Heart Failure

Essentials of Diagnosis

• Left ventricular (LV) failure

  • Either due to systolic or diastolic dysfunction

  • Predominant symptoms are those of low cardiac output and congestion, including dyspnea

• Right ventricular (RV) failure

  • Symptoms of fluid overload predominate

  • Usually RV failure is secondary to LV failure

• Assessment of LV function is a crucial part of diagnosis and management

• Optimal management of chronic heart failure (HF) includes combination medical therapies, such as

  • Angiotensin-converting enzyme (ACE) inhibitors

  • Aldosterone antagonists

  • Beta-blockers

General Considerations

• HF occurs as a result of

  • Depressed contractility with fluid retention and/or impaired cardiac output or

  • Diastolic dysfunction with fluid retention

• Acute exacerbations of chronic HF are caused by

  • Patient nonadherence to or alterations in therapy

  • Excessive salt and fluid intake

  • Arrhythmias

  • Excessive activity

  • Pulmonary emboli

  • Intercurrent infection

  • Progression of the underlying disease

• High-output HF is caused by

  • Thyrotoxicosis

  • Beriberi

  • Severe anemia

  • Arteriovenous shunting

  • Paget disease

• Systolic dysfunction is caused by

  • Myocardial infarction (MI)

  • Ethanol abuse

  • Long-standing hypertension

  • Viral myocarditis (including HIV and SARS-CoV-2)

  • Chagas disease

  • Idiopathic dilated cardiomyopathy

• Diastolic dysfunction is

  • Associated with abnormal filling of a ("stiff") LV

  • Caused by chronic hypertension, LV hypertrophy, and diabetes

Symptoms and Signs

• Symptoms of diastolic dysfunction are often difficult to distinguish clinically from those of systolic dysfunction

• LV failure

  • Exertional dyspnea progressing to orthopnea and then dyspnea at rest

  • Paroxysmal nocturnal dyspnea

  • Chronic nonproductive cough (often worse in recumbency)

  • Nocturia

  • Fatigue and exercise intolerance

• RV failure

  • Anorexia

  • Nausea

  • Right upper quadrant pain due to chronic passive congestion of the liver and gut

• Tachycardia, hypotension, reduced pulse pressure, cold extremities, and diaphoresis

• Long-standing severe HF: cachexia or cyanosis

• Physical examination findings in LV HF

  • Crackles at lung bases, pleural effusions and basilar dullness to percussion, expiratory wheezing, and rhonchi

  • Parasternal lift, an enlarged and sustained LV impulse, a diminished first heart sound

  • S₃ gallop

  • S₄ gallop in diastolic dysfunction

• Physical examination findings in RV HF

  • Elevated jugular venous pressure, abnormal pulsations, such as regurgitant v waves

  • Tender or nontender liver enlargement, hepatojugular reflux, and ascites

  • Peripheral pitting edema sometimes extending to the thighs and abdominal wall

Differential Diagnosis

• Chronic obstructive pulmonary disease (COPD)

• Pneumonia

• Cirrhosis

• Peripheral venous insufficiency

• Nephrotic syndrome

Laboratory Tests

• Obtain complete blood count, blood urea nitrogen, serum electrolytes, creatinine, thyroid-stimulating hormone ferritin

• ECG to look for

  • Arrhythmia

  • MI

  • Nonspecific changes, including low-voltage, intraventricular conduction delay; LV hypertrophy; and repolarization changes

• B-type natriuretic peptide (BNP)

  • Elevation is a sensitive indicator of symptomatic (diastolic or systolic) HF but may be less specific, especially in older patients, women, and patients with COPD

  • Adds to clinical assessment in differentiating dyspnea due to HF from noncardiac causes

Imaging Studies

• Chest radiograph shows

  • Cardiomegaly

  • Dilation of the upper lobe veins

  • Perivascular or interstitial edema

  • Alveolar fluid

  • Bilateral or right-sided pleural effusions

• Echocardiography can assess

  • Ventricular size and function

  • Valvular abnormalities

  • Pericardial effusions

  • Intracardiac shunts

  • Segmental wall motion abnormalities

• Radionuclide angiography and cardiac MRI: measure LV ejection fraction (EF) and assess regional wall motion

• Stress imaging: indicated if ECG abnormalities or suspected myocardial ischemia

Diagnostic Procedures

• ECG helps rule out

  • Valvular lesions

  • Myocardial ischemia

  • Arrhythmias

  • Alcohol- or drug-induced myocardial depression

  • Intracardiac shunts

  • High-output states

  • Hyperthyroidism and hypothyroidism

  • Medications

  • Hemochromatosis

  • Sarcoidosis

  • Amyloidosis

• Left heart catheterization

  • To exclude significant valvular disease

  • To delineate presence and extent of coronary artery disease

• Right heart catheterization: to select and monitor therapy in patients not responding to standard therapy

Medications

HF with reduced LVEF (HFrEF)

• A diuretic and an ACE inhibitor (or angiotensin receptor blocker [ARB]) with subsequent addition of a beta-blocker

• Diuretics (Table 11–8)

  • Thiazide

  • Loop

  • Thiazide and loop

  • Thiazide and spironolactone

• Aldosterone blockers (Table 11–8)

  • Spironolactone, 25 mg once daily orally (may decrease to 12.5 mg or increase to 50 mg depending on kidney function, K⁺, and symptoms)

  • Eplerenone, 25–50 mg once daily orally

• ACE inhibitors (Table 11–6): start at low doses and titrate to dosages proved effective in clinical trials over 1–3 months; for example

  • Captopril, 50 mg three times daily orally

  • Enalapril, 10 mg twice daily orally

  • Lisinopril, 20 mg once daily orally

• ARBs (Table 11–6) for ACE-intolerant patients

• ARB valsartan (titrated to a dose of 160 mg twice daily orally) added to ACE inhibitor therapy reduced composite of death or hospitalization for HF

• Beta-blockers (Table 11–9): in stable patients, start at low doses and titrate gradually and with great care; for example

  • Carvedilol started at 3.125 mg twice daily orally, increased to 6.25, 12.5, and 25 mg twice daily at intervals of ~2 weeks

  • Metoprolol extended-release, started at 12.5 or 25 mg once daily, increased to 50, 75, 100, 150, and 200 mg at intervals of ~2 weeks or longer

• Digoxin

  • Oral maintenance dose ranges from 0.125 mg three times weekly to 0.5 mg daily

  • May induce ventricular arrhythmias, especially when hypokalemia or myocardial ischemia is present

• Anticoagulation: for patients with LV HF associated with atrial fibrillation or large recent (within 3–6 months) MI

• Ivabradine

  • Approved for use in the United States for stable patients with HF and heart rate of 70 beats per minute or more on maximally tolerated (or contraindication to) beta-blockers

  • Approved by the European Medicines Agency for use in patients with a heart rate ≥ 75 beats per minute

  • Class IIa recommendation by European guidelines for patients in sinus rhythm with heart rate ≥ 70 beats per minute, EF ≤ 35%, and persisting symptoms despite treatment with an evidence-based dose of beta-blocker (or maximum tolerated dose below that), ACE inhibitor (or ARB), and an aldosterone antagonist (or ARB)

• Combination sacubitril and valsartan

  • Improves clinical outcome

  • Sacubitril is a neprilysin inhibitor and valsartan is an angiotensin II receptor blocker

  • Inhibiting neprilysin reduces breakdown of beneficial peptides (like natriuretic peptides) while valsartan inhibits the effects of angiotensin II

  • Compared to the ACE inhibitor enalapril, the angiotensin-neprilysin inhibitor was shown to reduce cardiovascular death and hospitalization for HF by 20%

  • Angioedema is a common side effect, particularly in blacks

  • American College of Cardiology/American Heart Association and the European Society of Cardiology guidelines

    • Class I recommendation for the use of sacubitril/valsartan as a replacement for ACE inhibitors for patients with HFrEF who remain symptomatic while taking an ACE inhibitor, beta-blocker, and mineralocorticoid inhibitor

    • For some patients, cost will be a barrier to use, but analyses have shown that sacubatril/valsartan is cost effective

    • Symptomatic hypotension is more common with sacubitril/valsartan than ACE inhibitor

  • Dapagliflozin reduced the risk of hospitalization for heart failure and cardiovascular death for patients with HFrEF, with or without diabetes

HF with preserved EF

• Manage fluid overload with diuretic therapy (Table 11–8)

• Treat comorbidities (eg, hypertension)

• ACE inhibitors and ARBs have not been shown to improve outcome, despite being good for managing hypertension

• Spironolactone

  • Has not been shown to improve outcome but may have some benefit in patients who have more clearly defined HF

  • Should remain a therapeutic option, especially for patients who also have hypertension

Surgery

HFrEF

• Coronary revascularization appears warranted for some patients with HF, including those with more severe angina or left main coronary disease or selected patients with less severe symptoms

• Bypass surgery provides more complete revascularization than angioplasty

• Cardiac transplantation for advanced HF

• Implantable defibrillators for chronic HF and ischemic or nonischemic cardiomyopathy with EF < 35%

• Biventricular pacing (resynchronization) for patients with moderate to severe systolic HF and LV dyssynchrony

• Resynchronization therapy is indicated for patients with

  • Class II, III, and ambulatory class IV HF

  • EF ≤ 35%

  • Left bundle branch block pattern with QRS duration of ≥ 120 msec

HF with preserved EF

• Implantable defibrillators and resynchronization device treatments do not have a role

• Revascularization should be guided by the same considerations as for patients with HF with reduced EF

Therapeutic Procedures

• Moderate salt restriction (2.0–2.5 g sodium or 5–6 g salt per day)

• Temporary restriction of activity

Follow-Up

• Monitor patients taking diuretics and ACE inhibitors for hypokalemia, acute kidney injury

• Case management, home monitoring of weight and clinical status, and patient adjustment of diuretics can prevent rehospitalizations

Complications

• Myocardial ischemia in patients with underlying coronary artery disease

• Asymptomatic and symptomatic arrhythmias, especially nonsustained ventricular tachycardia

• Sudden death and unexplained syncope

Prevention

• Antihypertensive therapy

• Antihyperlipidemic therapy

• Treat valvular lesions (aortic stenosis and mitral and aortic regurgitation) early

Prognosis

• HF with reduced EF carries a poor prognosis

• 5-year mortality is approximately 50%

• Mortality rates vary from < 5% per year in those with no or few symptoms to > 30% per year in those with severe and refractory symptoms

• Higher mortality is related to

  • Older age

  • Lower LVEF

  • More severe symptoms

  • Chronic kidney disease

  • Diabetes

When to Refer

• Patients with new symptoms of HF not explained by an obvious cause should be referred to a cardiologist

When to Admit

• Patients with unexplained new or worsened symptoms, or positive cardiac biomarkers concerning for acute myocardial necrosis

• Patients with hypoxia, gross fluid overload, or pulmonary edema not readily resolved in outpatient setting