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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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…”

8. 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

9. 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?

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

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

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

24. 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

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

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

27. 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

28. 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

29. 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

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

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

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

33. 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

34. 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

35. 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 Liter/day is reasonable
Palliative care and hospice

36. 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

37. 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)