Management of heart failure

1. Mohamed Ashraf, MD
Consultant Cardiology

2.  HF is a complex clinical syndrome with symptoms and
signs that result from any structural or functional
impairment of ventricular filling or ejection of blood.
 It has significant physical, psychological, social and
economic burden.

3.  Asymptomatic stages with structural heart disease or
cardiomyopathies are not covered under the above
definition as having HF.

5. Paul A. Heidenreich. Circulation. 2022 AHA/ACC/HFSA Guideline for
the Management of Heart Failure: A Report of the American College
of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines, Volume: 145, Issue: 18, Pages: e895-e1032,
DOI: (10.1161/CIR.0000000000001063)
© 2022 by the American Heart Association, Inc., the American
College of Cardiology Foundation, and the Heart Failure Society of
America.
ACC/AHA Stages of HF

6. STAGE A and B HF
STAGE C and D HF

7. Paul A. Heidenreich. Circulation. 2022 AHA/ACC/HFSA Guideline for
the Management of Heart Failure: A Report of the American College
of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines, Volume: 145, Issue: 18, Pages: e895-e1032,
DOI: (10.1161/CIR.0000000000001063)
© 2022 by the American Heart Association, Inc., the American
College of Cardiology Foundation, and the Heart Failure Society of
America.
Trajectory of Stage C HF.

8.  Heart failure is considered to be a major health problem
with its prevalence in approximately 1% to 2% of the
global population, causing a significant economic
burden on all healthcare systems.

11. Alghamdi et al., Healthcare 2021, 9(8), 988

12. ◦ Ischemic heart disease
and myocardial
infarction (MI).
◦ Hypertension
◦ Valvular heart disease.
The INTER-CHF study International Journal of Cardiology, Volume 204, 1
February 2016, Pages 133-141
The common causes of
HF include:

13.  Chemotherapy and other cardiotoxic medications
 Rheumatologic or autoimmune
 Endocrine or metabolic (thyroid, acromegaly, pheochromocytoma, diabetes,
obesity)
 Familial cardiomyopathy or inherited and genetic heart disease
 Heart rhythm–related (e.g., tachycardia-mediated, PVCs, RV pacing)
 Infiltrative cardiac disease (e.g., amyloid, sarcoid, hemochromatosis)
 Myocarditis (infectious, toxin or medication, immunological, hypersensitivity).
 Peripartum cardiomyopathy.
 Stress cardiomyopathy (Takotsubo)
 Substance abuse (e.g., alcohol, cocaine, methamphetamine)

14.  Clinical Assessment: History and Physical Examination
◦ The history and physical examination remain a cornerstone in
the assessment of patients with HF.
◦ Give information about
 Cause of an underlying cardiomyopathy, including the possibility
of an inherited cardiomyopathy
 Condition requiring disease-specific therapy like amyloid heart
disease
 Reasons why a previously stable patient developed acutely
decompensated HF.

15.  Routine laboratory evaluation with:
◦ CBC, urinalysis, serum electrolytes (including sodium,
potassium, calcium, and magnesium).
◦ Blood urea nitrogen, serum creatinine, glucose, fasting lipid
profile, liver function tests.
◦ Iron studies (serum iron, ferritin, transferrin saturation), and
thyroid-stimulating hormone level.

16.  Specific diagnostic testing and evaluation identify
specific causes of HF (connective tissue disease,
amyloidosis, sarcoidosis,…)
 ECG is part of the standard diagnostic evaluation of a
patient with HF.

17.  In first-degree relatives of selected patients with genetic
or inherited cardiomyopathies, genetic screening and
counseling are recommended to detect cardiac disease.
 In select patients with nonischemic cardiomyopathy,
referral for genetic counseling and testing is reasonable
to identify conditions that could guide treatment for
patients and family members.

18.  The chest x-ray
 TTE
 CMR
 Electrocardiographic-gated cardiac CT
 Nuclear scintigraphy
 Noninvasive testing (ie, stress echocardiography, SPECT, CMR, or PET)
may be considered for detection of myocardial ischemia
 CAG

19. Paul A. Heidenreich. Circulation. 2022 AHA/ACC/HFSA Guideline for the Management
of Heart Failure: A Report of the American College of Cardiology/American Heart
Association Joint Committee on Clinical Practice Guidelines

20. Tomsoni et al., ESC heart failure volume 7, issue 6, December 2020

22. Paul A. Heidenreich. Circulation. 2022 AHA/ACC/HFSA Guideline for
the Management of Heart Failure: A Report of the American College
of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines, Volume: 145, Issue: 18, Pages: e895-e1032,
DOI: (10.1161/CIR.0000000000001063)
© 2022 by the American Heart Association, Inc., the American
College of Cardiology Foundation, and the Heart Failure Society of
America.

23. Paul A. Heidenreich. Circulation. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of
the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines,
Volume: 145, Issue: 18, Pages: e895-e1032, DOI: (10.1161/CIR.0000000000001063) © 2022 by the American
Heart Association, Inc., the American College of Cardiology Foundation, and the Heart Failure Society of America.
Treatment of HFrEF Stages C and D.

24.  Non-pharmacological Interventions
◦ Multidisciplinary teams, specific education and support to
facilitate HF self-care, vaccinating against respiratory illnesses,
screening for depression. Rehabilitation programs
 Dietary Sodium Restriction
 ICDs and CRTs
 Revascularization for CAD
 Management of valve disease (surgrical or percutaneous)

25. Paul A. Heidenreich. Circulation. 2022 AHA/ACC/HFSA Guideline for
the Management of Heart Failure: A Report of the American College
of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines, Volume: 145, Issue: 18, Pages: e895-e1032,
DOI: (10.1161/CIR.0000000000001063)
© 2022 by the American Heart Association, Inc., the American
College of Cardiology Foundation, and the Heart Failure Society of
America.

26. Eur Heart J, Volume 44, Issue 37, 1 October 2023, Pages 3627–3639, https://doi.org/10.1093/eurheartj/ehad195
The content of this slide may be subject to copyright: please see the slide notes for details.

27. Paul A. Heidenreich. Circulation. 2022 AHA/ACC/HFSA Guideline for
the Management of Heart Failure: A Report of the American College
of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines, Volume: 145, Issue: 18, Pages: e895-e1032,
DOI: (10.1161/CIR.0000000000001063)
© 2022 by the American Heart Association, Inc., the American
College of Cardiology Foundation, and the Heart Failure Society of
America.

28. Eur Heart J, Volume 44, Issue 37, 1 October 2023, Pages 3627–3639, https://doi.org/10.1093/eurheartj/ehad195
The content of this slide may be subject to copyright: please see the slide notes for details.

29.  GDMT for HFrEF now includes 4 medication classes (B.
blocker, RAS blocker, MRA and SGLT2i.
 New recommendations for HFpEF are made for SGLT2i
(Class 2a), MRAs (Class 2b), and ARNi (Class of 2b).
 Improved LVEF is used to refer to those patients with previous
HFrEF who now have an LVEF >40%. These patients should
continue their HFrEF treatment.
 Primary prevention is important for those at risk for HF (stage
A) or pre-HF (stage B).