This document summarizes two cases presented at a cardiology grand rounds meeting. Case 1 involves a 55-year-old male with ischemic dilated cardiomyopathy, heart failure with reduced ejection fraction, and coronary artery disease. Case 2 involves a 36-year-old male with non-ischemic dilated cardiomyopathy and heart failure with reduced ejection fraction. The document then reviews heart failure epidemiology, etiology, evaluation, classification, management, complications, and prognosis.

1. EWMSC
Cardiology
Grand Rounds
Dr Ramlal Unit
July 2023

2. Case 1
• 55-year-old male presents to AED with several weeks of progressive
exertional dyspnea and lower extremity edema.
• He has a history of HTN, DM, IHD and 15 pack year history of cigarette
smoking.
• O/E
• BP 108/68 PR 110.
• Cardiorespiratory Exam
• -> Bibasal crepitations and bilateral lower limb edema.
• Gross ascites.
• ECG – NSR at 98 bpm. LVH. Lateral T Wave inversions.
• CXR – Cardiomegaly, B/L Pleural Effusions.

3. Case 1
• Bloodwork Investigations:
• CBC - Normal
• RFT/ LFTS - Normal
• HBa1C - 7.8%
• Troponin – (-ve)
• HIV – (-ve)
• TTE:
- 4 Chamber DCM with EF 10-15%
- Small Pericardial effusion.
- Moderate MR.
- Mild to Moderate TR.
• Coronary Angiogram – Severe 2VD

4. Case 1
• Dx –
• Ischemic DCM
• HFrEF
• 2VD CAD
• HTN
• DM II
• Smoker

5. Case 2
• 36-year-old male who presented to AED with progressive SOBOE, reduced exercise tolerance and
worsening lower limb edema.
• No FHx of early CAD/HF/sudden cardiac death.
• Non-smoker with no illicit drug use or heavy alcohol use.
• O/E
• BP134/82 PR 98 RR 24 SpO2 97% (RA) RBS 104
• Cardiorespiratory Exam
• -> Bibasal crepitations and bilateral lower limb edema.
• ECG – NSR at 96 bpm. LBBB. No acute ST/T wave changes.
• CXR – Increased CTR with globular cardiac silhouette and evidence of pulmonary edema.
• UA – Nil proteinuria

6. Case 2
• Bloodwork Investigations:
• CBC - Normal
• RFT/ LFTS - Normal
• HBa1C - 5.1%
• FLP - Normal
• Troponin – (-ve)
• HIV – (-ve)
• TTE:
• Global hypokinesia with LVEF 20-25%
• Mild-Mod MR
• Normal RVSP
• Trace pericardial effusion
• Coronary Angiogram – Nil CAD
• Further investigations
1. TFTs - Normal
2. HIV – (-ve)
3. Ferritin - Normal
4. Autoimmune screen - Normal

7. Case 2
• Dx –
• Non-Ischemic DCM
• HFrEF

8. Heart Failure
• Heart failure is a complex clinical syndrome that results from a
functional or structural heart disorder impairing ventricular filling or
ejection of blood to the systemic circulation.

9. Epidemiology
• According to the Global Health Data Exchange registry, the current
worldwide prevalence of CHF is 64.34 million cases.
• The registry also notes a predilection for race with a 25% higher prevalence of
HF in patients of African-American descent than in Caucasians.
• This translates to 9.91 million years lost due to disability (YLDs) and
346.17 billion US dollars in healthcare expenditure.
• *In a joint assessment release, the Government of Ukraine, the European Commission, and
the World Bank, in cooperation with partners, estimate that the current cost of reconstruction
and recovery in Ukraine amounts to $349 billion.
Benjamin EJ, Blaha MJ, American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-
2017 Update: A Report From the American Heart Association. Circulation. 2017 Mar 7;135(10):Circulation. 2017 Mar 7;135(10 )

10. Etiology
• Congestive heart failure is caused by structural abnormalities of the heart, functional abnormalities,
and other triggering factors.
• Most common - Coronary artery disease and myocardial infarction.
• Importance of Etiology
• Inappropriate drug treatment
• Dietary sodium restriction, and
• Decreased physical activity
• Uncontrolled hypertension
• Extra-cardiac causes
• Severe anemia
• Thyrotoxicosis
• Obesity
• Nutritional deficiencies (thiamine deficiency, etc.)
• Pregnancy
Ziaeian B, Fonarow GC. Epidemiology and aetiology of heart failure. Nat Rev Cardiol. 2016
Jun;13(6):368-78.

11. Etiology
• Non-Ischemic
• Rheumatological/ Autoimmune
• Endocrine
• Infiltrative cardiac disease
• Inflammatory – Myocarditis
• Pregnancy – Peripartum Cardiomyopathy
• Substance Abuse
• Stress Cardiomyopathy - Takotsubo
• Familial Heart Disease/ Cardiomyopathy.

12. Evaluation
• Biochemical
• CBC/ Anemia workup
• Renal function –
• The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) trial demonstrated a significantly
increased risk of in-hospital mortality as well as 30-day mortality in patients with HF who presented with hyponatremia.
• Liver function,
• HBA1c + lipid profile
• Cardiac biomarkers
• *Viral causes, Amyloid, Sarcoid, Autoimmune.
• CXR
• ECG
• TTE
• CT
• Congenital heart disease
• MRI
• RV Function
• *MUGA
• Most accurate scan to assess for ejection fraction (EF).
• Cardiac catheterization
Hacker M, Hoyer X, Kupzyk S, La Fougere C, Kois J, Stempfle HU, Tiling R, Hahn K, Störk S. Clinical validation
of the gated blood pool SPECT QBS processing software in congestive heart failure patients: correlation with
MUGA, first-pass RNV and 2D-echocardiography. Int J Cardiovasc Imaging. 2006 Jun-Aug;22(3-4):407-16.
Klein L, O'Connor CM, OPTIME-CHF Investigators. Lower serum sodium is associated with increased short-term mortality in hospitalized
patients with worsening heart failure: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic
Heart Failure (OPTIME-CHF) study. Circulation. 2005 May 17;111(19):2454-60.

13. Classification
• Heart failure due to left ventricular dysfunction is categorized into
heart failure with
• reduced ejection fraction (HFrEF)
• Heart failure with improved ejection fraction
• heart failure with preserved ejection fraction (HFpEF)
• heart failure with mid-range ejection fraction (HFmrEF).

14. Type of HF
According to LVEF
Criteria
HFrEF
LVEF ≤40%
HFimpEF
Previous LVEF ≤40% and a follow-up measurement of LVEF >40%
HFmrEF
• LVEF 41%–49%
• Evidence of spontaneous or provokable increased LV filling pressures
(e.g., elevated natriuretic peptide, noninvasive and invasive
hemodynamic measurement)
HFpEF
• LVEF ≥50%
• Evidence of spontaneous or provokable increased LV filling pressures
2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

15. NYHA
Class Patient Symptoms
I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue,
palpitation or shortness of breath.
II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results
in fatigue, palpitation, shortness of breath or chest pain.
III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity
causes fatigue, palpitation, shortness of breath or chest pain.
IV Symptoms of heart failure at rest. Any physical activity causes further discomfort.

16. 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

17. COR LOE Recommendations
1 A
In patients with hypertension, blood pressure should be controlled in accordance
with GDMT for hypertension to prevent symptomatic HF
1 A
In patients with type 2 diabetes and either established cardiovascular disease or at
high cardiovascular risk, SGLT2i should be used to prevent hospitalizations for HF
1 B - NR
In the general population, healthy lifestyle habits such as regular physical activity,
maintaining a normal weight, healthy dietary patterns, and avoiding smoking are
helpful to reduce future risk of HF
2a B - R
For patients at risk of developing HF, natriuretic peptide biomarker–based screening
followed by team-based care, including a cardiovascular specialist optimizing GDMT,
can be useful to prevent the development of LV dysfunction (systolic or diastolic) or
new-onset HF
2a B - NR
In the general population, validated multivariable risk scores can be useful to
estimate subsequent risk of incident HF
2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

18. COR LOE Recommendations
1 A
In patients with LVEF ≤40%, ACEi should be used to prevent symptomatic HF and reduce mortality
1 A
In patients with a recent or remote history of myocardial infarction or acute coronary syndrome, statins
should be used to prevent symptomatic HF and adverse cardiovascular events
1 B - R
In patients with a recent myocardial infarction and LVEF ≤40% who are intolerant to ACEi, ARB should be
used to prevent symptomatic HF and reduce mortality
1 B - R
In patients with a recent or remote history of myocardial infarction or acute coronary syndrome and LVEF
≤40%, evidence-based beta blockers should be used to reduce mortality
1 B - R
In patients who are at least 40 days post–myocardial infarction with LVEF ≤30% and NYHA class I symptoms
while receiving GDMT and have reasonable expectation of meaningful survival for >1 year, an ICD is
recommended for primary prevention of sudden cardiac death to
reduce total mortality
1 C - LD
In patients with LVEF ≤40%, beta blockers should be used to prevent symptomatic HF
2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

19. Management of HF Stages A and B

20. GDMT
COR LOE Recommendations
1 A
In patients with HFrEF and NYHA class II to III symptoms, the use of ARNi is
recommended to reduce morbidity and mortality
1 A
In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is
beneficial to reduce morbidity and mortality when the use of ARNi is not feasible
1 B - R
In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEi or
ARB, replacement by an ARNi is recommended to further reduce morbidity and
mortality
1 A
In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta
blockers proven to reduce mortality is recommended to reduce mortality and
hospitalizations
1 A
In patients with HFrEF and NYHA class II to IV symptoms, an MRA is recommended to
reduce morbidity and mortality, if eGFR >30 mL/min/
1.73 m2 and serum potassium is <5.0 mEq/L
1 A
In patients with symptomatic chronic HFrEF, SGLT2i are recommended to reduce
hospitalization for HF and cardiovascular mortality, irrespective of the presence of
type 2 diabetes
2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

21. 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

22. Class MOA SE
Beta Blockers ↓ HR
↓ Cardiac afterload and preload
↑ Left ventricular systolic function
Fatigue
Bradycardia
Insomnia
Erectile Dysfunction
ACE-I ↓ Afterload, preload and systolic
wall stress
Cough
Hyperkalemia
Angioedema
ARB ↓ Afterload, preload and systolic
wall stress
Hyperkalemia
Dizziness
Loop Diuretic ↓ Blood volume and Preload Electrolyte imbalance
Aldosterone receptor antagonist ↓ LV hypertrophy, LV end-diastolic
pressure – improves LV relaxation
and filling
Gynecomastia
Hyperkalemia
HCN Channel Blockers
(Hyperpolarization activated-Cyclic
Nucleotide)-gated channels)
↓ Heart rate Blurry Vision
Bradycardia
Nitrates Vasodilator – releases NO Headache
Joint pain

23. Class MOA SE
ARNI
(Angiotensin receptor neprilysin
inhibitor)
Saccubitrilat inhibits enzyme
neprilysin that causes blood vessel
dilation and increases sodium
excretion.
Angioedema
Hyperkalemia
Hypotension
Guanylate Cyclase Stimulator
(sGC)
Causes relaxation of vascular
smooth muscle and vasodilation
Anemia
SOB
SGLT2 –
(Sodium-glucose cotransporter-2)
Inhibits sympathetic nervous and
increases sodium excretion
UTI
nsMRA
(non steroidal mineralocorticoid
receptor antagonists)
↓ LV hypertrophy, LV end-diastolic
pressure – improves LV relaxation
and filling
Hyperkalemia

24. 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

25. 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

26. Level Statements
High In patients with previous or current symptoms of chronic HFrEF, in whom ARNi is not feasible, treatment
with an ACEi or ARB provides high economic value
High In patients with chronic symptomatic HFrEF, treatment with an ARNi instead of an ACEi provides high
economic value
High In patients with HFrEF, with current or previous symptoms, beta-blocker therapy provides high economic
value
High In patients with HFrEF and NYHA class II to IV symptoms, MRA therapy provides high economic value
High
For patients self-identified as African American with NYHA class III to IV HFrEF who are receiving optimal
medical therapy with ACEi or ARB, beta blockers, and MRA, the combination of hydralazine and isosorbide
dinitrate provides high economic value
High
A transvenous ICD provides high economic value in the primary prevention of sudden cardiac death
particularly when the patient’s risk of death caused by ventricular arrythmia is deemed high and the risk of
nonarrhythmic death is deemed low based on the patient’s burden of comorbidities and functional status
High For patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS duration of ≥150 ms, and NYHA class II,
III, or ambulatory IV symptoms on GDMT, CRT implantation provides high economic value
Interme
diate
In patients with symptomatic chronic HFrEF, SGLT2i therapy provides intermediate economic value
Interme
diate
In patients with stage D (advanced) HF despite GDMT, cardiac transplantation provides intermediate
economic value
2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure – DOI: 10.1016/j.cardfail.2022.02.010

27. 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure - DOI: 10.1016/j.cardfail.2022.02.010

28. Mechanical Circulatory Support
• Refractory Stage D HFrEF/ NYHA Class IV
• Dependent on Inotropes.
• Bridge to transplant.

29. Cardiac Transplant
• Patients with progressive HF or those with acute, severe refractory HF
may be considered for heart transplantation.

30. Prognosis
• The mortality rate following hospitalization for heart failure is
estimated at around
• 10% at 30 days
• 22% at 1 year
• 42% at 5 years.
• This can increase to greater than 50% for patients with NYHA class IV, stage D heart
failure.
Lucas C, Johnson W, Hamilton MA, Fonarow GC, Woo MA, Flavell CM, Creaser JA,
Stevenson LW. Freedom from congestion predicts good survival despite previous class IV
symptoms of heart failure. Am Heart J. 2000 Dec;140(6):840-7.

31. Complications
• ↓
• Quality of life
• Functional capacity
• Weight (Cardiac cachexia)
• Renal function (Cardiorenal)
• Liver function (Hepatic congestion)
• Valvular function
• Sudden cardiac death.
• Nosocomial infections
• Frequent hospitalizations and procedures.
Habal MV, Garan AR. Long-term management of end-stage heart failure. Best Pract Res Clin
Anaesthesiol. 2017 Jun;31(2):153-166.

32. Patient Education
• Drug Adherence
• Recent data suggest SGLT2 reduce risk of HF with CAD.
• Self-monitoring of signs/ symptoms of HF.
• Patient and family education.
• Lifestyle modifications – Weight loss, Smoking cessation, exercise,
alcohol cessation
• Sodium restriction to 2-3g/day
• Fluid Restrict to 2L/day.
Correale M, Switch to SGLT2 Inhibitors and Improved
Endothelial Function in Diabetic Patients with Chronic Heart
Failure. Cardiovasc Drugs Ther. 2022 Dec;36(6):1157-1164.
van der Meer P, Gaggin HK, Dec GW. ACC/AHA Versus ESC Guidelines on Heart Failure:
JACC Guideline Comparison. J Am Coll Cardiol. 2019 Jun 04;73(21):2756-2768.

33. Enhancing Team Outcomes
• Heart failure is a complex clinical syndrome with high morbidity and
mortality. It requires a multifaceted treatment approach, including
patient education, pharmacologic management, and surgical
interventions to optimize clinical outcomes.
• A collaborative interprofessional team can greatly improve the quality
of life for patients with HF and decrease mortality.