6 interesting cases in graphic form to classify HF syndromes

1. Based on 30 years heart failure Experience
summary of clinical classification of heart failure.
6 simple and interesting cases in graphic form.
Asadullah Khan Soomro
Adult Cardiologist
King Abdullah Medical City Holy Makkah KSA
Email; hssbasadsoomro@gmail.com
Heart failure clinic or heart failure programme.
When and Who need what ?? Judge after 7 slides.

2. Soomro’s Classification of Heart Failure
Syndromes
.
Acute De-Novo
Heart Failure syndromes
Chronic Heart Failure
Syndromes
Chronic
Compensated
Stage C Acute
Decompensation
of Chronic HF
Stage C
Chronic
Advanced HF
Syndromes
Stage D
Acute
De-Novo
Simple Acute
De-Novo
Complex
Acute
De-Novo
Malignant
“Benign or Malignant ?”

3. Soomro’s Classification of Heart Failure
Syndromes
.
“Benign or Malignant ?”
RAHFC
Acute De-Novo Simple HF.
Uncomplicated without major organ
dysfunction. Non vulnerable for admission &
readmission. Art is to pick up such cases from
community clinics before severe symptoms to
visit ER and hospitalization or die suddenly .So
simple do not always mean benign but its
science and art in early diagnosis and
management of heart failure
62 year male, diabetic and smoker, presented to community physician clinic with exertional breathlessness FC 11, no PND, for 2 weeks, considered flu and
allergy given treatment but no symptom relief. Him self went to local private hospital did echo and found to had LV systolic dysfunction. Referred to KAMC seen
as RAHFC on 4.10.20 diagnosed to have moderate De-novo HF , considered ischemic following silent MI. started full guide line directed treatment and
,did echo and labs on same day. Reviewed after a week EF 25% BNP 145, Trop 0.072, no major organ dysfunction. CAG on 8.11.20 LM+ severe 3 VD CAD,
Inserted IABP shifted to CCU. Underwent CABG on 10.11.20 .Discharged on 17.11.20. ..This is fantastic typical RAHFC case to prevent first HF
hospitalization. Indeed this is the beauty of multidisciplinary heart failure program , certainly not possible on HF clinic which is mainly for
regular chronic compensated HF patients. So forget about heart failure admission and readmission syndromes without HF program.
Admitted electively through OPD ,No HF visit to ER, and no HF admission
indeed . Diagnosed and revascularized timely with in a month of HF
symptoms. So he was sitting on tip of iceberg . Right patient at right time

4. Soomro’s Classification of Heart Failure
Syndromes
.
De-novo heart failure
“Benign or Malignant ?”
Acute De-Novo Complex HF with
major organ dysfunction , vulnerable
for readmissions
41 year male father of 5 children employed only heavy smoker admitted on 22.7.2020, at private local hospital sudden severe chest pain diagnosed to had ant
wall STEMI with LV systolic dysfunction EF 35% no MR .CAG prox LAD occlusion did PCI to LAD.
Started symptoms of heart failure in November 2020 visited ER thrice in one week with typical PND ,admitted with De-novo heart failure on 3rd visit on
8.11.2020 . Echo showed worsening in EF 15-20% severe MR severe pulmonary hypertension RSVP 75mm . Patent LAD stent .Normal troponin, persistently raised
BNP ( 2683- 4170 ) mild major organ dysfunction. ( Vulnerable for readmission ) In hospital started sacubitril 50 mg bid on 13.11 20, virtually contacted by phone
on 8.12 .20 . Seen in post discharge HF clinic on 13.12.20 .Symptomatically improved organ function normalizing but persistently raised BNP sacubitril
increased to 100 mg. Discussed and accepted for mitral valve clip ,could not tolerated target dose of 200 mg because of dizziness. other wise no visit to ER no
readmission.
First red circle is Acute STEMI july 2020 .Visited ER thrice
with HF & PND in one week ,admitted with de novo HF.
Green dips are post discharge HF visits
Post discharge early HF clinic
review

5. Soomro’s Classification of Heart Failure
Syndromes
.
“ Benign or Malignant ? ”
Acute De-Novo Malignant HF
Admited first time and expired during
index hospitalization
47 year male no DM HTN but smoker indeed, started sudden severe chest pain at home , 25.11.2019 PM, arrested and
resuscitated ( OHCA ) Shifted to ER ,EKG showed ant wall STEMI complicated by cardiogenic shock and pulmonary edema,
inserted ECMO and shifted to cath lab. CAG showed multi vessel CAD .Did complete revascularization ( PCI) .Complicated by
cardio-renal ( creatnine 2.2, Bun 20 ) and acute cardiogenic liver injury ( hypoxic hepatitis AST 452 to 8228,ALT 166 to 3718,
LDH 1100, Alb 3.0,Tprot 4.7,T bil 0.4 to 2,8, INR 5.0, Trop 7.4 to 1409, CPK 6589 to 17872. Echo showed bi ventricular severe
systolic dysfunction. Remain critical despite all yet expired on 27.11.2019.

6. Soomro’s Classification of Heart Failure
Syndromes
.
“Benign or Malignant ?”
Chronic compensated HF
Stage C , FC 1 11, single red dip is
de novo HF in 2013 .Green dips
are all OPD visits
40 year male DM ,non smoker, known to have non ischemic heart failure with LV systolic dysfunction EF 25-30%,stage C since 2013
.He is our first patient seen in heart failure clinic on 9th october 2018. He was in FC 11 switched to sacubitril 50 mg on 9th
october 2018, titrated to 100 mg on 23.10.18, remain good no renal injury electrolytes normal titrated to target dose 200 mg on
16.4.2019 since then remain compensated no major organ dysfunction BNP remained less then 50 all along. No ER visit ,no
readmission ( Non vulnerable candidate )
Despite on GDMT full dose yet symptomatic so readmitted electively for repeat CAG done on 3.11.2020, normal CAG .
Discussed for device therapy EF remain same 25% despite on full medical treatment for two years .
De-novo HF in
2013
Since then remain in chronic
compensated phase .Regularly following
at HF clinic. Ever Green:

7. Soomro’s Classification of Heart Failure
Syndromes
.
“Benign or Malignant ?”
ER
Admit
ion
ER
ER
Ad
miti
on
39 year male HTN smoker drug abuser ( Captagon hashish since long time ) divorced unemployed had acute ANT wall STEMI 2016, severe LV systolic dysfunction
EF 10-15% .Non significant CAD .Recurrent NSTEMI with heart failure .Progressive worsening of heart failure stage C transition to stage D with persistently raised
BNP ( 2300 to 8254) major organ dysfunction ( cardio renal and passive liver congestion. Started sacubitril in August 2020 titrated to 200 mg on 22.9.20 but could
not tolerate ( reduced to 100 mg due to renal injury) Worsening of HF last admitted in march 2021 implanted CRTD since then remain better FC improved ,waiting
to see him back after vacation.
Acute decompensation of chronic
heart failure stage C .( ADCHF)
They usually have precipitating
factors for decompensation.
Admition

8. Soomro’s Classification of Heart Failure
Syndromes
.
“Benign or Malignant ?”
58 year male HTN, heavy smoker known to have had non ischemic heart failure with severe LV systolic dysfunction for 5 years EF 10 -15%. Started to have
progressive worsening of heart failure since 2019 ,implanted CRTD, Yet remained symptomatic started sacubitril 50 mg in May 2019 subsequently titrated to
200 mg in July 2020.Remain compensated until 23.11.2020 . Had recurrent ER visits ( 8 visits ) readmitted on 11.2 21 discharged with persistently elevated BNP
( 1191 to 11282) major organ dysfunction ( Cardio-renal creatnine 1.7 to 3.7) Passive liver congestion ( Tbil, 6.6 Dbil, 3.7 Alb 2.8,trot 5.2, AST 722 & ALT 243.
Readmitted 26.2.21 in general ward was hypotensive with dysrrhythmias shifted to CCU remain in shock on max ionotropes expired on 6.3.2021.
Chronic Advanced Heart failure
Syndromes. Stage D FC 111 & 1V , green dips
are OPD visits , Brown dips are ER visit and red
dips are admission and readmissions. They are
shuttling with in recurrent ER visits and
readmissions .
OPD phase
ER visits
Red dips are readmissions