CHF

Congestive Heart Failure - Madeleine Alder

Background

  • HFrEF
    • Ischemic (40%): Obstructive CAD, previous/current myocardial infarction
    • NICM (60%): HTN, idiopathic, myocarditis, genetic/familial, valvular, tachycardia/PVC-induced, infiltrative (amyloid, sarcoid, hemochromatosis), Takotsubo/stress cardiomyopathy, peripartum CM, substance abuse, chemotherapy/toxin-induced, "burned out" hypertrophic cardiomyopathy
  • HFpEF: HTN, CAD, obesity, DM, infiltrative, hypertrophic cardiomyopathy
  • Causes of Heart Failure Exacerbations (FAILURES)
    • Forgetting medications or taking drugs that can worsen HF (e.g. BB, CCB, NSAIDs, TZDs), chemo (anthracyclines, trastuzumab)
    • Arrhythmia: AF, VT, PVCs; Increased arrhythmia burden on device check?
    • Ischemia or Infarction or Infection; myocarditis; Acute vascular dysfunction (e.g. endocarditis), especially mitral or aortic regurgitation.
    • Lifestyle choices: Dietary indiscretions - high salt, EtOH, excessive fluid intake. Obesity.
    • Upregulation (pregnancy and hyperthyroidism)
    • Renal failure: acute, progression of CKD, or insufficient dialysis (Increased preload)
    • Embolus (pulmonary) or COPD (leads to increase right-sided afterload)
    • Stenosis (worsening AS, RAS) leading to hypertensive crisis high left-sided afterload

Presentation

  • Congestion: shortness of breath, dyspnea on exertion, Orthopnea, PND
  • Nausea/poor po intake
  • Confusion
  • Exam: Edema (legs, sacrum); Rales, S3, S4, murmur (AS, MR), Elevated JVD, + Hepatojugular reflex, Ascites

Evaluation

  • CBC, CMP, Magnesium 
  • Lactate, Troponin, BNP
  • Pro-BNP if on Entresto)
  • TSH
  • Iron studies
  • EKG
  • CXR, TTE
  • Determine Hemodynamic Profile 

 

                     Volume Status

Euvolemia

Hypervolemia

Normal

 

Cardiac Index

 

Warm Extremities

 

Adequate Urine Output

 

Normal Pulse Pressure

Warm and Dry

Forrester Class I

Warm and Wet

Forrester Class II

Low

 

Cardiac Index

Cardiogenic Shock

 

Cool Extremities

 

Renal Failure

 

Narrow Pulse Pressure

Cold and Dry

Forrester Class III

Cold and Wet

Forrester Class IV


Management

  • Telemetry, Daily STANDING weights, 2 L fluid restriction, 2g sodium diet, Strict I/Os 
  • Cold and Wetà may require ionotropic support or transfer to the CCU
  • Warm and Wet à Diuresis
    • Diuresis: Place on 2.5 x home dose of IV diuretic, dose BID-TID (DOSE Trial)
      • Goal is to be net negative (generally 1-2 L per day, but patient dependent)
      • Check BMP and Mg BID and keep K>4 and Mg>2
      • Monitor UOP and weights to determine if dosing adequate
      • Low threshold for substantial increase (double) in loop vs transition to drip
      • Can also augment with sequential nephron blockade (thiazides, acetazolamide)

 

 Goal-Directed Medical Therapy

ACE-Inhibitors/ARBs

  • Blocks harmful effects of renin-angiotensin-aldosterone system activation and attenuates adverse cardiac and vascular remodeling
  • If planning on using Entresto eventually, favor ARB over ACE-i in short term
  • Sacubitril-valsartan (Entresto):  Additional benefit of Neprilysin inhibition
    • 36-hour washout after stopping ACE-i before starting Entresto to avoid angioedema

Aldosterone receptor antagonists

  • Diuretic and blood pressure lowering effects and blocks deleterious effects of aldosterone on the heart (including hypertrophy and fibrosis)
  • May also reduce hospitalizations in HFpEF
  • Worry about hyperkalemia: avoid if CrCl<30 or K>5

Beta-blockers

  • Reduces catecholamine stimulation including elevated heart rate, increased myocardial energy demands, adverse remodeling due to cardiac myocyte hypertrophy and death
  • Mortality benefit shown with carvedilol, metoprolol succinate or bisoprolol
  • Avoid if pt is decompensated (cold); “start low and go slow”
  • Can continue during exacerbation if patient compensated, (ie not in shock)

Hydralazine/Isosorbide Dinitrate

  • Reduces cardiac afterload and preload and may also enhance nitric oxide bioavailability
  • Reduction in mortality for African American patients

SGLT-2 inhibitors

  • Osmotic diuresis and natriuresis, improve myocardial metabolism, inhibit sodium-hydrogen exchange in myocardium, reduce cardiac fibrosis

Cardiac resynchronization therapy (CRT)

  • Criteria: HFrEF with LVEF ≤35%, QRS ≥150 ms with left bundle branch block (LBBB); NYHA class II to ambulatory class IV HF and wide QRS

Mitra Clip

  • Criteria: mitral regurgitation of 3-4+, on maximally tolerated GDMT, an ejection fraction >20%, and a left ventricle end-systolic dimension of less than 7 cm

Iron repletion

  • Criteria: ferritin <100 µg/L or ferritin 100-299 µg/L AND transferrin saturation <20%.
  • Replete intravenous (IV) iron. IV iron sucrose (500 mg x2 doses 48 hours apart) or ferric carboxymaltose (maximum dose of 1000 mg per week) or iron dextran (1 g x1)

 

Additional Information:

  • ICD placement (See Below, eg Cardiac Devices)
  • Starting patients on low dose of multiple agents preferred to max dose of single agent
  • D/C summary should have discharge weight, diuretic regimen, and renal function
  • Daily weights at home with rescue diuretic plan (pm dose for 3 lbs in 1 day, 5 lbs in 3 days)