Heart Failure

1. In patients with newly diagnosed heart failure determine the underlying cause, as treatment will differ.

2. In an older patient presenting with fatigue include heart failure in your differential diagnosis.

3. In a patient with symptoms suggestive of heart failure and a normal ejection fraction do not exclude this diagnosis.

4. In patients with heart failure periodically assess functional impairment using validated tools (e.g., New York Heart Association class, activities of daily living).

5. To guide your management of a patient with an exacerbation of heart failure:

   • Identify possible triggers (e.g., infection, arrhythmia, adherence, diet, ischemia)

   • Consider comorbid conditions (e.g., renal failure)

6. When treating heart failure:

   • Identify the type of heart failure (e.g., systolic, diastolic) because the treatment is different

   • Appropriately prescribe medications to reduce mortality as well as treat the symptoms of congestive failure (e.g., diuretics, beta-blockers, ACE inhibitors, digoxin)

7. For patients with heart failure ensure you offer patient education and self-monitoring, such as routine self-weighing, healthy diet, medication adherence, smoking cessation, and exercise, to minimize exacerbations.

8. In a patient with heart failure recognize non-sustained response to treatment as an indicator of worsening prognosis.

9. In a patient with heart failure and a progressively deteriorating clinical course:

   • Provide a realistic prognosis to patients and families

   • Introduce palliative care principles when appropriate for the patient

Diagnosis

• History

  • Breathlessness

  • Fatigue

  • Weight gain

  • Peripheral edema

  • Orthopnea (LR 2.2)

  • Paroxysmal nocturnal dyspnea (LR 2.6)

  • Confusion in elderly

• Risk

  • Hypertension

  • Ischemic heart disease  (LR 3.1)

  • Valvular heart disease

  • Diabetes mellitus

  • Alcohol, substance use

  • Chemotherapy/radiation therapy

  • Family history cardiomyopathy

  • Smoking

  • Hyperlipidemia

• Exam

  • Bilateral lung crackles

  • Elevated JVP (LR 5.1), can use bedside ultrasound: incline bed 45 degrees, start at sternocleidomastoid muscle slide probe cranially until IJ is smaller dimater than carotid throughout respiratory cycle - this is the height of the JVP.

    • Positive abdominal jugular reflex (LR 6.4)

  • Peripheral edema (LR 2.3)

  • Laterally displaced cardiac apex (LR 16)

  • S3 (LR 11), S4 or any heart murmur

  • Low BP or HR>100

    • Note:  In heart failure with narrow pulse pressure, think high output heart failure (eg. anemia, thyrotoxicosis)

Definition

• HFrEF (reduced)

  • LVEF <40%

• HFmrEF (mid-range)

  • LVEF 40-49%

  • Elevated natriuretic peptide

  • Relevant structural heart disease (LVH +/- LAE)  or diastolic dysfunction

• HFpEF (preserved)
  💡 A preserved ejection fraction on a routine echocardiogram does not rule out the clinical syndrome of heart failure 

  • LVEF >50%

  • Elevated natriuretic peptide

  • Relevant structural heart disease (LVH +/- LAE)  or diastolic dysfunction

• NYHA classification for severity of symptoms

  • I = No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).

  • II = Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).

  • III = Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.

  • IV = Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

Management

Acute Management

💡 LMNOP (Lasix, Modify medications, Nitroglycerine, Oxygen, Position (upright) +/- Positive Pressure (BiPAP) 

• Oxygen ≥ 90-92%

• NIPPV (BiPAP > CPAP) if SpO2 < 90% despite supportive O2 

• Position upright

• Hypotension (cardiogenic shock)→ Pressor (eg. Norepinephrine) to maintain MAP 65-80

• Hypertension (SCAPE)→ High-dose nitroglycerin IV

  • Nitroglycerine (NTG) SL 0.4mg x 3  q5 mins until IV nitroglycerine started (note SL nitro only 40% bioavailable)

    • Nitroglycerine 100mcg/min IV infusion, increase by 20mcg/min every 10 mins until sBP decreases

      • Then maintain until improvement in symptoms, then gradually reduce IV infusion until stop

    • Alternatively may give intermittent nitroglycerin bolus 1-2mg IV q3-5 minutes

    • Avoid in PDE5 inhibitors (e.g., sildenafil) or concomitant inferior STEMI (preload dependent)

• If suspect total body hypovolemia, no B-lines on lung ultrasound, hypoperfusion,

  • Consider careful fluid bolus challenge (250mL isotonic crystalloid)

• If suspect total body hypervolemia (eg. B-lines on lung ultrasound, pedal edema, jugular vein distension, history of nonadherence to diuretics or missed hemodialysis)
  Note: Many patients may be euvolemic and have a maldistribution of fluids into the lungs

  • Furosemide (Lasix) 20-80mg IV bolus (once stable)

    • If taking regular furosemide at home, can give home PO dose as IV

    • Consider the addition of acetazolamide 500mg IV daily to improve loop diuretic efficiency

  • Monitor diuretic effect ~q6h while stabilizing

    • Monitor daily weights and urine output, goals: urine output 3-5 L; 0.5-1.5 kg weight loss 

      • Increase/decrease diuretic by ~25-50% to meet above criteria

      • If not responsive, consider adding metolazone 1.25-5mg one to seven times per week

• Consider consultations (e.g., cardiology, ICU) for advanced measures (e.g., intra-aortic balloon pumps, LVAD, ECMO, etc.)

Find and treat underlying cause/trigger

• Tachyarrhythmia

• Valve disease (eg. severe aortic stenosis, ruptured valve)

• Ischemia (r/o CAD if risk factors)

• LVH (likely hypertensive HF/cardiomyopathy)

• Other less common: Congenital/herditary, toxin, pregnancy-related, inflammatory, infectious, immune, metabolic, nutritional, infiltrative

Discharge Goals

• Improvement in clinical status (i.e., presenting symptoms & vital signs resolved and stable, return to “dry” weight, comorbidities under control)

• Supportive investigations 

  • Imaging evidence of resolution of congestion (CXR, ultrasound)

• BNP or NT-proBNP

  • Consider discharge home if > 30% ↓ from admission value (along with clinical improvement) 

💡 For ambulatory patients (i.e., outpatients), an increase in BNP/NT-proBNP of > 30% from baseline warrants more frequent follow-up +/- intensification of HF therapy

Chronic Management

Lifestyle Management 

• Treat risk factors

  • HTN, DM, smoking, obesity

  • Annual influenza vaccine

  • Periodic pneumococcal pneumonia vaccine

• Sodium restriction between 2-3g/day

• Weight daily if fluid retention

Pharmacologic Management 

💡 The classic “triple” therapy for HFrEF has recently expanded to “quadruple” therapy with the addition of SGLT2 Inhibitors in the updated CCS 2021 Guidelines.

• Quadruple Therapy for most patients with HFrEF (LVEF < 40% and symptoms)

  • ACEi (or ARB if not tolerated)

    • ACEi: Target Ramipril 10mg, Perindopril 8mg, or Lisinopril 20-35mg

    • ARB: Target Candesartan 32mg

  • BB (Careful initiating in NYHA III-IV)

    • Target Bisoprolol 10mg or Metoprolol CR/XL 200mg

  • MRA (Monitor potassium, creatinine)

    • Target Spironolactone 50mg

  • SGLT2 Inhibitor

    • Target Empagliflozin 10-25mg or Dapagliflozin 10mg

  • Convert from ACEi/ARB to ARNI if persistent/worsening symptoms despite adequate quadruple therapy (hospitalization and mortality benefit) 

    • Target Sacubitril/Valsartan 200mg BID (97mg:103mg) 

💡 There is less evidence supporting the benefit of pharmacotherapy for patients with preserved EF (HFpEF). For patients with HFpEF consider SGLT2 and MRA as first-line therapies. 

Symptom Management

Additional therapies should be considered for patients with HFrEF and persistent NYHA II-IV symptoms, despite optimization of quadruple therapy:

• Diuretic at lowest effective dose to maintain euvolemia

• Consider  (with specialist involvement)

  • Ivabradine if NSR and HR ≥ 70 bpm despite BB

  • Vasodilators (e.g., hydralazine/Isosorbide dinitrate) if renal intolerance to ACEi/ARB/ARNI 

  • Digoxin (e.g., if poorly controlled AF despite BB) 

  • Device therapy (ICD, CRT) if LVEF ≤ 35% and NYHA I-IV (ambulatory)

Advance Care Planning

• Especially when symptom progress and function declines (e.g., NYHA III/IV) despite maximal medical therapy, when considering invasive therapies, or as requested by patient/family 

  • http://www.advancecareplanning.ca/ for tools and resources to help patients and families with advance care planning 

Last edited 2022-10-01

B. Paul, K. Chan