LITERATURE REVIEW: HEART FAILURE Chief Residents
Heart Failure EF 40% HFrEF Problem with contractility EF 40-50% HFmrEF EF > 50% HFpEF Problem with filling/relaxation
RISK FACTORS Post MI HTN DM Obesity OSA
SYMPTOMS AND SIGNS Symptoms Mechanism Signs Mechanism SOB Pulmonary congestion 2/2 increased LA pressure Elevated JVP Holosystolic murmur Increased RA pressure MR or TR Orthopnea, PND Palpitations Increased venous return and lung congestion in supine position Tachyarrhythmias S3 gallop Pulmonary crackles, pleural effusion Increased LA pressure Increased atrial pressure, congestion Anorexia, Cachexia, Early Satiety Fluid retention, ingestional congestion, chronic inflammatory pathway activation Hepatomegaly, hepatojugular reflex, ascites Peripheral edema Increased RA pressure fluid retention
TTE (EF, wall motion, valvular disease) EKG CXR Troponin BNP Falsely low in obese Falsely high in elderly DIAGNOSTIC TOOLS
DIURETICS Diuretic PO IV Furosemide 40mg 20mg Bumetanide 1mg 1mg Torasemide 20mg 20mg Bumex and Torsemide are cleared by the liver rather than the kidney Bumex and Torsemide have 100% bioavailability (vs. variable with Furosemide) TORIC study: compared Torasemide (10mg) vs. Furosemide(40mg)/Other diuretics (not bumetanide) Torasemide well-tolerated, improved functional status, decreased overall mortality Not a therapeutic dose of torasemide
Gut wall edema à decreased absorption of PO IV for all hospitalized patients with ADHF (Class I) DOSE trial (2011): continuous vs spot dose IV infusion (EF < 35%) No change in patient-reported symptoms, change in creatinine, weight change, NT-proBNP levels, LOS, all-cause mortality, or rehospitalization high dose (2.5x home dose) vs low dose (home dose converted to IV equivalent) showed higher rates of Cr elevation but improved fluid reduction, decrease in NT-proBNP, and weight loss at 72hrs Dopamine? Low dose à renal protection? DAD-HF trial (2010): low-dose Lasix + low dose dopamine vs high-dose Lasix in HFrEF No change in urine output, dyspnea scores, LOS, mortality, rehospitalization rates; LDLD had better renal profile (lower change in Cr, lower drops in K) Class IIB: consider addition of dopa to improve diuresis
BETA BLOCKERS Bisprolol CIBIS-II (1999): addition of bisoprolol to standard therapy decreases all-cause mortality in patients with HFrEF (EF 35%) Metoprolol Succinate MERIT-HF (1999): in patients with EF 40%, MTP XL reduces all-cause mortality compared to placebo Carvedilol COPERNICUS (2002): addition of carvedilol decreases mortality and hospitalizations compared to placebo in patients with HFrEF (EF 25%) MTP vs Carvedilol? COMET (2003): coreg decreases all-cause mortality compared with MTP Used MTP tartrate; used inequivical doses of coreg and MTP Retrospective study 2015 compared coreg and MTP succinate; after multivariate adjustment no change in survival CO = HR x SV; in ADHF, SV so don t decrease HR (further worsen CO)
ACE-I/ARB All patients with HFrEF should be on ACE-I or ARB (if ACE-I intolerant) to reduce mortality AKI is relative contraindication, CKD ok if Cr < 2.5 in males and < 2.0 in females with K < 5.0 CONSENSUS (1987): NYHA IV HF showed reduction in mortality at 12mo with initiation of enalapril compared to placebo SOLVD (1991): NYHA 1-IV (primarily II, III) with EF 35%, use of enalapril showed reduction in CV-related hospitalization and mortality CHARM (2003): NYHA II-IV with EF 40%, patients who were intolerant to ACE-I were placed on candesartan with reduction in hospitalization for HF and CV-mortality compared to placebo
Aldosterone Antagonists ACC guidelines: Aldosterone antagonists recommended for NYHA class II-IV with LVEF 35% RALES (1999): NYHA III, IV and EF 35% the addition of spironolactone vs placebo decreased all-cause mortality without significant increase in hyperkalemia or renal failure EMPHASIS-HF (2011): NYHA II-IV, the addition of eplerenone to standard therapy reduces CV death or HF-related hospitalization Aldosterone antagonists recommended after MI if EF 40% if patient has sx of HF or hx of DM EPHESUS (2003): in patients with reduced EF ( 40%) following acute MI, addition of eplerenone decreased sudden cardiac death and hospitalization when combined with standard therapy
NEPRILYSIN INHIBITORS ARNI : Angiotensin Receptor Neprilysn Inhibitor
PARADIGM-HF (2014): f/u on OVERTURE (2002), which showed omapatrilat reduced mortality and hospitalization compared to ACE-I Entresto vs enalapril NYHA II-IV, EF 40 à 35% (2010) Stable on ACE-I/ARB Reduction in all-cause mortality, CV-mortality, or HF-related hospitalization 2017 ACC guidelines: In patients with NYHA II/III HFrEF tolerating ACE-I/ARB therapy should be switched to ARNI for morbidity and mortality benefit
Ivabradine SHIFT (2010): EF 35%, NYHA II-IV, resting HR > 70 despite max medical therapy including beta blockers 5% absolute reduction in HFhospitalization and 2% absolute reduction in HF-related mortality Reduces HR independent of BB ACC (2017): Ivabradine can be beneficial to reduce HF hospitalization for patients with NYHA II/III HFrEF who are on guideline-based therapy with maxtolerated beta blocker and in NSR with resting HR > 70 (class IIb)