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Heart Failure

Investigations

  • Look for etiology
    • Routine labs (CBC, creatinine, lytes)
    • Troponin
    • NT-pro BNP
    • ECG
    • CXR
    • Echocardiogram

General management

  • General principles
    • Furosemide IV to decrease volume overloading
    • Sodium restricted diet < 2 g Na
    • Fluid restricted diet < 2 L
    • Nitroglycerin infusion to decrease preload
    • Respiratory therapy, 100 % FiO2 +/- non-invasive positive pressure ventilation
  • If hypotensive
    • Consult CCU stat
    • Insert central line and arterial line for invasive monitoring and intiation of vasopressors and inotropes

2 kinds of heart failure:

  1. HFpEF – heart failure with preserved ejection fraction
    • Diastolic heart failure (HFpEF – heart failure with preserved ejection fraction)
      • Why is ejection fraction preserved in diastolic heart failure?
        • Recall that LVEF = stroke volume / EDV
        • In diastolic heart failure, there is an inability for the left ventricle to fill completely, so the EDV is reduced, but stroke volume is also reduced
          As a result, ejection fraction remains preserved
    • Management
      • No medications have been shown to reduced mortality or morbidity in preserved ejection fraction heart failure
  2. HFrEF – heart failure with reduced ejection fraction
    • Systolic heart failure (HFrEF – heart failure with reduced ejection fraction)
      • At least half of the blood left in the left ventricle at the end of diastole should be pumped out by the heart during each cardiac cycle
      • LVEF between 40 and 50 % is borderline systolic heart failure
      • LVEF under 40 % is considered systolic heart failure
    • Management
      • Long term management includes
        • ACE inhibitors or ARBs
          • For black people and ethnic groups intolerant of ACE/ARBs use isosorbide dinitrate and hydralazine
        • Beta blockers (carvedilol, bisoprolol, metoprolol)
        • Only if LVEF < 40 %
          • Triple therapy: add mineralocorticoid receptor antagonists (spironolactone) in addition to ACE/ARB and beta blockers
          • Avoid most CCBs when LVEF < 40 %
            • Even diltiazem and verpamil for arrythmia if LVEF < 40 %
          • Reassess symptoms after triple therapy
            • If NYHA class I
              • Continue triple therapy
            • If NYHA class II-IV, sinus rhythm, heart rate > 70 bpm
              • Add ivabradine
              • Switch ACE or ARB to ARNI
            • If NYHA class II-IV, sinus rhythm, heart rate < 70 bpm or AF or pacemaker
              • Switch ACE or ARB to ARNI
        • Devices (both used in severe heart failure)
          • Implantable cardioverter defibrillators (ICDs)
            • Arrhythmias are a common cause for sudden death in HF
            • We can prophylactically install this device so that if the person enters into a shockable rhythm, the device will automatically cardiovert or defibrillate the patient
          • Biventricular pacemakers
            • Artificial implanted pacemaker that helps both ventricles contract at the same time

Quick pearls of heart failure management

  • Isosorbide dinitrate can be considered
    • In addition to standard triple therapy for black patients with advanced symptoms
    • Patients unable to tolerate ACEi or ARB because of renal dysfunction or hyperkalemia
  • Ivabradine should not be added before BB is titrated to maximum evidence based and patient tolerated dose
  • If converting a patient from ACEi to ARNI, must wait at least 36 h after last dose before starting ARNI to lower risk of angioedema
  • ARNI should not be added before triple therapy has been attempted for at least 3 months
  • Patients who are volume overloaded can be given IV furosemide 20-80 mg bolus
    • If SBP < 100 and symptomatic can provide dopamine or dobutamine
    • If SBP > 100 can consider adding nitroglycerin (IV/SL) or nitroprusside (IV)
  • Flexible Diuretic Regimen (FDR) is a way for patients to adjust their lasix dose based on their own weight measurements
  • If patient is volume overloaded provide lasix dose that results in 1 kg or 2 lbs weight decrease per day
    • If > 1 kg weight decrease, reduce lasix diuretic by 25 – 50 %
    • If < 0.5 kg weight increase, increase lasix diuretic by 50 % and consider adding metolazone 1 to 7 times per week
  • ICD should not be considered for patients with life expectancy of less than 1 year of life
  • CRT should only be considered for patients who have tried optimal medical therapy for 3 months, who have NYHA II-IV symptoms (or without symptoms if their HF is from an ischemic cause) and who show ECG sinus rhythm, QRS duration > 130 msec with LBBB morphology