This document provides an overview of heart failure (HF), including definitions, epidemiology, pathophysiology, diagnosis, and treatment. Some key points: - HF is a clinical syndrome where cardiac output is insufficient to meet the body's demands. It can be acute or chronic, and involve systolic or diastolic dysfunction. - Risk factors include hypertension, coronary artery disease, and drugs like doxorubicin. Incidence increases with age. - Diagnosis involves history, physical exam, BNP, echocardiogram, and other tests. BNP is useful to differentiate cardiac from pulmonary causes of dyspnea. - Treatment depends on stage and includes ACE inhibitors, beta blockers,

1. Michael Kendall

2.  No conflicts of interests
 I’m NOT a cardiologist

3.  Define
 Diagnose
 Treatment
 Prevention
THEMES:
 Balance
 AVOID hospitals

4. 1. Heart disease: 635,260
2. Cancer: 598,038
3. Accidents (unintentional injuries): 161,374
4. Chronic lower respiratory diseases: 154,596
5. Stroke (cerebrovascular diseases): 142,14
 >650,000 new HF diagnoses annually
 Incidence increases with age:
 20/1000 for ages 65-69
 >80/1000 for ages >85
 50% mortality at 5 years

5.  Clinical syndrome in which cardiac output is insufficient for meeting the demands
of the body
 Symptoms include exertional dyspnea, fatigue, edema
 Acute vs chronic
 Systolic (left) dysfunction (HFrEF), EF <40
 Diastolic (biventricular) dysfunction (HFpEF), EF >50
 Half all hospital admission each

6. HFrEF
 ↓ SV and ↑ ventricular filling
pressure
 Decrease myocardial contraction
 Ventricular dilation
HFpEF
 ↓ SV and ↑ ventricular filling
pressure
 Decrease diastolic relaxation
 Increase HR
IRREVERSIB

7. HFrEF
 Hypertension
 CAD
 Myocarditis
 Drugs (ie doxorubicin, trastuzumab)
 Alcohol, cocaine, methamphetamine
 Hypo/hyperthyroid
 SLE, Scleroderma
 Stress cardiomyopathy
HFpEF
 Hypertension
 CAD
 Amyloidosis, hemochromatosis

8.  History + PE
 EKG
 BNP
 Troponin
 CXR
 Echocardiogram (most important)
 CMR
 Endomyocardial biopsy

11.  Brain Natriuretic Peptide (NT-pro BNP)
 When to order? Dyspnea present
 Differentiate between pulmonary and cardiac related dyspnea
Breathing Not Properly Study (2002, n=1586, ED visit for dyspnea)
 Exacerbated HF mean >600ng/L
 Compensated with h/o LV dysfunction mean approx. 200ng/L
 Non cardiac causes mean approx. 50ng/L
Note:
 Levels increase with age and decrease with increase BMI
 Outpatient serial BNP?

12.  To cath or not to cath?
 CAD causes approx. 2/3 of all HF
 Ischemic evaluation historically part of newly diagnosed HF, no longer due to
expense and radiation exposure
 Cath indication: angina, ischemia
 Levels increase with age

13. ACCF/AHA Stages
A. Risk without structural disease
B. Structural disease without
symptoms
C. Structural disease with symptoms
D. Refractory disease requiring
specialized intervention
NYHA functional classes
I. No limit
II. Symptoms with ordinary activity
III. Symptoms with < ordinary
activity
IV. Symptoms at rest

14.  Clinical trials awareness (ie mortality, symptoms, hospitalization)
 Titrate (there are optimal doses), goal keep outpatient
Symptom
improvement
Side
effects

16.  Stage B to D
 Decrease mortality, hospitalizations, and improves function (ACEi more research)
 ACEi > ARB
 Higher doses decrease hospitalization, but not mortality
 Side effects:
 Caution with CKD, especially Cr <3 mg/dL (both)
 Dry cough (20%), consider ARB
 Hyperkalemia (both)
 Angioedema (both)

17.  Stage B to D
 Decrease mortality, hospitalizations, and improves function
 Limited to Bisoprolol, Carvedilol, or Metoprolol Succinate
 Combined with ACEi leads to greater symptomatic improvement than either alone
 Side effects:
 Fluid retention
 Fatigue
 Bradycardia or heart block
 Hypotension

18.  Stages C and D, with clinical evidence of fluid retention
 Improves symptoms and exercise tolerance (morbidity or mortality unknown)
 Loop diuretics (NaCl at loop of Henle) > thiazides (distal portion of tubule)
 Furosemide, Bumetanide, Torsemide
 Combination (multiplier) can result in significant diuresis
 Side effects
 Electrolyte depletion
 Dehydration
 Hypotension
 Azotemia

19.  Stages C and D
 Decrease mortality and hospitalizations (RALES trial)
 Criteria
 NYHA II-IV
 EF < 35%
 s/p MI with EF < 40% and DM
 Cr < 2.5mg/dL (men) or < 2mg/dL (women), and K < 5 mEq/L
 Side effects:
 Hyperkalemia (requires close monitoring with change in ACEi)
 gynecomastia

20.  Stages C and D
 Decrease mortality and hospitalizations
 Criteria
 African American with NYHA III-IV (receiving
optimal therapy with ACEi and beta blocker)
 Cannot tolerate ACEi or ARB
 Side effects
 Headaches, dizziness, GI discomfort

21.  Stages C and D
 Modest decrease hospitalizations and improves symptoms
 Side effects: (levels >2 ng/mL)
 Arrythmias (ie heart block)
 GI symptoms (anorexia, nausea/vomiting)
 Visual disturbance
 Confusion
 NOT for elderly

22. 2013 ACCF/AHA Heart Failure Guidelines

23.  None of the above medications have demonstrated a reduction morbidity or
mortality for HFpEF
 Treatment of HFpEF should focus on underlining cause (HTN) and symptoms (ie
diuretics)
 HFpEF in particular is sensitive to volume control

24.  Cardioverter-defibrillator
 Cardiac-resynchronization therapy (CRT)
 CardioMEMS

25.  Primary prevention
 Pacemaker single vs dual chamber, right atrial vs ventricular
 Criteria: (ACCF/AHA guidelines)
 NYHA class I or II (on medical therapy)
 EF < 35% or > 40% with history of ischemic cardiomyopathy
 History of ventricular arrythmia or cardiac arrest (secondary prevention)

26.  Second lead for LV through coronary sinus down coronary vein
 Criteria: (ACCF/AHA guidelines)
 Optimized on medical therapy
 NYHA class II to IV
 Ejection fraction < 35%
 Ventricular dysfunction (LBBB with QRS > 150msec)

27.  Abbott
 CHAMPION trial (2011, n=550, prospective): 37% reduction in hospitalization
 Criteria: (FDA approved)
 NYHA class III to IV
 Hospitalized for HF in the previous year
 Require anticoagulation for one month post implant

28.  Percutaneous vs surgical implant
 Bridge to transplant vs destination therapy

29.  Exacerbation of chronic HF
 Development of new HF
 DIET (low sodium), EXERCISE
 Risk factors and comorbidities of HF:
 HTN, particular benefit for elderly with h/o MI (80% risk reduction for incident HF)
 Diabetes, 4-fold increase risk of developing HF with A1c >10.5 compared to <6.5
 Atherosclerotic disease, statins
 Anemia, mortality approximately doubles (iron therapies, not epo)

30.  2013, HF costs in the US was estimated > $30 billion
 Mean cost of HF related hospitalization was $23,077
 Versus $10