HEART FAILURE

DR TARMESSRI RAMACHANDRAN
ACCESSOR :DR GAYETHRI
 Definition of Heart Failure
HF is a clinical syndrome due to any
structural or physiological abnormality of
the heart resulting in its inability to meet
the metabolic demands of the body or its
ability to do so only at higher than normal
filling pressures.
• Accompanied by signs and symptoms of systemic hypoperfusion and
or volume overload.

• typical signs and symptoms ,e.g :

-breathlessness,ankle swelling and fatigue
-elevated jugular venous pressure,ankle oedema,pulmonary crakcles
and displaced apex beat

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Clinical: Symptoms of HF
• Left Heart Failure:
 Dyspnea on exertion
 Dyspnea at rest
 Orthpnea
 Paroxysmal nocturnal dyspnea (PND)
 Fatigue, inability to exercise
• Right Heart Failure:
 Swelling of feet, hands
 Abdominal distention/fullness
 Right upper quadrant pain
 Early satiety
 Weight loss (cardiac cachexia)

ACC/AHA Guidelines 2013

 Clinical: Signs of HF
• Left Heart Failure:
• Rales
• Pleural effusions
• CM: Displaced apical impulse
• Tachycardia, LVS3, murmur of MR
• Narrow pulse pressure
• Right Heart Failure:
• Edema of lower extremities
• Elevated JVP/+ HJR
• RVS3, murmur of TR
• Hepatomegaly, RUQ tenderness
• Ascites
• Pleural effusions
ACC/AHA Guidelines 2013
 Stages of Heart Failure
Asymptomatic

A At high risk for HF but without NYHA Class

structural heart disease or symptoms
of HF (e.g., patients with HTN or CAD)

B Structural heart disease but without

symptoms of HF Class I Asymptomatic: No limitation of physical
activity. Ordinary activity does not cause sxs.

II Symptomatic with moderate exertion.

C Structural heart disease with prior or Ordinary physical activity causes SOB, fatigue
current symptoms of HF III Symptomatic with minimal exertion.
Less than usual activity causes sxs

D Refractory/advanced HF requiring IV Symptomatic at rest. Unable to carry on any

activity without discomfort.
specialized interventions

Symptomatic
ACC/AHA Guidelines 2013
 NYHA Class and Mortality
NYHA Class 1-Yr Mortality
Class I 5-10%
Asymptomatic: No limitation of physical activity.
Ordinary activity does not cause sxs.

10-15%
II Symptomatic with moderate exertion.
Ordinary physical activity causes SOB, fatigue

III Symptomatic with minimal exertion.

15-20%
Less than usual activity causes sxs

IV Symptomatic at rest. Unable to carry on any

20-50 %
activity without discomfort.

ACC/AHA Guidelines 2013

HF groups: 2013 ACC/AHA Guidelines
The current definition of HF based on left ventricular ejection
fraction (EF):

• HF with reduced EF (HFrEF, EF ≤40%)

• HF failure with preserved EF

(HFpEF, EF ≥50%)

• HFpEF, borderline (EF 41-49%)

• HFpEF, improved (EF >40%)

Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: a
report of the American College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. Circulation. 2013;128:e240–e327.
CLASSIFICATION :CLINICAL PRESENTATION
• Failure practical purpose ,HF can also be classified according to the
clinical presentation into :
ACUTE HEART FAILURE (ACUTE HF)
-Defined as the rapid onset of symptoms and signs of HF due to an
acute deterioration of cardiac function in the presence or absence of
previous cardiac diasease.

CHRONIC HEART FAILURE (CHRONIC HF )

-This is a chronic state when patients have stable symptoms .In these
patients ,an acute precipitating or aggravating factors may cause acute
cardiac decompensation.

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DIAGNOSIS
• Begins with clinical suspicion
• Initial investigations include ECG,chest radiograph and natriuretic
peptides (NP)
• Echocardiography :first choice for imaging of cardiac structure and
intracardiac pressure estimation.
• Additional tests,to determine specific causes.

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Management of
Patients with
Heart Failure
 • HYPOPERFUSION :
cold peripheries,capillary refill time more than 2
seconds,diaphoresis,oliguria
,dizziness,confusion,narrow pulse
pressure,hypotension.

CONGESTION :
Peripheral oedema,orthopnea,PND ,lung
creptitations,jugular venous dilatation
,hepatjugular reflux,congested hepatomegaly
,gut congestion ,ascites

FROM ONSET,EVALUATE TO IDENTIFY

CORRECTABLE/REVERSIBLE LESIONS -
arrythmias,hypertension ,myocardial ischaemia
/infarction ,valvular heart disease.

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 • MX OF CHF (HFrEF)..
-Emphasize the use of
inhibitors of RAAS and
sympathetic system
-Stepwise,uptitrate to target
dose
-continous reassessment for
clinical response
/improvement
-consider switch to ARNI
-consider device therapy

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Initial Workup of Stage C HF
• After detailed history; Initial laboratory evaluation:
• CBC, urinalysis, CMP (including calcium and magnesium),
fasting lipid profile, TSH, iron panel
• Serial monitoring, when indicated, should include serum
electrolytes and renal function.

• A 12-lead ECG should be performed initially on all patients

presenting with HF.

• Chest X-ray is all patients with new onset HF.

• Echocardiogram in all patients with new dx of HF (MUGA in some)

• Repeat echo usually for a significant change in clinical status or for
consideration of changes after therapy or to evaluate for device
therapy.

• Noninvasive stress imaging or cardiac cath is reasonable in HF

and suspected CAD
BNP (NT-proBNP) in HF
• BNP or B-type natriuretic peptide is
produced mostly by cardiac ventricles
in response to stress/strain/stretch on
the myocardium

• BNP has beneficial effects in heart

failure: promotes vasodilation,
diuresis and natriuresis

• Levels increased in patients with

HF; levels correlate with wedge
pressures and prognosis

• BNP < 100 pg/ml usually will r/o

significant HF in acute dyspnea
 BNP (NT-proBNP) in HF (2)
• Patients discharged with BNP > 400-500 pg/ml at discharge
are at a higher risk for HF readmissions and mortality

• However, patients with low LVEF can have normal levels if

diuresed well (20-25% chronic HF)

• Levels ↑ with age, especially in older women, and

with renal dysfunction
•↑ in HFrEF & HFpEF (overall higher in HFrEF)
•↓ ↓ in obesity
• Elevated BNP also seen with RV dysfunction, PE
• Although prognostic- no definitive data to recommend titrating diuretics or meds to
BNP levels- outside of structured HF programs.
 Stage C (HFrEF &
•
HFpEF)
Non-pharmacologic interventions
• Education to facilitate self care
• Regular physical activity; cardiac rehabilitation
• Sodium restriction
• Treat comorbidities: Hypertension, diabetes, CAD,
sleep apnea, anemia
• Influenza and pneumococcal immunization
• Decrease/stop alcohol, smoking, other drug abuse
• Close outpatient follow-up

• Avoid certain drug classes:

• NSAIDs
• Ca channel blockers except amlodipine (in HFrEF)
• Antiarrhythmics except amiodarone, dofetalide
• Thiazolidinediones (TZDs)
Pathophysiology of HFrEF &
Therapeutic Targets

SNS

LV remodeling

SNS= sympathetic nervous system

RAAS= Renin angiotensin aldosterone system

Adapted from Langenickel TH, Dole WP. Drug Discovery Today 2012;9:131–9.
 HFrEF: Medications &
↓ Symptoms ↓ Hospitalizations ↓ Mortality
Devices
Diuretics √ √ (?) ?
ACE I /ARBs √ √ √
Beta-Blockers √ √ √
Aldosterone
Antagonists √ √ √
Digitalis √ √ X
Nitrates/Hydralazine √ √ √
ARNI √ √ √
Ivabradine √ √ X
AICD (Defibrillators) X X √
CRT (BiV pacemakers) √ √ √
Commonly Used Diuretics

23
 Medical Therapy for Stage C HFrEF:
Magnitude of Benefit in RCTs
RR NNT to ↓ mortality RR
↓ Mortality (standardized 36 ↓ HF Hospital.
months)

ACE I / ARB 17% 26 31%

Beta-Blockers 34% 9 41%

Aldosterone
Antagonists 30% 6 35%

Nitrates/Hydralazine 43% 7 33%

2013 ACCF/AHA Guideline for the Management of Heart Failure
25
 Use of Beta Blockers in HFrEF
• Indicated for symptomatic or asymptomatic EF
≤40%.
• Use agents and target doses used in clinical
trials.
• Initiate when relatively euvolemic, off IV
vasoactive agents and prior to hospital d/c.
• Titrate upward every 2 to 4 weeks as long as
stable.
• Most trials held titration for HR <60 or SBP <90.
• Adjust other agents if dyspnea, BP, or weight
gain occur in order to titrate to target doses.

ACC/AHA Guidelines 2013

 Which Beta Blocker; How Much?

Initial Daily Maximum Mean Doses Achieved

Drug
Dose(s) Doses(s) in Clinical Trials

Beta Blockers
Bisoprolol 1.25 mg qd 10 mg qd 8.6 mg/d
Carvedilol 3.125 mg bid 50 mg bid 37 mg/d
Carvedilol CR 10 mg qd 80 mg qd ---------
Metoprolol
succinate extended 12.5 - 25 mg
200 mg qd 159 mg/d
release (metoprolol qd
CR/XL)

2013 ACCF/AHA Guideline for the Management of Heart Failure

 Which ACE I; How Much?
Mean Doses
Initial Daily Maximum
Drug Achieved in Clinical
Dose(s) Doses(s)
Trials
ACE Inhibitors
Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d
10 to 20 mg
Enalapril 2.5 mg twice 16.6 mg/d
twice
Fosinopril 5 to 10 mg once 40 mg once ---------
20 to 40 mg
Lisinopril 2.5 to 5 mg once 32.5 to 35.0 mg/d
once
Perindopril 2 mg once 8 to 16 mg once ---------
Quinapril 5 mg twice 20 mg twice ---------
1.25 to 2.5 mg
Ramipril 10 mg once ---------
once
Trandolapril 1 mg once 4 mg once ---------
2013 ACCF/AHA Guideline for the Management of Heart Failure
 ACE I or ARB or Both?
• ARBs are recommended in patients with HFrEF who are
ACE inhibitor-intolerant (cough +/- angioedema),
unless contraindicated, to reduce morbidity and mortality.

• ARBs are reasonable to reduce morbidity and mortality

as alternatives to ACE inhibitors as first-line
therapy for patients with HFrEF, especially for patients
already taking ARBs for other indications

• Addition of an ARB may be considered in persistently

symptomatic patients with HFrEF who are already
being treated with an ACE inhibitor and a beta blocker
in whom an aldosterone antagonist is not indicated or
tolerated.

ACC/AHA Guidelines 2013

 Which ARB; How Much?

Mean Doses
Initial Daily Maximum
Drug Achieved in Clinical
Dose(s) Doses(s)
Trials

ARBs

Candesartan 4-8 mg qd 32 mg qd 24mg/d

Losartan 25-50 mg qd 50 to 100 mg qd 129 mg/d

Valsartan 20-40 mg BID 160 mg bid 254 mg/d

ACC/AHA Guidelines 2013

 Aldosterone Antagonists
• Aldosterone receptor antagonists [or mineralocorticoid receptor
antagonists (MRA)] are recommended in patients with NYHA class II-
IV and who have LVEF of < 35%.

• Patients with NYHA class II should have a history of prior

cardiovascular hospitalization or elevated plasma natriuretic peptide
levels to be considered for aldosterone receptor antagonists.

• Creatinine should be < 2.5 mg/dL or less in men or < 2.0 mg/dL in
women (or eGFR >30 mL/min/1.73m2) and potassium < 5.0 mEq/L.

• Careful monitoring of potassium, renal function, and diuretic dosing

should be performed at initiation, within 7-10 days after initiation and
followed thereafter to minimize risk of hyperkalemia and renal
insufficiency.
 Aldosterone Antagonists

Mean Doses
Initial Daily Maximum
Drug Achieved in
Dose(s) Doses(s)
Clinical Trials
Aldosterone Antagonists

Spironolactone 12.5 to 25 mg qd 25 mg qd 26 mg/d

Eplerenone 25 mg qd 50 mg qd 42.6 mg/d

• Eplerenone is a more specific aldosterone receptor antagonist; it can

be used if spironolactone causes gynecomastia or breast pain.
• It causes the same effects on potassium and renal function as
spironolactone.
Nitrate/Hydralazine (ISDN/HDZ)

• HDZ/ISDN combincation is recommended for African

Americans with NYHA class III–IV HFrEF receiving
optimal therapy with ACE inhibitors and beta blockers.

• HDZ/ISDN can be useful to reduce morbidity or mortality in

patients with current or prior symptomatic HFrEF who
cannot be given an ACE inhibitor or ARB because of
drug intolerance, hypotension, or renal insufficiency, unless
contraindicated.
 Digitalis
• Digoxin can be beneficial in patients with HFrEF
and sinus rhythm to decrease hospitalizations
for HF: consider adding if on other therapy and
still symptomatic

• Digoxin can be used in HF patients with atrial

fibrillation to help rate control

• **Dose: 0.125 -0.25 mg qd depending on renal

function (levels not for dosing but for toxicity)
• **Interaction with amiodarone, which ↑ Digoxin
levels
 Neprilysin as a Therapeutic Target
Natriuretic peptides
• Neprilysin breaks down endogenous
Adrenomedullin
vasoactive peptides, including the natriuretic
Bradykinin
peptides
Substance P
• Inhibition of neprilysin potentiates the action
(angiotensin II)
of those peptides
• Because angiotensin II is also a substrate Neprilysin
for neprilysin, neprilysin inhibitors must be
co-administered with a RAAS blocker Inactive
• The combination of a neprilysin inhibitor and fragments
an ACEI is associated with unacceptably high
rates of angioedema
Sacubitril/Valsartan (LCZ696):
Angiotensin Receptor–Neprilysin Inhibitor (ARNI)

Corti R et al. Circulation. 2001;104:1856-1862.

PARADIGM-HF: CV Death or HF
Hospitalization (Primary Endpoint)

1. McMurray JJ et al. N Engl J Med. 2014;371:993-1004

 SHIFT Trial Primary Composite Endpoint:
CV Death or Hospitalization for Worsening HF

Swedberg K et al. Lancet. 2010;376:875-885.

 2016 ACC/AHA/HFSA Focused Update on New Pharmacological
Therapy for Heart Failure: An Update of the 2013 ACCF/AHA
Guideline for the Management of Heart Failure
COR LOE Recommendation
I B-R ACEI or ARB or ARNI in conjunction with β blockers + MRA
(where appropriate) is recommended for patients with chronic
HFrEF to reduce morbidity and mortality
I B-R In patients with chronic, symptomatic HFrEF NYHA class II or III
who tolerate an ACEI or ARB, replacement by an ARNI is
recommended to further reduce morbidity and mortality
III B-R ARNI should NOT be administered concomitantly with ACEI or
within 36 hours of last ACEI dose
III C-EO ARNI should NOT be administered to patients with a history of
angioedema
COR LOE Recommendations
IIa B-R Ivabradine can be beneficial to reduce HF hospitalization for
patients with symptomatic (NYHA class II-III), stable, chronic
HFrEF (LVEF ≤35%) who are receiving GDMT, including a β
blocker at maximally tolerated dose, and who are in sinus
rhythm with a heart rate ≥70 bpm at rest
1. Yancy CW et al. J Am Coll Cardiol. 2016;68:1476-1488.
Implantable Cardiac Defibrillators (ICD)

• Sustained ventricular
tachycardia is associated
with sudden cardiac death in
HF.
• About one-third of mortality in
HF is due to sudden cardiac
death.
• ICDs for primary prevention
have been shown to improve
survival in selected patients
with HF
 Indications for ICD Therapy
• ICD therapy is recommended for primary prevention of
SCD in selected patients with HFrEF at least 40 days post-
MI with LVEF ≤35%, and NYHA class II or III symptoms on
chronic GDMT, who are expected to live ≥1 year

• ICD therapy is recommended for primary prevention of

SCD in selected patients with HFrEF at least 40 days post-
MI with LVEF ≤30%, and NYHA class I symptoms while
receiving GDMT, who are expected to live ≥1 year

• ** ICDs do not improve symptoms; most patients

should be on GDMT; should have an expected life-
2013 ACCF/AHA Guideline for the Management of Heart Failure
expectancy of at least 1 year
 Cardiac Resynchronization Pacing:
Consequences of a Prolonged QRS
Delayed Ventricular
Activation
Sinus Delayed lateral wall contraction
node Disorganized ventricular contraction
Decreased pumping efficiency

Reduction in diastolic filling

AV
node
times

Conduction Prolongation of the duration

block
of mitral regurgitation
 Mechanism:
Ventricular Resynchronization

Sinus • Intraventricular Activation

node
• Organized ventricular
activation sequence
• Coordinated septal and
freewall contraction
AV
node • Improved pumping
efficiency
Conduction
block Stimulation
therapy
 Cardiac Resynchonization Rx (CRT)
• LVEF < 35%
• Greatest benefit in patients with sxtic HF
with LBBB + QRS > 150 msec already on
GDMT and in sinus rhythm

• Can consider in patients with symptomatic HF with LBBB

and QRS 120-149 msec
• Can consider in symptomatic HF with non-LBBB and
QRS > 150 msec
• Can be considered in atrial fibrillation if ventricular pacing
is needed and rate control will allow nearly 100%
ventricular pacing with CRT
2013 ACCF/AHA Guideline for the Management of Heart Failure
 HrEF IN SPECIAL GROUPS :
• DIABETES

• PREGNANCY

• ARRYTHMIA

• CARDIO-ONCOLOGY

• CHRONIC KIDNEY DISEASE

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 Summary
• Definition of HF
• Magnitude of the problem
•Symptoms & Signs of HF
• Types of HF: HFpEF & HFrEF
• Stages of HF and NYHA Functional
Classification of HF
• Management of Patients with HF:
Initial work up
Medical therapy
Device Therapy