Approach to Heart Failure in Family Medicine and Primary Care

1. Heart Failure in Primary Care
Hasan Ismail
PGY III – Family Medicine
Lebanese University
1

2. Objectives
- Stress on Primary care physicians role
- Discuss classic treatments of Heart failure
- Take a look to new management modalities
- Referral indications
2

3. OUTLINE
 Case Presentation
 Classic management of HF
 New modalities
 Referral Indiciations
 Comprehension Question 3

4. CASE 1
• A 66-year-old woman presents to your office complaining
of shortness of breath and bilateral leg edema that have
been worsening for 3 months.
• She emphatically tells you, "I get out of breath when I do
housework and I can't even walk to the corner.‘
• She has also noticed difficulty sleeping secondary to a dry
cough that wakes her up at night and further exacerbation
of her shortness of breath while lying flat.
• This has forced her to use three pillows
• She denies any chest pain, wheezing, or febrile illness.
• She has no past illnesses and takes no medications.
• She's never smoked and drinks socially.
4

5. On examination:
• Her blood pressure (BP) is 187 /90 mm Hg, her pulse is 97
beats/min
• her respiratory rate is 16 breaths/min, her temperature is
(36.6°C), and her oxygen saturation is 93% on room air by
pulse oximetry.
• She has a pronounced jugular vein.
• Cardiac examination reveals a pansystolic murmur.
• Examination of her lung bases produces dullness bilaterally.
• You find pitting edema of both ankles.
• An electrocardiogram (ECG) shows a normal sinus rhythm
and a chest x-ray demonstrates mild cardiomegaly with
bilateral pleural effusions.
• You decide she needs further workup, so you call the
hospital where you have admitting privileges and arrange for
a telemetry bed.
5

6. ACC/AHA Classification
A: At risk of heart failure but without structural disease
B: Structural heart failure but without symptoms
C: Structural heart failure with current or prior symptoms
D: Symptoms at rest
6
Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in
the adult: executive summary a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure):
Circulation. 2001; 104(24): 2996-3007

7. For patients at risk of developing HF (Stage A/B),
natriuretic peptide biomarker–based screening
(BNP or NT-pro-BNP) can be useful to prevent
the development of left ventricular dysfunction
(systolic or diastolic) or new-onset HF
7

8. OVERVIEW
• Prevention is the most important part of
managing CHF.
• Aggressive control of hypertension has been
shown to reduce incidence of heart failure by
up to 50%.
• Treating patients who have coronary artery
disease or who have had a myocardial
infarction with ACEI, ARBs, B-blockers, and
aldosterone antagonists reduces the risk of
progression to symptomatic heart failure.
8

9. • Treating dyslipidemia with statin therapy can
also reduce incidence of heart failure by 20%.
• Controlling other risk factors, such as diabetes
mellitus, atherosclerotic vascular disease, and
thyroid disease, as well as avoidance of
cardiotoxic drugs such as tobacco, alcohol,
cocaine, and amphetamines, are important for
reducing risk as well.
9
Case Files – Family Medicine 2016

10. MANAGING ACUTE CHF
• In all cases of acute decompensated CHF, the
initial management imperative is the
stabilization of the cardiopulmonary system.
• Supplemental oxygen, initially 100% via non-
rebreather face mask, should be administered
(CPAP, BiPAP, MV)
• Cardiac and continuous pulse oximetry
monitors + IV
10

11. Acute CHF Management : GOALS
 Stabilize hemodynamics,
 Treat reversible underlying conditions
contributing to CHF
 Establish an effective regimen for outpatient
therapy.
11

12. • About 90% of patients admitted to the
hospital with decompensated heart failure are
volume overloaded.
• When volume overload caused by CHF (which
frequently causes acute pulmonary edema) is
diagnosed, the next step in management is
the administration of a LOOP DIURETIC
12

13. FUROSEMIDE
Potent diuretic
effect Rapid bronchial
vasculature
vasodilation
13

14. • Volume overload may also be treated acutely
with vasodilators to reduce filling pressures.
• Nitrates, particularly nitroglycerin when given
IV, reduce myocardial oxygen demand.
14
PRELOAD AFTERLOAD

15. Most patients who present to the
emergency department (ED) with
symptomatic CHF will require
admission to CCU
15

16. DISCHARGE DIRECTLY FROM ED ?
A patient must have had :
• Gradual onset of symptoms
• Rapid resolution of symptoms with treatment
• Oxygen saturation of greater than 90%
• Exclusion of an acute coronary syndrome as the
cause of the CHF.
16

17. Outpatient
Management of
Chronic CHF
17

18. • Patient education is an important aspect of
care for all patients with CHF.
• All patients should be advised about the
importance of dietary sodium and fluid
restriction
• The American Heart Association, recommends
restricting to 1.5 g/d in patients with stage A
or B disease because of data correlating the
incidence of hypertension and heart failure
with sodium intake
18

19. • Patients should be warned to avoid NSAIDs 
worsen fluid retention, and reduce the efficacy of
diuretics and ACEis.
• Overweight and obese patients should be
counseled on appropriate caloric restrictions and
encouraged to exercise to reduce weight
• The importance of strict management of BP and
modification of other cardiac risk factors should
be emphasized as well
19

20. ACEis or ARBs
• 1st line therapy in patients with CHF and reduced
left ventricular function.
• Reduce preload, afterload,
• Improve cardiac output without increasing HR
• inhibit tissue renin-angiotensin systems which
improves myocardial relaxation and compliance
• class effect (ACEI)
20(Wong et al., 2004),

21. ACEis or ARBs
21
SYMPTOMS
MORTALITY
HOSPITALIZATION

22. • Can also delay the development of symptomatic
CHF in asymptomatic patients with a reduced
cardiac ejection fraction (NYHA I)
• Better outcomes are seen at higher doses, so
patients should be maintained at the highest
tolerable dose
22

23. Contraindications ?
• Pregnancy
• Hypotension
• Hyperkalemia
• Bilateral renal artery stenosis
Caution in patients with renal insufficiency
23

24. • Isosorbide dinitrate/ hydralazine is an option
for those intolerant of ACE inhibitors and ARBs
because of renal disease
• Indicated as adjunctive therapy in black
patients who remain symptomatic despite
treatment with ACE inhibitors
24

25. CASE 2
• A 57-year-old man who has known NYHA II heart
failure presents to clinic after noting to become
dyspneic with significant exertion.
• On physical examination, his BP is 140/86 mm Hg,
pulse 86 beats/min, and respiratory rate 20
breaths/min. A pansystolic murmur is heard.
• There is no JVD, but pretibial and pedal edema
are noted.
• He currently takes Aspirin and he mentionned a
drug called “Coverzin”
25

26. Which one of the following additional
medications has been shown to
improve longevity in this situation?
A. Digoxin
B. β-Blocker
C. Nondihydropyridine CCB
D. Amiodarone ( Cordarone)
26

27. β-blockers ?
27

28. • β -Blockers are recommended to reduce mortality
in symptomatic patients with HF
• Digoxin is only recommended in patients who are
already on maximal medical therapy*.
• Nondihydropyridine calcium channel blockers
should be used with caution in patients with HF
because they can cause peripheral vasodilation,
decreased heart rate, decreased cardiac
contractility, and decreased cardiac conduction
• Amiodarone is used for treatment of arrhythmias.
28
*Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients
with heart failure. N Engl J Med. 1997; 336(8): 525-533

29. • Effective at reducing mortality in patients with
symptomatic heart failure when combined
with ACE inhibitors.
• Preferentially be started when patients have
minimal evidence of fluid retention and few
symptoms
• Initial doses should be low and titrated up
over several weeks
29
** Packer M, Bristow MR, Cohn JN, et al.; U.S. Carvedilol Heart Failure Study Group. The effect of carvedilol on
morbidity and mortality in patients with chronic heart failure. N Engl J Med. 1996; 334(21): 1349-1355.
*The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999; 353(9146): 9-13.
β-blockers

30. β-blockers
Sympathetic tone
Cardiac muscle remodeling
30

31. Contraindications
• Symptomatic bradycardia
• Hypotension
• AV block In absence of a pacemaker
• Severe bronchospasm.
• Severe peripheral vascular disease
31

32. especially in high doses, in
the setting of acute CHF,
can worsen symptoms
32

33. CASE 3
• A 64-year-old man is noted to have congestive
heart failure because of coronary artery
disease.
• Over the past 2 days, he has developed
progressive dyspnea and orthopnea.
• On examination, he is found to be in moderate
respiratory distress, has JVD, and rales on
pulmonary examination.
• He is diagnosed with pulmonary edema.
33

34. Which of the following agents is most
appropriate at this time?
A. Hydrochlorothiazide
B. Furosemide
C. Carvedilol
D. Spironolactone
E. Digitalis
34

35. DIURETICS ?
35

36. • reduce volume overload
• In both the acute and chronic settings
• Symptom management ++
• With ACEI/ ARBs and β-blockers for long-term
reduction in CHF exacerbations
• Diuretic doses can be adjusted based on daily
weight measurements by the patient, and
patients should be monitored closely for
overdiuresis.
• Loop and Thiazide Diuretics do not provide
mortality benefit
36

37. Loop diuretics  increase sodium excretion by
20% to 25% and increase free water excretion.
WHILE
Thiazide diuretics  only increase sodium
excretion by 5% to 10% and this effect is reduced
in renal failure
37

38. 38
??????

39. Aldosterone Antagonists
• spironolactone and eplerenone
• reduce mortality in advanced heart failure
• improving symptoms and ↓ ↓ hospitalizations.
• potassium-sparing diuretic
• considered in NYHA class III and IV heart failure
39

40. Indicated in
- all symptomatic patients with heart failure
due to reduced ejection fraction
- three to 14 days post–myocardial infarction in
patients with reduced ejection fraction and
symptomatic heart failure or concomitant
diabetes mellitus.
40

41. Sodium and water
retention
Potassium and
magnesium loss
Myocardial
hypertrophy and
fibrosis
Endothelial
dysfunction
ALDOSTERONE
41

42. 42

43. WHAT’S NEW ? (1)
Based on limited high-quality evidence,
ACC/AHA/HFSA guidelines recommend
ARB/neprilysin inhibitor therapy as a first-line
alternative to ACE inhibitors for those with
symptomatic heart failure who are not
hypotensive
43
Yancy CW, Jessup M, Bozkurt B, et al. 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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2016; 68(13): 1476-1488

44. The American Academy of Family
Physicians did not endorse this
guideline because of concerns
about its methodology and
insufficient evaluation of harms
44

45. PARADIGM-HF
45

46. • Trial included 8,842 patients with symptomatic HF
• Sacubitril/valsartan VS the enalapril 10mg BID
• The primary outcome was a composite of death from
cardiovascular causes or a first hospitalization from
heart failure.
• Was stopped early because of demonstrated benefit.
• The primary outcome was reached in 26.5% of patients
taking enalapril vs. 21.8% of those taking
sacubitril/valsartan
• Death from cardiovascular causes was reduced (16.5%
vs. 13.3 as was the overall death rate (19.8% vs. 7.0%)
46
McMurray JJ, Packer M, Desai AS, et al.; PARADIGM-HF Investigators and Committees.
Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;
371(11): 993-1004

47. WHAT’S NEW ? (2)
• The U.S. Food and Drug Administration
approved ivabradine for heart failure
management in 2015
• According to ACC/AHA/HFSA guidelines,
ivabradine may be considered in appropriate
patients, but the beta blocker should first be
titrated to the target dosage if tolerated
47
Yancy CW, Jessup M, Bozkurt B, et al. 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: a report of the American
College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure
Society of America. J Am Coll Cardiol. 2016; 68(13): 1476-1488

48. • Ivabradine can be beneficial to reduce HF
hospitalization for patients:
 with symptomatic (NYHA Class II and III) stable
chronic HFrEF(LVEF ≤35%) who are receiving goal-
directed medical therapy, including a beta blocker
at maximum tolerated dose
 who are in sinus rhythm with a heart rate of 70
bpm or greater at rest.
–Starting dose: 5 mg 1 tab bid. Maximum dose 7.5
mg bid (dose can be increased after 1 mo as needed
based on resting HR and tolerability).
48
http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/206143Orig1s000lbl.pdf (Accessed on June 25, 2015).

49. SHIFT Study
49

50. Referral
• Diagnostic procedures
• Ventricular arrhythmias
• Revascularization procedures
• Valvular heart disease
• Worsening or refractory heart failure
• Consideration for transplantation
50

51. CASE 4
• A 70-year-old African-American man with NYHA
III heart failure sees you for follow-up.
• He has shortness of breath with minimal
exertion.
• The patient is adherent to his medication
regimen.
• His current medications include lisinopril 40 mg
twice daily, carvedilol 25 mg twice daily,
furosemide 80 mg daily, and spironolactone 25
mg daily.
51

52. • His blood pressure is 100/60 mm Hg, and his
pulse rate is 70 beats/min and regular.
• Physical examination findings include a few
scattered bibasilar rales, an s3 gallop, and no
peripheral edema.
• An ECG reveals a left bundle branch block and
echocardiography reveals an ejection fraction
of 25%.
52

53. Which of the following is the best next step
for this patient?
A. Increase the furosemide dosage to 80 mg
twice daily.
B. Refer for coronary angiography.
C. Increase the lisinopril dosage to 80 mg
twice daily.
D. Increase the carvedilol dosage to 50 mg
twice daily.
E. Refer for cardiac resynchronization
therapy.
53

54. • This patient is already receiving maximal
medical therapy.
• Cardiac resynchronization therapy is
recommended for patients :
 in sinus rhythm with an EF less than 35%
 QRS greater than 120 ms
 who remain symptomatic (NYHA III-IV)
despite optimal medical therapy.
54
Bristow MR, Saxon LA, Boehmer J, et al.; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure
(COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced
chronic heart failure. N Engl J Med. 2004; 350(21): 2140-2150.

55. TAKE HOME MESSAGES
• Family Physicians must have a crucial role in
managing people with HF before referring
• Prevention and Lifestyle modifications are an
essantial step in management
• Always Assess for Volume Status
• Never forget Kidney Function !
• Potassium, Potassium and Potassium !!!
55