CV Dr. Hayes Part 7!

Definition of Heart Failure

• Heart failure arises from a structural or functional cardiac issue hindering the ventricle's capacity to fill or eject blood eficiently.
• Heart failure is a complex clinical syndrome.

Left Ventricular Ejection Fraction (LVEF)

• LVEF is a measurement indicating how effectively the heart pumps blood.
• The LVEF is quantified as the percentage of blood volume ejected with each heart contraction.
• A normal LVEF is considered to be greater than 55%.

HFpEF vs HFrEF

• Heart Failure with Preserved Ejection Fraction(HFpEF); or Diastolic Failure is when the heart struggles to relax and fill with blood.
• Diastolic Failure occurs when EF is greater than 45-50%.
• Heart Failure with Reduced Ejection Fraction (HFrEF) or Systolic Failure occurs when the heart struggles to eject blood.
• Systolic Failure occurs when EF is less than or equal to 40%.

Classification and Trajectories of HF Based on LVEF

• HFrEF: LVEF is ≤40%.
• HFimpEF: Previous HFrEF with improved LVEF to >40%.
• HFmrEF: LVEF is between 41% and 49%.
• HFpEF: LVEF is ≥50%.

Risk factors for HFpEF

• Hypertension has a prevalence of 60-89%
• Obesity
• Diabetes
• Atrial fibrillation
• Hyperlipidemia
• Older age
• OSA

Risk Factors for HFrEF

• HTN
• Diabetes
• Metabolic syndrome
• Atherosclerotic disease
• Valve disease
• Dilated cardiomyopathy

Key Findings for HF Diagnosis

• Family history of heart failure in 1st degree relatives
• Social history of drug and alcohol use.
• SCD in family < 55 for males and < 65 for females.
• Elevated BNP
• The presence of HF symptoms with LVEF > 40-45% indicates HFpEF.
• LVEF <40% on Echocardiogram or MUGA scan.
• HFrEF is present when LVEF is less than or equal to 40-45%.

Common Symptoms of HF

• Dyspnea at Rest
• Dyspnea on Exertion
• Reduction in Exercise Capacity
• Orthopnea
• PND
• Edema
• Ascites
• Scrotal Edema

Symptoms of HF

• Progressive weight gain.
• Left sided symptoms include DOE, PND, Orthopnea, and Fatigue
• Right sided symptoms include Edema, Early Satiety, and Ascites.

Less Common Symptoms of HF

• Wheezing or cough
• Confusion or delirium
• Depression or weakness (especially in the elderly)
• Unexplained fatigue
• Gastrointestinal symptoms like early satiety, nausea, vomiting, and abdominal discomfort

Physical Exam for Heart failure patients

• Vital signs (HR and B/P)
• Electrolytes
• Renal function
• Cardiac Rhythm
• Neck Vein Assessment
• Pulmonary Exam
• Cardiac Exam
• Abdominal exam
• Extremities

JVP Measurement

• If the JVP is 2 cm above the angle of Louis and 5cm from the sternal notch, the JVP equals 7cmH2O

Wet vs Dry

• Warm & Dry: Normal PCW and Cl
• Warm & Wet: Elevated PCW and normal Cl, indicating congestion with symptoms like orthopnea, PND, and edema.
• Cold & Dry: Low to normal PCW and decreased Cl.
• Cold & Wet: Elevated PCW and decreased Cl.

Signs and Symptoms of HF

• Volume Excess: Decreased exercise tolerance, SOB, orthopnea, DOE, PND, edema, RUQ tenderness and GI discomfort.
• Low Cardiac Output: Decreased exercise tolerance, fatigue, malaise, decreased appetite and weight loss, Cachexia, muscles loss.

Differential Diagnoses for HF Symptoms

• Myocardial ischemia
• Pulmonary disease
• Sleep disordered breathing
• Obesity
• Deconditioning
• Malnutrition
• Anemia
• Hepatic Failure
• Chronic Kidney Disease
• Venous Stasis
• Depression
• Anxiety and hyperventilation syndromes
• Hyper/Hypo thyroidism

Diagnostic Testing for HF

• ECG
• 6-minute hall walk
• Echocardiogram (TTE)
• Ruling out ischemic disease
• Ruling out OSA
• LHC and RHC
• Lab findings: BNP
• Routine BMP labs after adjustments in diuretics, ACE/ARB, Aldosterone Antagonist.

Echocardiogram

• An echocardiogram is the most useful test in evaluating heart failure.
• It gives better information.

Transitioning from Hospital to Home

• Follow-up phone calls within 72 hours of hospital discharge improve outcomes and are billable through Transitional Care Management services CPT code.
• The first post-discharge visit should include a review of history, exam, testing, medications, therapy considerations, patient education, and consultations.

Transitional Care Management (TGM) Services

• CPT Code 99495: Communication within 2 business days of discharge, moderate complexity medical decision-making, and a face-to-face visit within 14 days of discharge.
• CPT Code 99496: Communication within 2 business days of discharge, high complexity medical decision-making, and a face-to-face visit within 7 days of discharge.

Management of HF in Primary Care

• Partner with local heart specialists or cardiologists
• Connect with community resources such as home health and medication delivery services.
• Communicate any medication changes or concerns for disease progression to the cardiologist.
• Know when to refer for advanced care.

Heart Failure Treatment

• Guideline Directed Medical Therapy (GDMT)
• ACE-I or ARB or ARNI
• Beta blocker (metoprolol XL, carvediolol, bisoprolol)
• Aldosterone antagonist -Hydralazine/Isosorbide (for AA and those who cannot tolerate ACE-I/ARB)
• SGLT2 inhibitors- These all have mortality benefit proven with Large RCTs.

GDMT for HF

• Loop Diuretics treat volume overload.
• Potassium supplements address deficiencies from diuretics.
• Digoxin is beneficial for symptomatic relief and lowers hospitalization rates.
• Thiazide diuretics can be added to loop diuretics as boosters.
• This list addresses all of the components for symptomatic treatment.

HF: Medical Management

• ACE-I/ARB/ARNI's: Lisinopril (any ACE-I /any ARB/Valsartan/sacubitril-valsartan NOT ALL THREE Pick one
• SGLT2i: Dapagliflozin (Farxgia) or Empagliflozin (Jardiance)
• Beta Blockers: Bisoprolol, carvedilol, Metoprolol XL
• Aldosterone antagonists: Spironolactone or Epleranone
• Hydralazine/Isosorbide: Brand__ Bidil
• Diuretics:
• Potassium supplement if needed
• Digoxin (very small dose)
• Amiodarone possibly for ant-arrhythmic

Refer for advanced stages

• New onset with moderate-severe symptoms
• All HFr EF would benefit from seeing a heart failure specialist for consultation at least once for their input
• Unclear etiology
• Frequent readmissions for heart failure
• Renal impairment
• Chronic daily disease management is needed
• Not responding to treatment

I-NEED-HELP criteria for advanced care referral

• I: IV inotropes
• N: NYHA IIIB/IV or persistently elevated natriuretic peptides
• E: End-organ dysfunction
• E: Ejection fraction < 35%
• H: Hospitalized > 1
• E: Edema despite escalating diuretics
• L: Low blood pressure, High heart rate
• P: Prognostic medication-progressive intolerance or down-titration of GDMT

HFpEF Clinical Pearls

• Manage hypertension, fluid overload, and comorbidities.
• Labs: Remember that BNP might not always be elevated in those with HFpEF and or Obesity
• Assess Socioeconomic Factors

HFrEF Clinical Pearls

• Increase beta blocker dose if patient is dry as long as HR and BP allow
• Increase ACE/ARB/ARNI if patient is wet as long as B/P and Labs allow
• When switching from ACE to ARNI allow 36 hour wash-out period.
• Higher Creatine indicates need for Higher Diuretic Dose
• Furosemide 80mg is equivalent to Torsemide 20mg or Bumetanide 2mg, and should be administered with KCL 20meq.