CHF

Definition

Classification

Overview of Heart Failure with Reduced Systolic Function

Evaluation of Acute Heart Failure

  1. BNP is released from the heart (mainly the LV) in response to increased wall tension.
  2. BNP measurement has limited utility after a good clinical assessment. If the diagnosis of HF is clinically apparent, a BNP test is not indicated. Measurement of BNP levels should not be used as a screening test. If the clinical picture is consistent with HF, do not let a low or normal BNP level necessarily deter appropriate diagnosis and therapy. 
  3. In one study, BNP < 100 pg/mL was helpful in ruling out cardiac causes of dyspnea (<50 pg/mL had 96% negative predictive value for CHF) while BNP > 400 pg/mL is helpful for ruling in cardiac causes of dyspnea. For values <100 pg/mL and >400 pg/mL, consider other causes of dyspnea as well as CHF.
  4. The level of BNP correlates with the severity of HF.  However, patients who are stable and well-compensated may run high BNP levels chronically. 
  5. Obese patients have decreased BNP levels due to adipose clearance.
  6. Higher baseline levels of BNP are seen in older patients and women. BNP is falsely low in obesity, diuretics, ACEi, beta-blockers, and aldosterone antagonist use. BNP is low in constrictive pericarditis

Acute Management of Heart Failure Exacerbation. 

Therapy should be tailored to the hemodynamic profile (Volume status vs Perfusion) as described below:

  1. Volume Overload (Wet) with Good Perfusion (Warm) -> Most common hospital presentation of CHF. IV diuretics ± nitrates, afterload reduction (ACEI/ARB, hydralazine, nitrates), ± aldosterone antagonists and beta-blockers when optimized. 
  2. Volume Overload (Wet) with Poor Perfusion (Cold) -> Likely requires ICU care. IV diuretics, ± afterload reduction, ± inotropes/inodilators. In severe or refractory cases, sometimes PA catheter-guided therapy* is needed, PUF/CVVH, consideration of advanced therapies (LVAD, transplant evaluation).
  3. Non-volume Overload (Dry) with Poor Perfusion (Cold) -> Represents 10% of cases, challenging to treat. Often associated with cardio-renal syndrome. Inotropes/inodilators, afterload reduction, and advanced therapies can be considered.
  4. Non-volume Overload (Dry) with Good Perfusion (Warm) -> Compensated HF. Usually can be treated as an outpatient. Maintain volume status and prevent disease progression with rx. Chronic management with beta-blockers, ACEI/ARB, aldosterone antagonists, loop diuretics.                                   

In general patients should be closely monitored:

Overview and Specifics of Treatment

  1. Immediate Considerations: Diuresis, Inotropes, Afterload reduction
  2. Guideline Directed Therapy: ACE-i, Beta blockers, Aldosterone antagonists, Hydralazine/Nitrates
  3. Devices: ICD, CRT, CRT-D
  4. Advanced Therapies: Mechanical circulatory support, Transplant

Diuresis:

Loop diuretics:

Ultrafiltration:

Fluid removal with no effect on serum electrolytes, consideration reserved for in cases of acute decompensated heart failure inadequately responsive to aggressive diuretic regimen. Increased risk of serious adverse advents and no difference in weight loss at 96 hours when compared to pharmacologic therapy (CARRESS-HF). 

Optimizing Hemodynamics/Inotropes:

Dobutamine:

Dopamine:

Milrinone:

Digoxin:

Nitrates:

Guideline-Directed Therapy

ACE inhibitors:

Beta-blockers:

Aldosterone Antagonists:

Hydralazine + Nitrates:

ICD and CRT 

Indicated only after medical optimization and removal of applicable vices (no active drug use) – please see applicable section.

Implantable cardiac defibrillator (ICD): Primary prevention of sudden cardiac death in populations at increased risk for life-threatening ventricular arrhythmias. Mortality benefit for NYHA class II-III HF + LVEF ≤ 35% despite optimal medical management for at least 3 months (SCD-HeFT trial).

Cardiac resynchronization therapy (CRT): HF frequently leads to intraventricular conduction delay and ventricular dyssynchrony. Resynchronization (biventricular pacing) improves pump function with mortality benefit, symptom improvement, and decreased hospitalizations for NYHA class II-III HF + LVEF ≤ 35% + LBBB + QRS ≥ 150 ms despite optimal medical management (MIRACLE, CARE-HF, COMPANION, MADIT-CRT trials).

Most patients who meet criteria for ICD also meet criteria for CRT and vice versa. Combination devices (CRT-D) confer superior mortality benefit when compared to ICD or CRT alone (REVERSE, MADIT-CRT, COMPANION trials).

Advanced Therapies

Mechanical circulatory support

  1. Intra-aortic balloon pump (IABP): Temporary treatment for HF refractory to medical management, systolic unloading and improved coronary perfusion, particularly useful in patients with ischemia or mitral regurgitation, placed in cath lab (see corresponding section). 
  2. Left ventricular assist device (LVAD): Can be used as a bridge to recovery, a bridge to transplant, or “destination” therapy for outpatient use. Placed in OR.    

Cardiac transplantation: Consider early involvement of transplant/advanced HF team in patients with new, rapidly progressive, severe HF, or advanced HF refractory to treatment.

Overview and Management of Heart Failure with Preserved Systolic Function

Etiologies

Evaluations

Treatment

Discharge Planning

References

Felker GM et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011;364(9):797-805.

Jessup M, Brozena S. Heart failure. N Engl J Med 2003 348:2007-2018.

Kadish A, Mehra M. Heart Failure Devices: Implantable Cardioverter-Defribillators and Biventricular Pacing Therapy. Circulation 2005;111:3327-3335.

McMurray JJ, Pfeffer MA. Heart failure. Lancet 2005;365:1877-1889.

Najjar S. Heart Failure with Preserved Ejection Fraction. J Am Coll Cardiol 2009;54: 419-421.

Owan TE et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006 Jul 20; 355:251-9.

Rathore SS, Curtis JP, Wang Y, et al. Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA 2003;289:871-878.

 


Revision #4
Created 25 February 2022 06:30:51 by Katarina Soewono
Updated 3 April 2022 09:08:42 by Harinder Gill