Heart Failure Lecture #100 by Eleanor Yusupov PDF

Heart Failure: Epidemiology, Pathophysiology, Patient Evaluation, and Guideline-Directed Management Eleanor Yusupov, DO, MPH, FACP Department of Clinical Specialties [email protected]  Session Objectives 1. Describe the risk factors for developing heart failure. 2. Identify types...

Heart Failure: Epidemiology, Pathophysiology, Patient Evaluation, and Guideline-Directed Management Eleanor Yusupov, DO, MPH, FACP Department of Clinical Specialties [email protected]  Session Objectives 1. Describe the risk factors for developing heart failure. 2. Identify types and stages of heart failure: A → D; HFrEF, HFpEF; right- and left-sided heart failure, acute and chronic heart failure. 3. Apply and interpret appropriate tests for heart failure diagnosis. 4. Review the clinical manifestations of heart failure. 5. Apply guideline-directed medical therapy (pharmacologic and non-pharmacologic) in management of heart failure across the spectrum of stages and classes. 6. Explain the importance of improving care coordination amongst interprofessional team members to decrease mortality of patients with heart failure. Source: Course Syllabus 8. Patient Presentations Related to the Circulatory and Cardiovascular System Hematologic Systems Organ structure and function chambers, valves cardiac cycle, 8.6 Shortness of Breath/Dyspnea and Orthopnea mechanics, heart sounds, cardiac conduction hemodynamics, blood pressure abnormalities – diastolic or systolic cardiac including blood volume and systemic vascular resistance circulation dysfunction in specific vascular beds, including pulmonary and coronary PHYSICAL EXAM FINDINGS cardiac auscultation, murmurs, and Abnormal Processes: Health and Health Maintenance, Screening, heart sounds cardiac percussion and palpation (eg, thrills, point Diagnosis, Management, Risks, Prognosis of maximal impulse, parasternal heave) hemodynamic Heart failure: chordae tendineae rupture; congestive heart failure; assessment (eg, blood pressure measurement, tilt test, jugular cor pulmonale; diastolic dysfunction; systolic dysfunction; mitral venous pressure, pulses, edema) valve dysfunction; heart failure secondary to myocardial infarction; LABORATORY TEST FINDINGS AND DIAGNOSTIC IMAGING ECG, high-output heart failure, including thyrotoxicosis-induced, anemia- 12-lead and rhythm strips induced; tachycardia-induced; cardiogenic pulmonary edema https://www.nbome.org/assessments/comlex-usa/master-blueprint/clinical-presentations/circulatory-and-hematologic-systems/ https://www.usmle.org/prepare-your-exam/step-1-materials/step-1-content-outline-and-specifications  Case A 65-year-old man with a history of HTN, hyperlipidemia, and tobacco use reports to the clinic because of 2 weeks of increasing dyspnea on exertion. He now sleeps on 4 pillows at night to aid in breathing. He has T2DM variably controlled with metformin and diet, and drinks 3-4 glasses of wine/day. Physical examination: jugular venous distention, an S3 heart sound, and bilateral LE edema. ECG shows Q waves in leads V2-V4. He gives a history of hospitalization for "issues with my heart" about a year ago when he had sudden chest pain that radiated to his left arm, after which he had been asymptomatic. Which of the following is the most likely cause of this patient’s condition? A. Alcohol B. Aortic stenosis C. Coronary artery disease D. Coronavirus E. Coxsackievirus B F. Sarcomere gene mutation https://scholarrx.com/  Heart Failure is a Clinical Syndrome Heart is unable to pump blood at a rate sufficient to meet metabolic demands leading to symptoms of fatigue, shortness of breath and volume overload Abnormalities in cardiac function and neurohormonal regulation, which are accompanied by effort intolerance, fluid retention, and a reduced longevity Complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of ventricle to fill or pump From Heart Failure Management for the Internist, Kelly M. Axsom MD, Presented at the 28th Annual Update & Intensive Review of Internal Medicine Columbia Medicine, June 20-24, 2022 Murphy SP, Ibrahim NE, Januzzi JL Jr. Heart Failure With Reduced Ejection Fraction: A Review. JAMA. 2020 Aug 4;324(5):488-504. doi: 10.1001/jama.2020.10262. Erratum in: JAMA. 2020 Nov 24;324(20):2107. PMID: 32749493. Epidemiology 6.2 million adults in US >20 million worldwide 50% mortality within 5 years of diagnosis $30 billion in annual cost 12 million office visits/year #1 cause for hospital admission in pts over 65 https://www.cdc.gov/heartdisease/heart_failure.htm Types of Heart Failure: by Structure From Chapter 10: Cardiomyopathy. Leonard S. Lilly. Pathophysiology of Heart Disease: An Introduction to Cardiovascular Medicine, 7e, 2021  Types of Heart Failure: Right vs. Left Left-side heart failure: pump failure: HFrEF and HFpEF Right-side heart failure: most commonly caused by left-sided HF Cor pulmonale: isolated right heart failure, infrequent, secondary to lung pathology Robins and Cotran Pathological Basis of Disease. Chapter 12. 527-582. The Heart. Tenth Edition. Mann DL, Chakinala M. Heart Failure: Pathophysiology and Diagnosis. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e New York, NY: McGraw-Hill  Classification of HF by Left Ventricular function Left-sided heart failure can be divided into HFrEF (systolic) and HFpEF (diastolic) failure Normal EF= 55-70% Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263– e421.https://doi.org/10.1016/j.jacc.2021.12.012 Bozkurt, B., Coats, A. J., Tsutsui, H., Abdelhamid, M., Adamopoulos, S., Albert, N.,... & Zieroth, S. (2021). Universal definition and classification of heart failure: a report of the heart failure society of America, heart failure association of the European society of cardiology, Japanese heart failure society and writing committee of the universal definition of heart failure. Journal of cardiac failure, 27(4), 387-413.  Types of HF: Functional Classification ACC/AHA Stages of HF Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263– e421.https://doi.org/10.1016/j.jacc.2021.12.012 https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure ACC/AHA Stages of HF ACC indicates American College of Cardiology; AHA, American Heart Association; CVD, cardiovascular disease; GDMT, guideline- directed medical therapy; and HF, heart failure. Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263– e421.https://doi.org/10.1016/j.jacc.2021. 12.012 11 Causes of HF Pathophysiology of HFrEF Inciting event (MI; pressure or volume overload; genetic cardiomyopathy) Activation of compensatory mechanisms Decline in the heart’s pumping capacity Mann DL, Chakinala M. Heart Failure: Pathophysiology and Diagnosis. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e. McGraw Hill; 2018. Accessed July 23, 2022. https://accessmedicine-mhmedical-com.arktos.nyit.edu/content.aspx?bookid=2129&sectionid=192028958 Pathophysiology: Neurohormonal Activation BP=CO x SVR Adrenergic Nervous System Renin-Angiotensin- Aldosterone System Increased production of Antidiuretic Hormone (ADH) Mann DL, Chakinala M. Heart Failure: Pathophysiology and Diagnosis. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e. McGraw Hill; 2018. Accessed July 23, 2022. https://accessmedicine-mhmedical-com.arktos.nyit.edu/content.aspx?bookid=2129&sectionid=192028958 Pathophysiology of HFpEF Impaired diastolic relaxation of the LV Vascular stiffness Renal dysfunction Metabolic inflammation Oxidative stress and impaired nitric oxide signaling Ferreira J, Sharma K, Butler. Diagnosis and Management of Heart Failure with Preserved Ejection Fraction. In: Fuster V, Narula J, Vaishnava P, Leon MB, Callans DJ, Rumsfeld J, Poppas A. eds. Fuster and Hurst's The Heart, 15e. McGraw Hill; 2022. Accessed August 07, 2022. https://accessmedicine-mhmedical-com.arktos.nyit.edu/content.aspx?bookid=3134&sectionid=265682515 Givertz MM, Mehra MR. Heart Failure: Pathophysiology and Diagnosis. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. eds. Harrison's Principles of Internal Medicine 21e. McGraw Hill; 2022. Accessed August 07, 2022. https://accessmedicine-mhmedical-com.arktos.nyit.edu/content.aspx?bookid=3095&sectionid=265451573  Clinical Manifestations Dyspnea Fatigue Exercise intolerance Cough Orthopnea Paroxysmal Nocturnal Dyspnea (PND) Cheyne-Stokes Respiration Acute pulmonary edema Abnormal cardiovascular exam (HTN, murmur, elevated JVP, pulmonary crackles, S3) Lower extremity edema Wu A. Heart Failure. Ann Intern Med. 2018;168:ITC81–ITC96. doi: 10.7326/AITC201806050 Image from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm Mann DL, Chakinala M. Heart Failure: Pathophysiology and Diagnosis. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e New York, NY: McGraw-Hill;. Left-sided HF: Pathophysiology & Clinical Manifestations Pump failure, “forward failure”: Elevated pressure and congestion in the pulmonary veins and capillaries: Orthopnea Dyspnea PND Chang P. (2010) Netter's Cardiology, 18, 145-153 Retrieved from https://www.clinicalkey.com Francis GS, Tang W, Walsh RA. Francis G.S., Tang W, Walsh R.A. Francis, Gary S., et al.Chapter 26. Pathophysiology of Heart Failure. In: Fuster V, Walsh RA, Harrington RA. Fuster V, Walsh R.A., Harrington R.A. Eds. Valentin Fuster, et al.eds. Hurst's The Heart, 13e. New York, NY: McGraw-Hill; 2011. Right-sided HF: Pathophysiology & Clinical Manifestations “Backward heart failure”: abnormal function of the LV overloads the RV from increased pulmonary pressures: Jugular venous distention Hepatomegaly Peripheral edema Chang P. (2010) Netter's Cardiology, 18, 145-153 Retrieved from https://www.clinicalkey.com Francis GS, Tang W, Walsh RA. Francis G.S., Tang W, Walsh R.A. Francis, Gary S., et al.Chapter 26. Pathophysiology of Heart Failure. In: Fuster V, Walsh RA, Harrington RA. Fuster V, Walsh R.A., Harrington R.A. Eds. Valentin Fuster, et al.eds. Hurst's The Heart, 13e. New York, NY: McGraw-Hill; 2011.  Right-Sided Heart Failure Cardiac causes Left-sided heart failure Pulmonic valve stenosis Right ventricular infarction Pulmonary parenchymal diseases Chronic obstructive pulmonary disease Interstitial lung disease (eg, sarcoidosis) Chronic lung infection or bronchiectasis Pulmonary vascular diseases Pulmonary embolism Pulmonary arteriolar hypertension From Chapter 9: Heart Failure. Leonard S. Lilly. Pathophysiology of Heart Disease: An Introduction to Cardiovascular Medicine, 7e, 2021  Diagnosis of Heart Failure Physical Examination General Appearance and Vital Signs Jugular Venous Distention Pulmonary crackles (rales or crepitations) Cardiac exam: displaced PMI, sustained PMI, S3 or S4, murmurs Abdomen: hepatomegaly, ascites, jaundice Extremities: peripheral edema Sacral or scrotal edema Skin: cool, indurated, pigmented extremities, cyanosis of lips and nail beds Mann DL, Chakinala M. Heart Failure: Pathophysiology and Diagnosis. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 20e. McGraw Hill; 2018. Accessed July 23, 2022. https://accessmedicine-mhmedical-com.arktos.nyit.edu/content.aspx?bookid=2129&sectionid=192028958  Physical Examination Measure the JVP with a horizontal card Pretibial Edema and vertical ruler. Bates' Guide to Physical Examination and History Taking, 12e, 2017  Diagnosis of Heart Failure Chest X ray ECG Labs (CBC, CMP, TFTs, HIV, lipids, A1C, COVID-19), natriuretic peptide Ischemic - Troponins, Coronary Angiogram Echo - dilated, valve disease, infiltrative cardiomyopathies Cardiac MRI Arrhythmia Family history Myocarditis Chronic HF with acute decompensation (all of the above plus): Infection; Medication or dietary non-adherence; Toxins (NSAIDs, EtOH); Arrhythmia From Heart Failure Management for the Internist, Kelly M. Axsom MD, Presented at the 28th Annual Update & Intensive Review of Internal Medicine Columbia Medicine, June 20-24, 2022 Diagnostic Algorithm for HF and EF-Based Classification BNP indicates B-type natriuretic peptide; ECG, electrocardiogram; EF, ejection fraction; HF, heart failure; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; LV, left ventricular; NP, natriuretic peptides; and NT-proBNP, N-terminal pro-B type natriuretic peptide. Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263– e421.https://doi.org/10.1016/j.jacc.2021. 12.012 23  Diagnosis: Biomarkers BNP (B-type natriuretic peptide) NT-proBNP (N-terminal pro-brain natriuretic peptide) Released from ventricular myocytes when ventricular diastolic pressure rises Risk-stratify patients as part of the initial evaluation In patients with dyspnea Falsely low in obesity Elevated in Anemia Advancing age Renal failure Women Image from http://www.medscape.com/viewarticle/531930 Khan M, Vaduganathan M, Butler J. Diagnosis and Management of Chronic Heart Failure. In: Fuster V, Narula J, Vaishnava P, Leon MB, Callans DJ, Rumsfeld J, Poppas A. eds. Fuster and Hurst's The Heart, 15e. McGraw Hill; 2022. Accessed August 07, 2022. https://accessmedicine-mhmedical- com.arktos.nyit.edu/content.aspx?bookid=3134&sectionid=265682370 Diagnosis of Heart Failure: ECG #1 https://ecg.bidmc.harvard.edu/maven/dispcase.asp?rownum=60&ans=1&caseid=61 Diagnosis of Heart Failure: ECG #2 https://ecg.bidmc.harvard.edu/mavendata/images/case240/1350x900.gif Left ventricular hypertrophy (LVH) increases the amplitude of electrical forces directed to the left and posteriorly. In addition, repolarization abnormalities may cause ST-segment depression and T-wave inversion in leads with a prominent R wave. Right ventricular hypertrophy (RVH) may shift the QRS vector to the right; this effect usually is associated with an R, RS, or qR complex in lead V1. T-wave inversions may be present in right precordial leads. Citation: Chapter 235 Electrocardiography, Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, 20e; 2018. Available at: http://accessmedicine.mhmedical.com/content.aspx?sectionid=186950143&bookid=2129 Accessed: August 29, 2020 Copyright © 2020 McGraw-Hill Education. All rights reserved  Diagnosis of HF: Chest X-ray Enlarged cardiac silhouette Pulmonary edema Kerley lines are the result of interstitial edema DynaMed. Acute Heart Failure. EBSCO Information Services. Accessed July 24,2022. https://www.dynamed.com/condition/acute- heart-failure#MAKING_THE_DIAGNOSIS Acute Decompensated Heart Failure Clyde W. Yancy et al. Circulation. 2013;128:e240-e327  Guideline-Directed Medical Therapy Pharmacologic Therapy: HFpEF, HFpEF, HFmrEF Lifestyle modifications Sodium restriction (2-3gm) Fluid restriction (1.5-2L in Stage D) Alcohol restriction/abstinence Smoking cessation Cardiac rehabilitation Device Therapy: Implantable cardioverter-defibrillator (ICD) Cardiac resynchronization therapy (CRT) Advanced HF Care: Mechanical circulatory support, Transplant, Palliative care Desai AS, Mehra MR. Heart Failure: Management. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. eds. Harrison's Principles of Internal Medicine, 21e. McGraw Hill; 2022. Accessed August 11, 2022. https://accessmedicine-mhmedical-com.arktos.nyit.edu/content.aspx?bookid=3095&sectionid=265451702 Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263–e421.https://doi.org/10.1016/j.jacc.2021.12.012  HFrEF: Management Pharm Therapy Diuretic Angiotensin Receptor- Neprilysin Inhibitor, ACEI or ARB (if not tolerated: Hydralazine/Nitrate) Beta-blocker Sodium-Glucose Cotransporter 2 Inhibitors (SGLT-2 i) Aldosterone antagonist Device Therapy Implantable cardioverter- defibrillator (ICD) Cardiac resynchronization therapy (CRT) HFimEF: HFrEF treatment European Heart Journal, Volume 42, Issue 36, 21 September 2021, Pages 3599–3726, https://doi.org/10.1093/eurheartj/ehab368 Acute Decompensated HF: Management Clyde W. Yancy et al. Circulation. 2013;128:e240-e327  HFpEF: Management No standard treatment regimen exist Treat Underlying Conditions: HTN, diabetes, atrial fibrillation, myocardial ischemia/CAD Volume Overload: diuretics Heart Rate control ARNI/ACEI/ARBs SGLT2 inhibitor Aldosterone antagonists Beta-blockers Implanted Hemodynamic Monitoring Lifestyle modifications: diet, exercise Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263– e421.https://doi.org/10.1016/j.jacc.2021.12.012 Recommendations for Patients With Preserved LVEF (≥50%) *Greater benefit in patients with LVEF closer to 50%. ARB indicates angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium-glucose cotransporter 2 inhibitor. Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263– e421.https://doi.org/10.1016/j.jacc.2021. 12.012 34 Recommendations for Patients With Mildly Reduced LVEF (41%– 49%) ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor-neprilysin inhibitor; HRmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; and SGLT2i, sodium- glucose cotransporter 2 inhibitor. Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263– e421.https://doi.org/10.1016/j.jacc.2021. 12.012 35  SODIUM-HF: Does the low-salt diet reduce events in patients with HF? 841 pts with NYHA II to III HF at 26 sites, 6 countries Low sodium group: less than 1500 mg/day, dietary materials, behavioral counseling Control group: general advice to restrict sodium CV hospitalizations, ED visits, all-cause deaths/1 yr — 15% of the low sodium group and 17% in the usual care group (P = 0.53) Modest benefit on quality of life Limitations Small difference in sodium reduction between groups Unblinded; unavoidable recall bias Stopped early due to the COVID-19 1 yr may have been too short to detect the true effect of intervention Armanious A, Mechanick JI. SODIUM-HF: Does the often-recommended low-salt diet reduce events in patients with heart failure?. Hurst's the Heart Updates, 27 June 2022. McGraw Hill, 2022. AccessMedicine. https://accessmedicine- mhmedical-com.arktos.nyit.edu/updatesContent.aspx?gbosid=594590&sectionid=268236348 Ezekowitz JA, Colin-Ramirez E, Ross H, et al. Reduction of dietary sodium to less than 100 mmol in heart failure (Sodium-hf): an international, open-label, randomised, controlled trial. Lancet. 2022;399(10333):1391–1400. Image from https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/sodium  GDMT: Weight Monitoring Daily weight Nurses, PT, home health staff, dietitians Multidisciplinary HF programs, home visiting programs, structured telephone support Goal “Dry” weight Outpatient action plan Sliding-scale diuretic regimen Intensive surveillance of weight and vital signs with use of telemonitoring has not decreased hospitalizations Wu A. Heart Failure. Ann Intern Med. 2018;168:ITC81–ITC96. doi: 10.7326/AITC201806050 Desai AS, Mehra MR. Heart Failure: Management. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. eds. Harrison's Principles of Internal Medicine 21e. McGraw Hill; 2022. Accessed August 07, 2022. https://accessmedicine-mhmedical-com.arktos.nyit.edu/content.aspx?bookid=3095&sectionid=265451702  GDMT: Exercise Prescription Stable HF, NYHA II-III Improves functional status Improves exercise tolerance Improves quality of life Reduces hospitalizations Reduces mortality Contraindications: worsening HF; exercise-induced ischemia Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263– e421.https://doi.org/10.1016/j.jacc.2021.12.012 GDMT: Implantable Cardioverter Defibrillator (ICD) Prevents Sudden Cardiac Death Prior sustained Vtach, Vfib; Prior MI and LVEF ≤ 30%; NYHA class II-III symptoms of HF and EF