Heart Failure: Management¶
Chapter 265 | Part 6: Disorders of the Cardiovascular System
KEY CLINICAL POINTS¶
- HFrEF management includes RAAS antagonists (ACEIs, ARBs, ARNIs), beta-blockers, mineralocorticoid receptor antagonists, and SGLT-2 inhibitors as cornerstone therapies.
- HFpEF treatment focuses on lifestyle modifications, control of comorbidities, and emerging therapies like SGLT-2 inhibitors and GLP-1 agonists.
- ADHF management prioritizes diuresis, vasodilators, and inotropic agents, with sacubitril-valsartan showing benefit in reducing HF hospitalizations.
- Mineralocorticoid receptor antagonists (e.g., spironolactone) are recommended for HFrEF but require monitoring for hyperkalemia and renal function.
- Cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillators (ICDs) are indicated for specific HFrEF patients with QRS duration >149 ms and reduced LVEF.
1. DEFINITION & OVERVIEW¶
Heart failure (HF) is a clinical syndrome characterized by impaired cardiac pump function. Classification is based on ejection fraction (EF): HFrEF (EF ≤ 40%), HFmrEF (EF 41–49%), and HFpEF (EF ≥ 50%). Management varies by HF phenotype, with HFrEF benefiting from neurohormonal antagonists and HFpEF requiring comorbidity-focused strategies.
Table 265-1: Vasoactive Therapy in Acute Decompensated Heart Failure¶
| DRUG CLASS | GENERIC DRUG | USUAL DOSING | SPECIAL CAUTION | COMMENTS |
|---|---|---|---|---|
| Inotropic therapy | Dobutamine | 2–20 mg/kg per min | Increased myocardial oxygen demand, arrhythmia | Short acting, variable efficacy in presence of beta blockers |
| Inotropic therapy | Milrinone | 0.375–0.75 mg/kg per min | Hypotension, arrhythmia | Decrease dose in renal insufficiency; effectiveness retained with beta blockers |
| Inotropic therapy | Levosimendan | 0.1 mg/kg per min; range, 0.05–0.2 mg/kg per min | Hypotension, arrhythmia | Long acting; similar effectiveness as dobutamine |
| Vasodilators | Nitroglycerin | 10–20 mg/min, increase up to 200 mg/min | Headache, flushing, tolerance | Most common vasodilator but often underdosed |
| Vasodilators | Nesiritide | Bolus 2 mg/kg and infusion at 0.01 mg/kg per min | Hypotension | Decrease in blood pressure may reduce renal perfusion |
| DRUG CLASS | GENERIC DRUG | USUAL DOSING | SPECIAL CAUTION | COMMENTS |
|---|---|---|---|---|
| Vasodilators | Nitroprusside | 0.3 mg/kg per min titrated to 5 mg/kg per min | Thiocyanate toxicity in renal insufficiency (>72 h) | Requires arterial line placement for titration |
| Diuretics | Furosemide | 20–240 mg daily | Monitor for electrolyte loss | In severe congestion, use intravenously and consider continuous infusion |
| Diuretics | Torsemide | 10–100 mg daily | Monitor for electrolyte loss | High bioavailability; anecdotally more effective in advanced heart failure |
| Diuretics | Bumetanide | 0.5–5 mg daily | Monitor for electrolyte loss | Can be used orally; intermediate bioavailability |
1.1 Ejection Fraction Classification¶
HFrEF (EF ≤ 40%): Treated with RAAS inhibitors, beta-blockers, and SGLT-2 inhibitors. HFmrEF (EF 41–49%): Similar to HFrEF but with less evidence. HFpEF (EF ≥ 50%): Managed with lifestyle changes, comorbidity control, and emerging therapies like SGLT-2 inhibitors.
1.2 Acute Decompensated Heart Failure (ADHF)¶
ADHF is a heterogeneous syndrome requiring urgent decongestion, hemodynamic optimization, and targeted therapy. Management includes diuretics, vasodilators, and inotropes, with sacubitril-valsartan showing potential benefits in reducing hospitalizations.
2. EPIDEMIOLOGY¶
HF is a leading cause of hospitalization and mortality. HFrEF is more common in men, while HFpEF is prevalent in women and older adults. Prevalence increases with age, and comorbidities like diabetes, hypertension, and obesity are major risk factors.
2.1 Risk Factors¶
Hypertension, diabetes, obesity, coronary artery disease, and atrial fibrillation are key risk factors. HFpEF is associated with obesity, sleep apnea, and metabolic syndrome.
2.2 Demographics¶
HFrEF is more common in men, while HFpEF predominates in women and older adults. Prevalence rises with age, with significant racial disparities in outcomes.
3. ETIOLOGY & PATHOPHYSIOLOGY¶
HF results from impaired cardiac function due to myocardial damage, neurohormonal activation, and comorbidities. HFrEF involves systolic dysfunction, while HFpEF is linked to diastolic stiffness and microvascular dysfunction.
3.1 HFrEF Pathophysiology¶
Myocardial remodeling, neurohormonal activation (RAAS, SNS), and ventricular dysfunction drive HFrEF. SGLT-2 inhibitors and ARNIs target these pathways.
3.2 HFpEF Pathophysiology¶
Diastolic dysfunction, microvascular inflammation, and endothelial dysfunction are central. Obesity, sleep apnea, and metabolic syndrome contribute to impaired myocardial relaxation.
4. CLINICAL FEATURES¶
Symptoms include dyspnea, fatigue, and fluid retention. Signs include jugular venous distension, pulmonary rales, and peripheral edema. Complications include arrhythmias, renal failure, and sudden cardiac death.
4.1 Symptomatology¶
Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fatigue, and reduced exercise tolerance are hallmark symptoms.
4.2 Physical Findings¶
Jugular venous distension, pulmonary rales, peripheral edema, and hepatomegaly are common. Cardiac enlargement and S3 gallop may be present.
5. DIFFERENTIAL DIAGNOSIS¶
Differential diagnoses include pulmonary hypertension, valvular heart disease, and myocardial infarction. Echocardiography and biomarkers (BNP/NT-proBNP) aid in differentiation.
5.1 Non-Cardiac Causes¶
Pulmonary embolism, anemia, and thyroid dysfunction can mimic HF. Sleep apnea and obesity hypoventilation syndrome are common comorbidities.
5.2 Cardiac Causes¶
Valvular disease, hypertrophic cardiomyopathy, and arrhythmias must be excluded. Echocardiography is critical for assessing ventricular function.
6. INVESTIGATIONS & DIAGNOSIS¶
Diagnosis involves clinical evaluation, biomarkers (BNP/NT-proBNP), echocardiography, and imaging. Electrocardiography and chest X-ray are essential for assessing cardiac size and rhythm.
6.1 Biomarkers¶
Elevated BNP/NT-proBNP levels correlate with HF severity. Levels normalize with effective treatment but may persist in chronic cases.
6.2 Imaging¶
Echocardiography assesses EF, ventricular size, and valvular function. Cardiac MRI may identify myocardial scar in ischemic cardiomyopathy.
7. MANAGEMENT & TREATMENT¶
Guideline-directed medical therapy (GDMT) includes RAAS inhibitors, beta-blockers, and SGLT-2 inhibitors. ADHF requires aggressive diuresis, vasodilators, and inotropes. CRT and ICDs are indicated for specific patients.
Table 265-2: Guideline-Directed Pharmacologic Therapy and Target Doses in HFrEF¶
| DRUG CLASS | GENERIC DRUG | MEAN DAILY DOSE IN CLINICAL TRIALS (mg) | INITIATION (mg) | TARGET DOSE (mg) |
|---|---|---|---|---|
| Angiotensin-Converti ng Enzyme Inhibitors | Lisinopril | 4.5–33 | 2.5–5 qd | 20–35 qd |
| Angiotensin-Converti ng Enzyme Inhibitors | Enalapril | 17 | 2.5 bid | 10–20 bid |
| Angiotensin-Converti ng Enzyme Inhibitors | Captopril | 123 | 6.25 tid | 50 tid |
| Angiotensin-Converti ng Enzyme Inhibitors | Trandolapril | N/A | 0.5–1 qd | 4 qd |
| Angiotensin Receptor Blockers | Losartan | 129 | 50 qd | 150 qd |
| Angiotensin Receptor Blockers | Valsartan | 254 | 40 bid | 160 bid |
| Angiotensin Receptor Blockers | Candesartan | 24 | 4–8 qd | 32 qd |
| Aldosterone Antagonists | Eplerenone | 42.6 | 25 qd | 50 qd |
| Aldosterone Antagonists | Spironolactone | 26 | 12.5–25 qd | 25–50 qd |
| Beta Blockers | Metoprolol succinate CR/XL | 159 | 12.5–25 qd | 200 qd |
| Beta Blockers | Carvedilol | 37 | 3.125 bid | 25–50 bid |
| Beta Blockers | Bisoprolol | 8.6 | 1.25 qd | 10 qd |
| Arteriovenous Vasodilators | Hydralazine isosorbide dinitrate | 270/136 | 37.5/20 tid | 75/40 tid |
| Arteriovenous Vasodilators | Fixed-dose hydralazi ne/isosorbide dinitrate | 143/76 | 37.5/20 qid | 75/40 qid |
| Angiotensin Receptor-Neprilysin Inhibitor | Sacubitril-valsartan | 375 | 100 bid | 200 bid |
| SGLT-2 Inhibitor | Dapagliflozin | 10 | 10 qd | 10 qd |
| SGLT-2 Inhibitor | Empagliflozin | 10 | 10 qd | 10 qd |
| SGLT-2 Inhibitor | Sotagliflozin | 200 | 200 qd | 200 qd |
| Novel Therapies | Vericiguat (sGC stimulator) | 9.2 | 2.5 qd | 10 qd |
| Novel Therapies | Omecamtiv mecarbil (myosin activator) | Not reported | 25 bid | Up to 50 mg bid |
7.1 HFrEF Treatment¶
RAAS antagonists (ACEIs, ARBs, ARNIs), beta-blockers (carvedilol, bisoprolol), mineralocorticoid receptor antagonists, and SGLT-2 inhibitors are first-line. Sacubitril-valsartan reduces hospitalizations and mortality.
7.2 ADHF Management¶
Diuretics (loop, thiazide), vasodilators (nitroglycerin, nitroprusside), and inotropes (dobutamine) are used. Sacubitril-valsartan may reduce hospitalizations in ADHF.
7.3 CRT & ICD¶
CRT is indicated for QRS >149 ms and LVEF ≤ 35%. ICDs are used for primary prevention in patients with EF ≤ 35% and high risk of sudden death.
8. PROGNOSIS & COMPLICATIONS¶
HF is associated with high mortality and morbidity. Complications include arrhythmias, renal failure, and sudden cardiac death. Prognosis is worse in HFpEF and advanced stages.
8.1 Mortality¶
Annual mortality in HFrEF is ~5–10%. HFpEF has higher mortality due to comorbidities and limited therapeutic options.
8.2 Complications¶
Worsening heart failure, acute decompensation, and arrhythmias are common. Renal dysfunction and thromboembolism are significant risks.
9. SPECIAL CONSIDERATIONS¶
Management varies by age, gender, and comorbidities. Pregnancy requires careful monitoring, while elderly patients may need dose adjustments. Sleep apnea and obesity are critical comorbidities in HFpEF.
9.1 Pregnancy¶
Beta-blockers and ACEIs are contraindicated. Spironolactone is preferred for mineralocorticoid antagonism. Close monitoring for decompensation is essential.
9.2 Obesity and Sleep Apnea¶
Weight loss and CPAP therapy are critical in HFpEF. Obesity is a major risk factor for HF and worsens outcomes.
10. KEY POINTS & CLINICAL PEARLS¶
- HFrEF management includes RAAS antagonists, beta-blockers, and SGLT-2 inhibitors. 2. HFpEF requires comorbidity control and lifestyle modifications. 3. ADHF is managed with diuresis, vasodilators, and inotropes. 4. CRT and ICDs improve outcomes in specific HFrEF patients. 5. Early postdischarge follow-up reduces readmissions and improves outcomes.