Heart Failure

Heart Failure

David Ray Velez, MD

Table of Contents

Definitions
Causes
Evaluation
Management

Definitions

Timing

  • Congestive Heart Failure (CHF): Chronic Condition in Which the Heart Cannot Pump Enough Blood to Meet Body Demands
  • Acute Decompensated Heart Failure (ADHF): An Acute Worsening of Heart Failure Requiring Medical Care

Clinical Profiles of Acute Decompensated Heart Failure (ADHF)

  • ADHF without Pulmonary Edema
  • ADHF with Severe Pulmonary Edema
  • Cardiogenic Shock
  • High-Output Heart Failure
  • Right Heart Failure
  • *Groups are Not Mutually Exclusive and Often Present Together

Function

  • Systolic Heart Failure: Impaired Cardiac Contractility
  • Diastolic Heart Failure: Impaired Cardiac Relaxation, Stiffness, or Filling
  • *Both Most Often Coexist Together

Left Ventricular Ejection Fraction (LVEF)

  • Heart Failure with Preserved Ejection Fraction (HFpEF): LVEF ≥ 50%
  • Heart Failure with Reduced Ejection Fraction (HFrEF): LVEF < 50%

New York Heart Association (NYHA) Classification

  • Generally Used in Describing Chronic CHF and Outside the Acute Care Setting
  • Class I: No Limitation of Physical Activity
    • Ordinary Physical Activity Does Not Cause Fatigue, Palpitations, Shortness of Breath, or Chest Pain
  • Class II: Slight Limitation of Physical Activity but Comfortable at Rest
    • Ordinary Physical Activity Causes Fatigue, Palpitations, Shortness of Breath, or Chest Pain
  • Class III: Marked Limitation of Physical Activity but Comfortable at Rest
    • Less Than Ordinary Physical Activity Causes Fatigue, Palpitations, Shortness of Breath, or Chest Pain
  • Class IV: Symptomatic at Rest
    • Any Physical Activity Causes Further Discomfort

Causes

Risk Factors for Heart Failure

  • Coronary Artery Disease (CAD)
  • Cardiomyopathy
  • Myocarditis
  • Tobacco
  • Hypertension
  • Obesity
  • Diabetes
  • Valvular Pathology

Causes of Acute Decompensated Heart Failure (ADHF)

  • Acute Coronary Syndrome (ACS)/Myocardial Ischemia (MI)
  • Arrhythmias
  • Myocarditis
  • Valvular Pathology:
    • Acute or Severe Progressive Aortic Regurgitation
    • Acute or Severe Progressive Mitral Regurgitation
    • Severe Progressive Aortic Stenosis
    • Severe Progressive Mitral Stenosis
  • Cardiomyopathy
  • Poorly Controlled Hypertension

Causes of Right Heart Failure (RHF)

  • Left Heart Failure – Most Common Cause
  • Increased Afterload:
    • Pulmonary Arterial Hypertension (PAH)
    • Pulmonary Embolism (PE)
    • Mechanical Ventilation
  • Decreased Preload:
    • Hypovolemia
    • Sepsis
    • Cardiac Tamponade
  • RV Myocardial Infarction
  • LVAD – Increased Venous Return to Right Heart and Septal Bowing Due to Decreased LV Pressures

Causes of High-Output Heart Failure

  • Anemia
  • Obesity
  • Thyrotoxicosis
  • Liver Failure
  • Chronic Lung Disease

Evaluation

Clinical Manifestations

  • Dyspnea
  • Fatigue
  • Refractory Volume Overload
    • Pulmonary Congestion
    • Peripheral Edema
    • Ascites
    • Jugular Venous Distention (JVD)
  • Recurrent Ventricular Arrhythmias
  • Decreased Cardiac Output with Hypotension and Poor Perfusion
  • Congestive Hepatopathy
  • Hyponatremia – Due to Increased ADH
  • Hypoalbuminemia – Due to Decreased Liver Synthesis, Increased Vascular Permeability, and Renal/GI Losses

Evaluation

  • Elevated BNP
  • EKG – Abnormalities are Common but None are Specific for Heart Failure
  • Chest XRray – May See Signs of Fluid Overload (Pulmonary Vascular Congestion, Pulmonary Edema, Pleural Effusion)
  • Echocardiogram – The Primary Diagnostic Test in Heart Failure

Management

Chronic Management

  • Goals:
    • Reduce Symptoms
    • Improved Quality of Life and Functional Status
    • Decreased Rate of Hospitalization
    • Reduced Mortality
  • Treat Any Underlying Causes (Ischemic Heart Disease, Valvular Disease, Cardiomyopathy)
  • Sodium and Fluid Restriction
  • Guideline-Directed Medical Therapy (GDMT)
    • The Cornerstone of Pharmacologic Therapy for Patients with HFrEF
    • Involves Taking a Combination of Medications from Four Primary Classes:
      • Beta Blockers
      • Renin-Angiotensin System Inhibitors (ACE Inhibitors and ARB)
      • Mineralocorticoid Receptor Antagonists (MRA)
      • SGLT2 Inhibitors
    • These Medications Have Been Shown to Reduce Mortality in Heart Failure

Acute Decompensated Heart Failure (ADHF)

  • *Often Avoid the Medications Used in Chronic Management During the Initial Resuscitation (Beta Blockers, etc.)
  • Supplemental Oxygenation and Ventilator Support as Needed
  • Non-Invasive Positive Pressure Ventilation (NIPPV/BiPAP) Can Be Beneficial in Cardiogenic Pulmonary Edema
    • Reduces LV Preload (Via Decreased Venous Return)
    • Reduces Afterload (Via Decreased Transmural Pressure)
  • Sodium and Fluid Restriction
  • Diuresis
  • Consider Vasodilators (Nitroprusside) for Severe Hypertension
  • Diastolic Dysfunction – Beta Blockers to Control Hypertension and Tachycardia

Management of Hypotension/Cardiogenic Shock

Acute Management of Right Heart Failure (RHF)

  • Treat Any Underlying Causes (PE, MI, etc.)
  • Supplemental Oxygenation and Ventilator Support as Needed
  • Optimize Preload
    • Diuresis if Overloaded
    • Fluid Bolus if Hypovolemic
  • Reduce Afterload
    • Inhaled Pulmonary Vasodilators vs PDE-5 Inhibitors
    • RV is More Sensitive to Afterload than LV
  • Improve Contractility
    • Inotropes (Dobutamine)
  • ECMO or Mechanical Circulatory Support in Severe Refractory Cases