Heart Failure

Heart Failure Definition Structural or functional impairment in the heart Heart failure with reduced ejection fraction: HF with LVEF of 40% of less Heart failure with mildly reduced ejection fraction: LVEF of 41 to 49% Heart failure with preserved ejection fraction: LVEF is 50% or higher Epidemiology Most commonly in older people Left heart failure is most common Diastolic heart failure is more common than systolic Causes/Risk Factors of Heart Failure Hypertension Coronary artery disease Diabetes mellitus Arrythmias Excess alcohol recreational stimulant drugs Valvular heart disease Cardiomyopathies Chronic lung disease Pulmonary embolism Pericardial effusion Precipitating or Exacerbating Factors Lack of treatment adherence Diet: excessive fluid, salt or alcohol Tachyarrhythmia or bradyarrhythmia Myocardial ischemia or infarction Medications Infections Pulmonary embolism IDA Anaemia Worsening kidney function Hyperthyroidism Acute valvular dysfunction Clinical Features Most are due to salt and water retention and the consequent rise in cardiac filling pressure Left Heart Failure Right Heart Failure Features of pulmonary congestion Dyspnoea Peripheral pitting edema Orthopnoea Hepatic venous congestion Pulmonary oedema Abdominal pain Paroxysmal nocturia dyspnoea Jaundice Cardia asthma Nausea, loss of appetite in congestive gastropathy Wheezing, shortness of breath and coughing Physical examination Pallor, cold and clammy Jugular venous distension Physical examination Kussmaul sign Bilateral basilar rales on auscultation Hepatosplenomegaly Laterally displaced apical heartbeat Cardiac cirrhosis and ascites Coolness and pallor of lower extremities Hepatojugular reflux Hypotension Investigations Labs For all patients BNP CBC BMP Normal or high Cr HbA1c Liver biochemistry Fasting lipids TSH Iron studies 12 lead ECG CXR All patients Changes Cardiomegaly Boot-shaped heart -> RV enlargement Signs of pericardial effusion Features of pulmonary congestion Signs of concomitant heart conditions: Valvular calcifications in valvular disease Pericardial calcification TTE Preferred initial imaging modality Can be done when for assessment for treatment change or response of evaluation for device therapy Findings: LV systolic or diastolic dysfunction Quantitative measurement of LVEF Atrial and ventricular size and thickness Evidence of complications E.g. functional MR, LA Underlying causes LV hypertrophy in HTN, regional wall motion abnormalities due to CAD Additional studies Cardiac MRI: high accuracy for assessing ventricular volume, mass and ejection fraction Non-invasive stress imaging Right heart catheterisation Most sensitive for HFPEF Expensive and invasive Endomyocardial biopsy Heart Failure Staging Management Aims Identify cause Identify precipitating or exacerbating factors Management for HFrEF Key Info All four drug classes should be started at diagnosis or within 2 to 4 weeks of diagnosis Preferably to start all before up titrating any Optimisation of doses may take 2 to 3 months Aim to achieve optimum dosage by then The four classes to be used RAAS inhibitors Choice depends based on drug efficacy and patient tolerability Options: Angiotensin-receptor neprilysin inhibitor Sacubitril + valsartan First line in newly diagnosed patients More effective than ACE inhibitors are reducing death risk and hospitalisation More likely to cause HoTN ACE inhibitor Can also be considered first line May be preferred over above if patient has HoTN Angiotensin II receptor blockers Only used if patients cannot tolerate the above two Key info: If ACE or ARB were used as first line but still have a persistent HFrEF -> substitute them with sacubitril + valsartan Do not use more than one RAAS inhibitor at the same time Patients should be monitored for: HoTN Kidney impairment Hyperkalaemia Transient asymptomatic fall in BP and small rise in Cr or K+ is normal when therapy is initiated or dose is increased Heart failure specific beta blockers For all patients including those whom BBs are usually avoided for Need careful consideration in patients with PDA and critical limb threatening ischemia Can initially worsen HF and cause severe HoTN and bradyarrhythmia To minimise the above: To do not start during acute decompensation or if patient has signs of congestion Start are low dose Increase dose gradually Monitor symptoms frequently and measure weight daily E.g. bisoprolol or carvedilol etc. Mineralocorticoid receptor antagonist This in combo with RAAS inhibitors can cause life threatening hyperkalemia in patients with kidney impairment In these patients start at a low dose Small rise in Sr K+ may happen at initiation or dose increase -> transient and normal E.g. eplerenone or spironolactone SGLT2 inhibitors With or without diabetes E.g. dapagliflozin or empagliflozin Others Loop diuretics can be added at any stage to control symptoms and acute exacerbations E.g. furosemide or bumetanide Alternative vasodilator therapy Digoxin Vericiguat Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF) Same as patients with HFrEF Heart Failure with Preserved Ejection Fraction The same drugs as the ones used in HFrEF Drugs that cause harm in these patients: Vasodilators -> severe reduction in cardiac output Powerful Digoxin -> unless the patient has AF Interventions for Refractory or Advanced Stage Heart Disease Higher doses of loop diuretics and IV furosemide may be needed Heart transplantation Vascular resistance devices Bride to transplantation May be a long-term alternative Automated implantable cardioverter devices Aims to prevent sudden death: Cardiomyopathy -> tachyarrhythmia -> sudden cardiac death CRT Synchronizing contractions in LV and RV Improved ventricular function Reverse ventricular remodelling Reduction in secondary MR Mechanically circulatory support Short or long term Included an intra-aortic balloon pump and Veno arterial extracorporeal membrane oxygenation IV inotropic support Pleurocentesis and pericardiocentesis For refractory or advanced stage heart failure significant pleural effusions pericardial aspiration Complications Acute decompensated heart failure Cardiorenal syndrome Central sleep apnoea Arrhythmias Most common complication Stroke Cardiogenic shock Manage with for heart failure and renal failure management as AKI Chronic kidney disease Cardiac cirrhosis Venous stasis and leg ulcers