Heart Failure for the Internist Phil Camp and Paul Andre R3s UNM IM

Goals Be able to diagnose HF Recognize other possible diagnoses on the differential Understand treatment goals of ADHF Understand GDMT in the treatment of HF

Outline of lecture Most patient care is initiated by ED call, will start there Continue with admission orders and care while patient is in ADHF GDMT Discharge and follow up

Heart Failure: Diagnosis HF is a clinical diagnosis Objective data can help differentiate HFpEF from HFrEF, along with ADHF from other diagnoses Diagnosis is made with Framingham Criteria for Heart Failure Need 2 major OR 1 major and 1 minor

Major Criteria PND or orthopnea JVD; increased venous pressure >16 cm H2O Rales Cardiomegaly on CXR Acute pulmonary edema on CXR S3 gallup Hepatojugalar reflux Weight loss of 4.5 kg in 5 days of presumed HF treatment

Minor Criteria Bilateral LE edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion on CXR Tachycardia > 120 bpm Weight loss > 4.5 kg in five days

Common ED calls “This guy has a history of HFpEF and is short of breath…” “This lady with ESRD on HD has a BNP of >30000…” “This guy is in ADHF… his HR is 155 in Afib with RVR…”

BNP: Why it matters and why it doesn’t BNP reflects wall tension Wall tension = radius x pressure wall thickness HFrEF = thin walls; dilated LV radius = high BNP HFpEF = thick walls; nml LV radius = low BNP Other factors effecting BNP interpretation: Age, weight, renal function BNP is metabolized by kidney -> don’t present a BNP without giving a GFR (creatinine) No one cares

ADHF: Initial evaluation Quick chart biopsy Previous cardiac studies; especially EF evaluations, cath reports, and BNPs Recent HF clinic notes and DC summaries; DRY WEIGHT/Last HF weight on discharge, medications, reason for previous admission Thorough history and physical Precipitating event? JVD? S3? crackles? LE edema? Orthopnea?

Causes of Decompensation Every admission of ADHF needs a reason for why they are in ADHF Common precipitants MY HEARTS DIE

Precipitants of ADHF MY HEARTS DIE MYocardial ischemia Hypertension (uncontrolled) or Hypoxia (OSA) Endocrine (DM, hypo/hyperthyroid) Arrhythmias (afib, brady and tachy) or Anemia Reduction in therapy (nonadherence) or Renal insufficiency Too much Na and fluid Second CV disorder (endocarditis,myocarditis, dissection) Drugs (neg inotropes, toxins, Na retaining meds) Infections (sepsis, PNA) Embolism (PE)

Hemodynamic Profiles: What are they and why do they matter? Warm or cold: narrow pulse pressure, cool skin, hypotension, CI <2.2 Wet or dry: orthopnea, JVD, rales, S3, edema, PCWP >18 Cold patients must be warmed up before they can be dried out

ED HF dispositions ADHF due to medication/diet noncompliance Admit to Cards ADHF due to inadequate/improper medical therapy ADHF due to cardiac decompensation Cardiogenic shock -> typically MICU ADHF due to acute illness, toxic ingestion requiring treatment, endocrine issues Admit to medicine FLUID OVERLOAD in someone who is ESRD on HD Family Medicine admits their own ADHF

HFpEF? HFrEF? EF >50% -> HFpEF (preserved EF) EF 40-49% -> HFpEF borderline EF previously <40%, now >40% -> HFpEF improved EF <40% -> HFrEF (reduced EF) Why it matters: Most studies divide patients into either HFpEF or HFrEF AHA/ACCF guidelines vary by HFpEF and HFrEF

HFpEF masqueraders Cardiac Noncardiac Think outside-in anatomically Pericardium, epicardium, myocardium, electrical disease, valvular disease, vascular disease Noncardiac Obesity, deconditioning, anemia, hypothyroidism Neuromuscular disease Pulmonary: OSA, COPD Renal Artery stenosis High output heart failure: anemia, sepsis, AV shunt, hyperthyroid

AHA/ACCF HF Stages Stage A: high risk for HF; no structural disease or symptoms of HF Stage B: Structural heart disease; no signs or symptoms of HF Stage C: Structural heart disease; prior or current symptoms of HF Stage D: Refractory HF requiring specialized interventions

NYHA Functional Classes I – No limitations of physical activity II – Slight limitation of physical activity Comfortable at rest. Ordinary activity results in symptoms III – Marked limitation of physical activity Comfortable at rest. Less than ordinary activity results in symptoms IV – Unable to carry on physical activity without symptoms or symptoms at rest

Questions? Diagnose HF? Classify/stage HF? Evaluate DDx?

Admission Orders HF power plan Beta blocker at ½ normal dose Fluid restriction: 2 L If hyponatremic: 1.5 L Beta blocker at ½ normal dose Safe to start/resume when dry Hold if cold – start dobutamine/milrinone Diuresis with IV loop diuretic Pick your poison. If no response after 6 hrs, double or try another loop. If no response, change to gtt, add metolazone/chlorothiazide If AKI; hold ACEi/ARB Start Nitrate/hydralazine combo for afterload reduction As always, treat underlying cause of decompensation

Daily Goals/Common Pitfalls of Managment Don’t be scared with aggressive diuresis Vascular refill rapid 1st 24 hrs of diuresis Continue on IV diuretics until dry If AKI, hold diuresis. Don’t give fluids. Hydralazine can be rapidly titrated after each dose if tolerated

What to look for on prerounds? Chart review Labs: Cr, K, Na Vitals: Orthostatic? Weight? I/Os? Review tele: particularly in the paper chart Physical exam Wet or dry Cold or warm

HFpEF Treatment Guidelines HHAARDN – 5 guideline treatments + 2 H – HTN; treat to guideline goals H – HTN drug choices; ACEi/ARB or Beta blocker A – Afib; Control by guidelines A – Aldosterone antagonist; Spironolactone decreases hospitalization and reduces mortality R – Revascularize; if ischemic D – Diuretic; if wet, diuresis N – n3 PUFA; n3 polyunsaturated fatty acids

HFrEF Treatment Guidelines Medications ACEi/ARB Beta blocker Diuretic Nitrate/hydralazine Aldosterone antagonist Digoxin n3 PUFA

ACEi Class 1, LOE A Contraindication – angioedema, pregnancy/plan for pregnancy Caution – Cr >3.0, bilateral RAS, K >5, hypotension (SBP <80) Enalapril Captopril Lisinopril Ramapril Quinapril Fosinopril Perindopril Trandolapril

ARB ACEi intolerant patients, Class 1, LOE A Candesartan Losartan Valsartan

Beta Blocker Class 1, LOE A ADHF safe dose – ½ home dose Start new when on oral diuretic Carvedilol Metoprolol succinate Bisoprolol

Diuretic Furosemide Bumetanide Torsemide Metolazone Chlorothiazide Know patient’s dry weight, get daily weights on home scale and instruct on diuretic use based on weight

Nitrate and hydralazine Recommended in African Americans with NYHA class III-IV on optimal medical therapy. Class 1, LOE A Can’t tolerate ACEi/ARB. Class IIa, LOE B Nitrate mean daily dose 136 mg Hydralazine mean daily dose 270 mg

Aldosterone antagonist Recommended in NYHA class II-IV: EF<35%; Cr <2.5 in men, <2.0 in women; K<5, GFR>30. Class I, LOE A Monitoring: Chem7 day 3, 7; Wk 2, 3; Month 1 and every 3 months after Spironolactone Eplerenone

Digoxin Can be beneficial to reduce HF hospitalizations unless contraindicated. Class IIa, LOE B Goal serum level 0.5 – 0.9

n3 PUFA Reasonable to use as adjunct in NYHA class II-IV to reduce mortality and hospitalizations. Class IIa, LOE B. Dose 1200 TID

ARNi No current recommendations at this time LCZ696 (Entresto) Combination pill of valsartan and sacubitril Superior to enalapril by PARADIGM trial

Medications to be aware of Statins – no benefit in HF; OK to give for other indications Nebivolol – No benefit by SENIORS trial Non-dihydropyridine calcium channel blockers – EF<40%, Class III, LOE C, MAY CAUSE HARM Amlodipine OK

Devices ICD – implantable cardioverter defibrillator EF <35%, >40 days post MI, NYHA class II or III on GDMT with >1yr estimated survival. Class I, LOE A. EF <30%, >40 days post MI, NYHA class I on GDMT with >1yr estimated survival. Class I, LOE B. CRT – cardiac resynchronization therapy EF <35%, SR, LBBB with QRS >150 ms, NYHA class II-IV on GDMT. Class I, LOE A for NYHA III/IV, LOE B for NYHA class II Look at the EKG for rhythm, QRS duration and morphology Evaluate patient for NYHA class, GDMT, and EF

Stage D HF Definition Goals Therapeutic options Control symptoms with GDMT Improve quality of life Reduce admissions Establish end of life goals Therapeutic options LVAD, heart transplant Inotropic support Fluid restrict 1.5-2 Liter/day is reasonable Palliative care and hospice

Discharge Day of discharge: Follow up: BNP, H/H, dry weight Cards: DC summary dictated on day of DC Med rec with indications for all meds given All GDMT medications must be listed Need reasons patients not DC’d with ACEi/ARB or Beta blocker Follow up: 1 week with HF clinic, PCP

Questions? Know treatment goals of ADHF? Know GDMT for HFpEF and HFrEF? Aware of stage D HF as unique? Discharge requirements? Always ACEI 1st (all BB studies done on ACEI) Class I & III (goes for any guidelines on boards)