Understanding Heart Failure Responsibilities

• This presentation covers ethical/legal/professional responsibilities, patient care, product distribution, practice setting, health promotion, knowledge and research application, communication and education, intra and inter-professional collaboration, and quality and safety related to heart failure.

Introduction

• Heart failure stems from issues with either filling or pumping.
• HF with preserved ejection fraction occurs with filling problems often due to hypertension, stiff heart muscle, calcification, or arterial thickening.
• Reduced ejection fraction involves pumping problems with ejection fraction of <40%, generally from coronary artery disease.
• Clinical presentation includes dyspnea with crackles, exercise intolerance with hypotension/fatigue/hypoxia/nausea, and fluid overload symptoms like weight gain and jugular venous congestion.
• Heart failure is the impaired ability of ventricles to fill or eject blood.
• Decompensated HF means acute worsening of symptoms caused by volume overload.

Clinical Presentation

• Hypotension, Hypoxia, fatigue, cyanosis, confusion, chest pain.
• Dyspnea: Sudden nocturnal dyspnea, orthopnea, tachypnea, crackles, cough.
• Systemic congestion: Jugular venous congestion, hepatomegaly, ascites, nausea, vomiting.
• Peripheral edema: Weight gain, abdominal distension.

NYHA Classification of Heart Failure

• Class I: No limitation of physical activity.
• Class II: Slight limitation of physical activity with symptoms during physical activity.
• Class III: Marked limitation of activity, symptoms occur during less than ordinary activity but comfortable at rest.
• Class IV: Symptoms at rest causing severe limitation of activity.

Risk Factors and Causes

• Risk factors include hypertension, diabetes, CAD, male sex (HF-rEF), smoking, increased age, obesity, dyslipidemia, valvular heart disease, heavy alcohol use, and physical inactivity.
• Causes include CAD, hypertension, valvular disease, tachyarrhythmia, infection, diabetes, pregnancy, obesity, congenital abnormalities, and certain medications.
• Managing hypertension can significantly reduce the risk of heart failure by 50%

Drug-Induced Causes

• Cardiotoxic drugs like 5-Fluorouracil, alcohol, alkylating/anthracycline agents, bevacizumab, clozapine, trastuzumab, tyrosine kinase inhibitors, amphetamines, and heavy metals.
• Drugs that reduce cardiac contractility like antiarrhythmics (except amiodarone and dofetilide), beta-blockers/CCBs (except amlodipine and felodipine), itraconazole, and some anesthesia meds.
• Drugs that increase sodium and water retention like androgens/estrogens, corticosteroids, licorice, minoxidil, NSAIDs, and thiazolidinediones.
• Saxagliptin has increased risk of heart failure hospitalizations.
• Other DPP4 inhibitors should be used with caution.

Goals of Therapy for Heart Failure

• Improve exercise tolerance.
• Reduce symptoms.
• Improve survival.
• Improve functional capacity/quality of life.
• Minimize morbidity, exacerbations, and hospitalizations.
• Minimize side effects of drug therapy.

Non-Pharmacological Measures

• Salt restrictions of <2-3 g Na+/day or <1-2g/day for severe cases, and fluid restrictions to 2 L/day.
• Reducing alcohol intake is advised due to possible negative health effects.
• Regular moderate exercise and frequent weight monitoring.
• Immunizations against influenza and pneumococcal infections.
• Treating risk factors, and smoking cessation.
• PCI or CABG for symptomatic ischemia.
• ICD for those with history of sudden cardiac arrest or ventricular fibrillation.

Treatment Algorithm for HF with Reduced Ejection Fraction

• Initiate ARNI or ACEi/ARB, Beta Blocker, MRA and SGLT2 inhibitor
• Substitute ARNI for ACEi/ARB.
• Assess clinical factors to decide for additional interventions. These interventions may include consideration of vericiguat and digoxin dependent on if the patient has been recently hospitalized with HF, has HR > 70bpm and sinus rythm, suboptimal rate control for AF, or if the patient is experiencing persistent symptoms but is on optimized therapy
• Titrate is every 2–4 weeks over 3–6 months
• Throughout treatment: Use diuretics to relieve fluid overload
• If LVEF≤35% and NYHA (ambulatory) is 1-IV then refer to specialist care
• If LVEF >35%, NYHA I and patient is low risk then continue treatment
• Throughout treatment offer non-pharmacologic therapies like, education, self-care and exercise.

Heart Failure with Preserved Ejection Fraction (HF-PEF)

• Identifying and addressing underlying factors like ischemia or valvular disease
• The angiotensin II receptor blocker (ARB) candesartan has a great data
• Initial data is showing that ARNIs may reduce HF hospitalizations
• Treating hypertension, using loop diuretics if indicated, and considering beta-blockers.
• Anticoagulation for those with atrial fibrillation, MRA as appropirate
• SGLT2i might be applicable with or without diabetes
• There is weaker evidence to suggest that management is still developing.

Treatment Considerations for HF with Reduced Ejection Fraction

• Mortality is the priority when choosing medications.
• Consider ARB when ACE is not tolerated
• ACE and ARB combo is not recommended
• ARBs such as candesartan and valsartan have data.
• ARNI may be switched to if ACE is suspected to cause cough
• Beta blockers can mask hypoglycemia symptoms in diabetic patients so look out for other symptoms such as sweating and confusion
• MRA should not be initiated if K > 5.0
• MRA include eplerenone or spironolactone. spironolactone comes has more ADRs

Heart Failure with Reduced Ejection Fraction (HF-rEF)

• Valsartan/sacubitril over ACEi/ARB in first-line quadruple therapy.
• do not use K> 5.0 mmol/L, eGFR < 30, or SBP<100
• Ivabradine used as an addition when HR is over 70 bpm.
• hydralazine/nitrates requires nitrate free period to avoid tachyphylaxis

Empagliflozin and dapagliflozin

• Best evidence in patients with type 1 diabetes
• SGLT2 inhibitors should be held on days that patients are when eGFR is low or on days patients are feeling sick to reduce ketoacidosis risk
• Digoxin if patient requires atiral fibrilation and requires rate control but cannot have beta blockers.

Acute Decompensation

• Defined as sudden worsening of heart failure symptoms such as dyspnea, swelling, volume overload, fatigue.
• High dose loop diuretics are common to remove excess fluid.
• Treat underlying cause if known such as infection or MI.
• Continue Beta-blockers. If BB naive, then start only when stable.

Special Populations: Pregnancy

• ACEi, ARB, ARNI, and MRAs are contraindicated.
• Ivabradine should be avoided.
• Beta-blockers (except atenolol), digoxin, hydralazine/ISDN, and diuretics are preferred.
• Use diuretics cautiously due to potential placental perfusion reduction.

Special Populations: Breastfeeding

• Beta-blockers can be used with metoprolol having the most evidence.
• ACEi preferred over ARB and ARNI due to the limited data available
• Avoid ivabradine.
• Furosemide, spironolactone, captopril, enalapril, fosinopril, quinapril, and ramipril are relatively safe.

Natural Products: Omega-3 Fatty Acids

• Consider in patients with mild to moderate heart failure with systolic dysfunction
• Side effects involve, mild gastrointestinal upset, fishy aftertaste and excessive bleeding at higher doses (>3 grams/day)
• Patients on antiplatelets or anticoagulants should be cautious

Monitoring Parameters

• Improve and stabilize signs of CHF (fatigue, peripheral edema, weight etc.)
• Duration of therapy, monitor vitals frequently if high-risk.

Switching Between ACEIs, ARBs, and ARNIs

• 36-hour washout period when switching to ARNI due to increased risk of angioedema.
• Angioedema symptoms involve swollen tissue (lips, face, upper airway).
• If a patient experiences angioedema with an ACEi, they may have an ARB.
• They should not be switched to an ARNI because it has similar rates of angioedema.

Case study notes:

• Patient presents with SOB, dry cough, and orthopnea for 1 week.
• Medications include ASA, ramipril, metoprolol, atorvastatin, levothyroxine, pantoprazole, Tylenol Arthritis, Advil Cold and Sinus Nighttime®, and vitamin D3.
• Relevant findings include LVEF 37%, high BNP, BP 110/58, HR 98, respiratory rate 20, SPO2 90% on room air, TSH 1.8, elevated JVP, and weight gain.
• For the case study, spironolactone, carvedilol, and perindopril reduce CV mortality in HFrEF patients, furosemide does not.
• the treatment that should be started includes furosemide and spironolactone.
• Check Creatine, Potassium and Volume status for treatment.