Understanding Heart Failure

• Heart failure is when the heart cannot pump enough blood to meet the body's metabolic needs

Epidemiology

• Affects 1-2% of the adult population
• Affects 10% of adults older than 70 years
• The main cause in Brazil is ischemic and hypertensive heart disease
• In the North region, Chagas disease accounts for 42% of cases
• Survival rate after 5 years post-diagnosis is approximately 35%

NYHA Classification

• NYHA I: No symptoms with exertion, patients tolerate normal daily activities
• NYHA II: Fatigue or dyspnea occurs with normal daily activities
• NYHA III: Fatigue or dyspnea occurs with minor exertion
• NYHA IV: Unable to perform any activity without fatigue or dyspnea, symptoms happen at rest

Ejection Fraction

• Heart Failure evaluation involves echocardiogram analysis of ejection fraction (EF)
• EF ≥ 50% implies HF with preserved EF (HFpEF)
• EF between 40-49% implies HF with mid-range EF (HFmrEF)
• EF < 40% implies HF with reduced EF (HFrEF)

Stages

• Stage A considers patients at risk for heart failure
• Stage B considers patients with heart damage
• Stage C considers patients with symptoms
• Stage D represents advanced heart failure

Etiology regarding Heart Failure Types

• Systolic Heart Failure: Arterial coronary disease, valve disorders increasing ventricular load, hypertension( late stage), Alcohol/Drugs , Chagas Disease, Myocarditis, Peripartum Cardiomyopathy
• Diastolic Heart Failure: Hypertensive Cardiomyopathy (early), hypertrophic cardiomyopathy, non-compacted myocardiopathy, Amyloidosis, Endomyocardial fibrosis, Coronary artery disease, Aortic stenosis
• Right Heart Failure: Cor Pulmonale, TEP, Primary HAP
• High Output Heart Failure: Hyperthyroidism, Beriberi, Hepatic Cirrhosis, Paget's Disease, Obesity, Arteriovenous Shunt

Pathophysiology

• The Frank-Starling mechanism explains heart function based on ventricular filling
• Hypovolemic: Limited distension leads to impaired ejection
• Normovolemic: Optimal distension leads to optimal ejection
• Hypervolemic: Excessive distension leads to impaired ejection

ICFER Pathophysiology

• Reduced cardiac output leads to renal hypoperfusion, triggering SRAA activation, causing sodium and water retention, further increasing volume and vasoconstriction
• Reduced cardiac output leads to activation of baroreceptors, triggering release of catecholamines, increasing inotropism and chronotropism and increasing sympathetic tone

ICFEN Physiopathology

• Elevated pulmonary capillary pressure leading to pulmonary congestion

Primary Symptoms

• Orthopnea
• Paroxysmal nocturnal dyspnea
• Nocturnal cough

Symptomatology

• Pulmonary congestion presents: Orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, pulmonary crackles and pleural effusion
• Systemic congestion presents: Pathological jugular distension, hepatojugular reflux, ascites, hepatomegaly, weight gain and peripheral edema
• Low cardiac output presents: Cold extremities, decreased urination, somnolence, prostration, fatigue, anorexia, weak pulses, alternating pulse
• Increased sympathetic tone presents: Tachycardia, palpitations and syncope
• Chamber overload presents: B4 (pressure overload), B3 (volume overload), displaced cardiac apex, mitral murmur (annulus dilation), palpable RV pulse

Framingham Criteria

• Used for diagnosing heart failure

Framingham Major Criteria

• Paroxysmal nocturnal dyspnea
• Jugular distension
• Pulmonary crackles
• Cardiomegaly on chest X-ray
• Acute pulmonary edema
• S3 gallop
• Increased CVP (>16cmH2O)
• Weight loss of >4.5 kg in 5 days in response to treatment

Framingham Minor Criteria

• Bilateral ankle edema
• Night cough
• Dyspnea on exertion
• Hepatomegaly
• Pleural effusion
• Decreased functional capacity to 1/3 of previous maximum
• Tachycardia > 120 bpm

Diagnosis

• Requires two major criteria or one major and two minor criteria
• Suspicion arises from serum BNP levels

BNP Serum Level

• <100 mg/dL has ruled out diagnosis
• 100-400 mg/dL indicates and requires echocardiogram
• 400 mg/dL indicates and requires echocardiogram

Echocardiogram

• Initial assessment for all patients
• Assesses ventricular function, cavity dimensions, valve function, and volume status
• Repeat when there are changes in clinical presentation

Cardiac Catheterization

• Used when there is angina related chest pain
• Used when the patient has a history of symptomatic ventricular arrhythmia
• Used when the patient is a survivor of cardiac arrest
• Used when there is a high pre-test probability ( presence of risk factors for CAD)
• Used when there is documented ischemia on non-invasive exam

Lab Testing

• CBC to rule out anemia
• ABG to assess for hypoxemia and tissue perfusion
• Electrolytes should show if hyponatremia is present
• Assess renal function for cardiorenal syndrome
• Troponin levels gives prognostic value
• Natriuretic peptide levels help with diagnosis
• A liver panel shows bilirubin level elevation
• check iron levels to check for iron deficiency

Non-Pharmacological Management

• Multidisciplinary care program is needed
• Exercise for HFrEF.
• Avoid High salt intake up to 7 grams a day, 2.8 grams of sodium

Pharmacological Treatment

• Use ACEI/ARB or ARNI
• Beta blocker
• Mineralocorticoid antagonist
• SGLT2 inhibitor
• Digoxin and diuretics don't reduce mortality

Contraindications for ACEI/ARB

• Elevated potassium (>5.5 mg/dL)
• Bilateral renal artery stenosis or stenosis in a solitary kidney
• History of angioedema
• Symptomatic hypotension
• Severe renal impairment (Cr >3 mg/dL)
• Pregnancy

Beta Blockers

• B-1 blockade: Bradycardia and reduced cardiac contractility
• B-2 blockade: Peripheral vasoconstriction and bronchoconstriction
• Carvedilol
• Nebivolol
• Bisoprolol
• Metoprolol succinate

Angiotensin Receptor Neprilysin Inhibitors (ARNIs)

• Used for patients with symptomatic Heart Failure with reduced ejection fraction, who don't improve with standard triple therapy

Digitalis

• Cause sustained increase of BNP
• Inhibits Na+/K+ ATPase pump
• Increases intracellular calcium augmenting cardiac contractility (positive inotropic effect)
• Reduces sympathetic tone and enhances parasympathetic activity
• Slows AV node conduction reducing heart rate (negative chronotropic effect)
• Digoxin does not decreases mortality

Digoxin Use Considerations (HFrEF)

• Ejection fraction 45% despite optimized triple therapy
• Patients with FEVE 45% and permanent atrial fibrillation with difficulty in controlling ventricular response

Digitalis Toxicity

• ECG changes
• Prostration
• Nausea and vomiting
• Xanthopsia presents with yellow vision