Case

Your guy had a few “no shows” in the clinic and you

get a call from your hospitalist colleagues that he

got admitted for CHF exacerbation. He presented to the hospital with shortness of breath and 30 lbs

weight gain. BP is 160/96, HR is 93, sat 90% on RA.

Positive JVDs, crackles bilaterally. BNP is 2000. Now

on Coreg 6.25 mg, Lisinopril 10 mg and

Spironolactone 25 mg

How should approach his CHF exacerbation.

Triggers for acute

decompensation

Non compliance with medications

Non compliance with diet

Poorly controlled HTN

Ischemia/ACS

Afib

Infections (demand ischemia)

PE

Worsening renal function

Management of acute

decompensation

Volume control

Afterload and preload reduction

Positive pressure ventilation

Initiation of neuro-hormonal drugs

Morphine use

Implantable Cardiac Defibrillators (ICD)

• Sustained ventricular tachycardia is associated with sudden cardiac death in HF.

• About one-third of mortality in HF is due to sudden cardiac death.

• ICDs for primary prevention have been shown to improve survival in selected patients with HF

Indications for ICD Therapy

• ICD therapy is recommended for primary prevention of

SCD in selected patients with HFrEF at least 40 days post-

MI with LVEF ≤35%, and NYHA class II or III symptoms on

chronic GDMT, who are expected to live ≥1 year

• ICD therapy is recommended for primary prevention of

SCD in selected patients with HFrEF at least 40 days post-

MI with LVEF ≤30%, and NYHA class I symptoms while

receiving GDMT, who are expected to live ≥1 year

• ** ICDs do not improve symptoms; most patients

should be on GDMT; should have an expected life-

expectancy of at least 1 year

2013 ACCF/AHA Guideline for the Management of Heart Failure

Cardiac Resynchronization Pacing:

Consequences of a Prolonged QRS

Delayed Ventricular

ActivationDelayed lateral wall contraction

Disorganized ventricular contraction

Decreased pumping efficiency

Reduction in diastolic filling

times

Prolongation of the duration

of mitral regurgitation

Sinus

node

AV

node

Conduction

block

• Intraventricular Activation

• Organized ventricular activation

sequence

• Coordinated septal and freewall

contraction

• Improved pumping efficiency

Mechanism:

Ventricular Resynchronization

Sinus

node

AV

node

Stimulation

therapy

Conduction

block

Device Therapy for Stage C HFrEF

ICD therapy is recommended for primary prevention of

SCD to reduce total mortality in selected patients with

nonischemic DCM or ischemic heart disease at least 40

days post-MI with LVEF of 35% or less, and NYHA class II or III

symptoms on chronic GDMT, who have reasonable

expectation of meaningful survival for more than 1 year.

CRT is indicated for patients who have LVEF of 35% or less,

sinus rhythm, left bundle-branch block (LBBB) with a QRS

duration of 150 ms or greater, and NYHA class II, III, or

ambulatory IV symptoms on GDMT.

I IIa IIb III

I IIa IIb III

NYHA Class III/IV

I IIa IIb III

NYHA Class II

STAGE AAt high risk for HF but

without structural heart

disease or symptoms of HF

STAGE BStructural heart disease

but without signs or

symptoms of HF

THERAPY

Goals

· Control symptoms

· Improve HRQOL

· Prevent hospitalization

· Prevent mortality

Strategies

· Identification of comorbidities

Treatment

· Diuresis to relieve symptoms

of congestion

· Follow guideline driven

indications for comorbidities,

e.g., HTN, AF, CAD, DM

· Revascularization or valvular

surgery as appropriate

STAGE CStructural heart disease

with prior or current

symptoms of HF

THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality

Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists

Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin

In selected patients· CRT· ICD· Revascularization or valvular

surgery as appropriate

STAGE DRefractory HF

THERAPY

Goals

· Prevent HF symptoms

· Prevent further cardiac

remodeling

Drugs

· ACEI or ARB as

appropriate

· Beta blockers as

appropriate

In selected patients

· ICD

· Revascularization or

valvular surgery as

appropriate

e.g., Patients with:

· Known structural heart disease and

· HF signs and symptoms

HFpEF HFrEF

THERAPY

Goals

· Heart healthy lifestyle

· Prevent vascular,

coronary disease

· Prevent LV structural

abnormalities

Drugs

· ACEI or ARB in

appropriate patients for

vascular disease or DM

· Statins as appropriate

THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital

readmissions· Establish patient’s end-

of-life goals

Options· Advanced care

measures· Heart transplant· Chronic inotropes· Temporary or permanent

MCS· Experimental surgery or

drugs· Palliative care and

hospice· ICD deactivation

Refractory symptoms of HF at rest, despite GDMT

At Risk for Heart Failure Heart Failure

e.g., Patients with:

· Marked HF symptoms at

rest

· Recurrent hospitalizations

despite GDMT

e.g., Patients with:

· Previous MI

· LV remodeling including

LVH and low EF

· Asymptomatic valvular

disease

e.g., Patients with:

· HTN

· Atherosclerotic disease

· DM

· Obesity

· Metabolic syndrome

or

Patients

· Using cardiotoxins

· With family history of

cardiomyopathy

Development of

symptoms of HFStructural heart

disease

• Trials have not shown

significant mortality or morbidity

benefit with use of ACEI/ARB

specifically in HFpEF

• No trials showing definite

benefit of Beta blockers,

sildenafil

• TOPCAT trial: Randomized-

double blind trial of

spironolactone (15-45 mg) vs.

placebo in HFpEF patients

(LVEF >45%) with

• Prior HF hospitalization or

• BNP > 100 pg/ml

HFpEF