Chronic heart failure resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Chronic Heart Failure Resident Survival Guide Microchapters
Overview
Classification
Causes
Diagnosis
Treatment Diuretic Therapy Medications
Do's
Don'ts

Overview

There are several goals in the chronic management of systolic heart failure. One goal of therapy is to improve the patient's symptoms, exercise tolerance and quality of life. Diuretics, along with regular assessment of the patient's weight, minimizes fluid accumulation and the accompanying symptoms of dyspnea and orthopnea. Another goal is to reduce hospitalization and mortality. To achieve the second goal, patients with chronic heart failure should be administered an ACE inhibitor (or ARB if they are ACE intolerant) and a beta blocker. If the patient remains symptomatic, additional therapy may include an aldosterone antagonist.

Goals of Therapy

Goals	Therapeutic intervention
To alleviate symptoms and signs	Diuretics, morphine (no mortality benefit)
To reduce mortality	ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, hydralazine plus isosorbide dinitrate, Omega-3 fatty acid, CRT, ICD
To reduce hospitalization	Digoxin, ARBs (in HFpEF)

Classification

Based on the Stage of Heart Failure

ACCF/AHA Stages	Description
A	At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
B	Structural heart disease but without signs or symptoms of HF
C	Structural heart disease with prior or current symptoms of HF
D	Refractory HF requiring specialized interventions

ACCF - American College of Cardiology Foundation; AHA - American Heart Association

Based on the Severity of Congestive Heart Failure

NYHA classification	Description
I	No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (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

NYHA - New York Heart Association

Causes

Life Threatening Causes

Chronic heart failure is life threatening and should be treated as such irrespective of the underlying cause.

Common Causes

• Cardiotoxic drugs (e.g. NSAIDs, thiazolidinedione, and certain chemotherapy drugs)
• Concurrent infections e.g., pneumonia, viral illnesses
• Electrolyte imbalances
• Endocrine abnormalities - diabetes mellitus, thyroid disorders (hyperthyroidism, hypothyroidism)
• Excessive alcohol or illicit drug use (e.g. cocaine)
• Medication noncompliance
• Myocardial ischemia or infarction
• Noncompliance with dietary restrictions (e.g., sodium and fluid restriction)
• Progressive valvular disease (e.g. mitral regurgitation)
• Pulmonary embolus
• Uncontrolled arrhythmias
• Uncontrolled hypertension

Complete Diagnostic Approach

The algorithm below describes the diagnostic approach to a patient with chronic heart failure.

Abbreviations: ARDS: Acute respiratory distress syndrome; BNP: B-type natriuretic peptide; BUN: Blood urea nitrogen; CAD: Coronary artery disease; CBC: Complete blood count; CCB: Calcium channel blocker; CT: Computed tomography; CXR: Chest x-ray; DM: Diabetes mellitus; EKG: Electrocardiogram; HTN: Hypertension; LVEF: Left ventricular ejection fraction; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; MRI: Magnetic resonance imaging; NT-pro BNP: N-terminal pro-brain natriuretic peptide; OCPs: Oral contraceptive pills; PAWP: Pulmonary artery wedge pressure TSH: Thyroid stimulating hormone

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Characterize the symptoms: Symptoms of fluid accumulation: ❑ Dyspnea ❑ At rest ❑ Exertional ❑ Paroxysmal nocturnal dyspnea ❑ Orthopnea ❑ Cough ❑ Peripheral edema ❑ Ascites Symptoms of reduced cardiac output: ❑ Fatigue ❑ Oliguria ❑ Dizziness ❑ Altered mental status ❑ Cyanosis ❑ Abdominal pain (may be suggestive of mesenteric ischemia) Symptoms suggestive of precipitating events: ❑ Chest pain (if myocardial ischemia is present) ❑ Palpitation (suggestive of arrhythmias) ❑ Fever (suggestive of sepsis) Nonspecific symptoms: ❑ Anorexia ❑ Bloating ❑ Nausea ❑ Weight loss Obtain a detailed history: ❑ Past medical history: ❑ Atrial fibrillation ❑ Cardiomyopathy ❑ Diabetes mellitus ❑ Hypertension ❑ Myocarditis ❑ Previous myocardial infarction ❑ Prior heart failure ❑ Sleep apnea ❑ Thyroid disease ❑ Valvular heart disease ❑ Medication history: ❑ Noncompliance with medications ❑ Intake of the following drugs: ❑ Alcohol ❑ Beta blockers ❑ Calcium channel blockers ❑ Chemotherapy drugs - anthracyclines ❑ NSAIDs ❑ Thiazolidinedione ❑ Family history: ❑ History of dilated cardiomyopathy ❑ Radiation to the chest

Examine the patient: General appearance: ❑ Ill-looking ❑ In respiratory distress ❑ Usually in upright sitting position Vitals: ❑ Temperature ❑ Fever (suggestive of underlying infection) ❑ Pulse ❑ Tachycardia ❑ Narrow pulse pressure (<25 mmHg) ❑ Blood pressure ❑ Hypotension (suggestive of circulatory collapse) ❑ Hypertension ❑ Respiration ❑ Tachypnea (commonest symptom) ❑ Pulse oximetry Assess weight: ❑ Subtract 'dry weight' from value to assess edema Skin: ❑ Cool and clammy, in hypoperfusion or cardiogenic shock ❑ Cyanosis, in severe hypoxemia ❑ Anasarca Neck examination: ❑ Jugular vein distention Respiratory examination: ❑ Tachypnea ❑ Wheeze (suggestive of cardiac asthma) ❑ Dullness at lung bases, suggestive of pleural effusion ❑ Crackles/crepitations/rales Cardiovascular examination: ❑ Displaced apex beat (suggestive of enlarged left ventricle) ❑ Parasternal heave (when right ventricular pressure is increased) ❑ S3 (typical) or S4 or both ❑ New or changed murmur (suggestive of an underlying valvular heart diseases) ❑ Mitral regurgitation - Holosystolic murmur ❑ Aortic regurgitation - Decrescendo diastolic murmur ❑ Aortic stenosis - Crescendo-decrescendo systolic ejection murmur with ejection click Abdominal examination: ❑ Hepatojugular reflux ❑ Hepatomegaly ❑ Ascites Extremity examination: ❑ Pedal edema Neurological examination: ❑ Altered mental status ❑ Syncope (suggestive of aortic stenosis or pulmonary embolism)

Order tests: Routine (Class I, level of evidence C) ❑ CBC (rule out anemia) ❑ Troponin ❑ Elevated in myocardial ischemia and acute cardiogenic pulmonary edema ❑ Troponin T ≥0.1 ng/mL (associated with poor survival) ❑ Electrolytes ❑ Dilutional hyponatremia (with the presence of edema) ❑ Serum calcium ❑ Serum magnesium ❑ BUN, creatinine ❑ Urinalysis ❑ Fasting blood sugar ❑ Fasting lipid profile ❑ Liver function tests ❑ TSH ❑ BNP or NT-pro BNP Heart failure is unlikely if: ❑ BNP ≤ 35 pg/mL ❑ NT-pro BNP ≤ 125 pg/mL ❑ Chest X-ray (Class I, level of evidence C) ❑ Cardiomegaly (cardiothoracic ratio >50%) ❑ Cardiogenic pulmonary edema ❑ Kerley B lines ❑ Peribronchial cuffing ❑ Cephalization Chest X-ray findings in a patient with acute heart failure ❑ EKG ❑ Low QRS voltage ❑ Arrhythmia (usually atrial fibrillation) ❑ Poor R wave progression (suggestive of a prior MI) ❑ Left ventricular hypertrophy (consistent with a history of hypertension) ❑ Left bundle branch block (LBBB) ❑ Left atrial enlargement ❑ Non-specific ST segment and T wave changes ❑ 2-D echocardiography with doppler (Class I, level of evidence C) ❑ Ventricular size, function, wall thickness, wall motion, and valve function ❑ Radionuclide ventriculography or MRI ❑ To assess LVEF and volume when echocardiography is inadequate ❑ To assess myocardial infiltrative processes or scar burden (MRI) ❑ Coronary angiography (in settings of ischemia) ❑ Pulmonary artery catheterization - in respiratory distress or shock Additional tests to rule out other etiologies: ❑ ANA, rheumatoid factor (for rheumatologic diseases) ❑ Diagnostic tests for hemochromatosis, pheochromocytoma ❑ Endomyocardial biopsy (when myocarditis is suspected)

Consider alternative diagnoses: Alternative diagnoses Features COPD ❑ Dyspnea, cough, sputum, history of smoking ❑ Spirometry reveals obstructive pattern Pneumonia ❑ Fever, cough, sputum ❑ CXR - consolidation Liver cirrhosis ❑ Jaundice, fatigue, peripheral edema, coagulopathy ❑ Abnormal liver function tests ❑ Liver biopsy confirms the underlying cause Pulmonary embolism ❑ Pleuritic chest pain, cough, S4 ❑ Risk factors - trauma, immobilization, smoking, OCPs ❑ CT pulmonary angiography - clot in pulmonary artery Peripartum cardiomyopathy ❑ Dyspnea, orthopnea, PND ❑ Pregnancy ❑ Absence of heart disease prior to onset of heart failure ❑ Echocardiography confirms left ventricular enlargement and systolic dysfunction Nephrotic syndrome ❑ Dyspnea, fatigue, peripheral edema ❑ Urinalysis reveals proteinuria > 3.5g/24 hours

Treatment

Consider admission: ❑ Hypotension and/or cardiogenic shock ❑ Poor end-organ perfusion - worsening renal function, cold clammy extremities, altered mental status ❑ Hypoxemia - Sa02 ↓90% ❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension ❑ Presence of an acute coronary syndrome

Assess hemodynamic and volume status ❑ Congestion at rest e.g., orthopnea, ↑JVP, rales, S3, pedal edema ❑ Low perfusion at rest e.g., narrow pulse pressure, cool extremities, hypotension

Classify the patient based on the left ventricular ejection fraction

Systolic heart failure LVEF ≤ 40%

Diastolic heart failure LVEF ≥ 50%

First step: Diuresis ❑ ❑ ❑ ❑ ❑

Second step: ACE Inhibition and Angiotensin Receptor Blockade ❑ ❑ ❑ ❑ ❑

Third step: Beta blockers ❑ ❑ ❑ ❑ ❑

Fourth step: Aldosterone Antagonism ❑ ❑ ❑ ❑ ❑

Fifth step: The Combination of Hydralazine and a Nitrate ❑ ❑ ❑ ❑ ❑

Sixth step: Digoxin ❑ ❑ ❑ ❑ ❑

Diuretic Therapy

Evidence of volume overload

❑ Low sodium diet (<2 g daily) ❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L ❑ Commence IV diuretics ❑ Frusemide 40 mg, or ❑ Torsemide 20 mg, or ❑ Bumetanide 1 mg Contraindications ❑ Hypotension and cardiogenic shock Note - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)

Symptomatic improvement?

Yes

No

Maintain current IV diuretic dose

Double IV diuretic dose and titrate according to patient's response or when the maximum dose is reached

No symptomatic improvement

Add ❑ Another diuretic e.g., IV chlorothiazide or oral metolazone or ❑ An aldosterone antagonist e.g., spironolactone or eplerenone, in post MI patients

Adjuvants to diuretics ❑ Low dose dopamine to preserve renal function and renal blood flow ❑ IV nitroprusside, nitroglycerin, or nesiritide for hemodynamically stable patients to relieve dyspnea ❑ Vasopressin antagonists (e.g. tolvaptan; start with 15mg orally daily)

No symptomatic improvement (refractory edema)

Ultrafiltration or dialysis

General measures ❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts ❑ Convert all IV diuretic to oral ❑ Daily serum electrolytes, urea & creatinine ❑ DVT prophylaxis

Medications

Drug Class	Drug	Daily doses, maximum daily dose
Loop diuretics	Furosemide	20 to 40 mg once or twice, 600 mg max daily dose In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.
	Bumetanide	0.5 to 1.0 mg once or twice, 10 mg
	Torsemide	10 to 20 mg once, 200 mg
Thiazide diuretics	Chlorothiazide	250 to 500 mg once or twice, 1000 mg
	Hydrochlorothiazide	25 mg once or twice, 200 mg
	Metolazone	2.5 mg once, 20 mg
K+- sparing diuretic	Amiloride	5 mg once, 20 mg
	Spironolactone	12.5 to 25.0 mg once, 50 mg
	Triamterene	50 to 75 mg twice, 200 mg
ACE inhibitors	Enalapril	2.5 mg twice, 10 to 20 mg twice
	Lisinopril	2.5 to 5 mg once, 20 to 40 mg once
	Ramipril	1.25 to 2.5 mg once, 10 mg once
ARBs	Candesartan	4 to 8 mg once, 32 mg once
	Losartan	25 to 50 mg once, 50 to 150 mg once
	Valsartan	20 to 40 mg twice, 160 mg twice
Beta blockers	Bisoprolol	1.25 mg once, 10 mg once
	Carvedilol	3.125 mg twice, 50 mg twice
	Metoprolol succinate	12.5 to 25.0 mg once, 200 mg once
Aldosterone antagonists	Spironolactone	12.5 to 25.0 mg once, 25 mg once or twice
	Eplerenone	25 mg once, 50 mg once
Inotropes	Dopamine	5 to 10 mcg/kg/min
	Dobutamine	2.5 to 5 mcg/kg/min
	Milrinone	0.125 to 0.75 mcg/kg/min
Vasodilators	Nitroglycerin	5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated, max is 400mcg/min
	Nitroprusside	5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated, max is 400mcg/min
	Nesiritide	2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion, maximum of 0.03 mcg/kg/minute
Hydralazine and isosorbide dinitrate	Fixed-dose combination	37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
	Individual doses	Hydralazine: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses Isosorbide dinitrate: 20 to 30 mg 3 or 4 times daily, 120 mg daily in divided doses
Digoxin		0.125 to 0.25 mg daily

Do's

• Ensure guideline-directed medical therapy (GDMT) - This is a term which represents the optimal medical therapy in the management of heart failure as defined by ACCF/AHA. These are primarily the class 1 recommendations. It involves the use of ACE inhibitors or (ARBs), beta blockers, aldosterone antagonists, and hydralazine/nitrate medications.
• Order an echocardiogram as soon as possible if no recent one available or if the patient's clinical status is deteriorating.
• Digitalis decreases hospitalization but not mortality. It can be beneficial in symptomatic patients with low EF.
• Make sure your patient is on DVT prophylaxis unless contraindicated.
• Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
• Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .

Advanced heart failure refers to severe symptoms of heart failure with dyspnea and/or fatigue at rest or with minimal exertion (NYHA class III or IV). These parameters assist in identifying patients with advanced heart failure:

• Repeated (≥2) hospitalizations or ED visits for HF in the past year
• Progressive deterioration in renal function (eg, rise in BUN and creatinine)
• Weight loss without other cause (eg, cardiac cachexia)
• Intolerance to ACE inhibitors due to hypotension and/or worsening renal function
• Intolerance to beta blockers due to worsening HF or hypotension
• Frequent systolic blood pressure <90 mm Hg
• Persistent dyspnea with dressing or bathing requiring rest
• Inability to walk 1 block on the level ground due to dyspnea or fatigue
• Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose over 160 mg/d and/or use of supplemental metolazone therapy
• Progressive decline in serum sodium, usually to < 133 mEq/L
• Frequent ICD shocks

Don'ts

• Avoid the use of NSAIDs, sympathomimetics, tricyclic antidepressants, class I and III antiarrhythmics (except amiodarone), and nondihydropyridine calcium channel blockers (diltiazem, verapamil.
• Don't Use parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion.
• Don't combine an ACEI, ARB, and aldosterone antagonist in patients with HFrEF unless otherwise indicated as this combination carries a risk of renal functions worsening and hyperkalemia.
• Avoid using statins solely for heart failure. It adds no benefit.

References

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