Congestive heart failure Treatment of associated conditions

Resident Survival Guide

Congestive Heart Failure Microchapters
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Patient Information
Overview
Historical Perspective
Classification
Pathophysiology Systolic Dysfunction Diastolic Dysfunction HFpEF HFrEF
Causes
Differentiating Congestive heart failure from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Clinical Assessment
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
Chest X Ray
Cardiac MRI
Echocardiography
Exercise Stress Test
Myocardial Viability Studies
Cardiac Catheterization
Other Imaging Studies
Other Diagnostic Studies
Treatment
Invasive Hemodynamic Monitoring
Medical Therapy:
Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
Exercise Training
Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Overview

Congestive heart failure can be associated with and exacerbated by rapid supraventricular as well as atrial fibrillation, ventricular arrhythmias, venous thromboembolism, renal insufficiency, and anemia.

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Anemia

Class III (No Benefit)

1. In patients with HF and anemia, erythropoietin- stimulating agents should not be used to improve morbidity and mortality. (Class III, Level of Evidence: B-R)

Class IIb

1. In patients with NYHA class II and III HF and iron deficiency (ferritin <100 ng/mL or 100 to 300 ng/mL if transferrin saturation is <20%), intravenous iron replacement might be reasonable to improve functional status and QoL. (Class IIb, Level of Evidence: B-R)

Atrial Fibrillation

Class IIa

1. Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF. (Class IIa, Level of Evidence: C)

Diabetes Mellitus

Class I

1. For patients with diabetes mellitus (who are all at high risk for developing HF), blood sugar should be controlled in accordance with contemporary guidelines. (Class I, Level of Evidence: C)

Class IIa

1. ACE inhibitors can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Class IIa, Level of Evidence: A)

2. ARBs can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Class IIa, Level of Evidence: B)

Hyperlipidemia

Class I

1. In patients with a recent or remote history of MI or acute coronary syndrome, statins should be used to prevent cardiovascular events. (Class I, Level of Evidence: A)

Class III (No Benefit)

1. Statins are not beneficial as adjunctive therapy when prescribed solely for the diagnosis of HF in the absence of other indications, and routine use of statins for the treatment of HF is not indicated outside of current practice guidelines for the primary and secondary preven- tion of atherosclerotic vascular disease. (Class III, Level of Evidence: A)

Class IIa

1. PUFA supplementation is reasonable to use as adjunctive therapy in patients with NYHA class II to IV symptoms and HFrEF or HFpEF, unless contraindicated, to reduce mortality and cardiovascular hospitalizations. (Class IIa, Level of Evidence: B)

Class IIa

1. Lipid disorders should be controlled in accor- dance with contemporary guidelines. (Class IIa, Level of Evidence: B)

Obesity

Class I

1. Obesity should be controlled or avoided to prevent the development of HF along with other CVDs. (Class I, Level of Evidence: C)

Class III (Harm)

1. Sibutramine or ephedra weight loss preparations are contraindicated in HF. Use of ephedra weight-loss preparations may contribute to the development of HF and should be avoided. (Class III, Level of Evidence: C)

Class IIb

1. Purposeful weight loss via healthy dietary intervention or physical activity for the purposes of improving health-related QOL or managing comorbidities such as diabetes mellitus, hypertension, or sleep apnea may be reasonable in obese patients with HF.. (Class IIb, Level of Evidence: C)

Sleep Disorders

Class III (Harm)

1. In patients with NYHA class II–IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm. (Class III, Level of Evidence: B-R)

Class IIa

1. In patients with NYHA class II–IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable. (Class IIa, Level of Evidence: C-LD)

Class IIb

1. In patients with cardiovascular disease and obstructive sleep apnea, CPAP may be reasonable to improve sleep quality and daytime sleepiness. (Class IIb, Level of Evidence: B-R)