HF

• Chronic Heart Failure


  Part II

  
• Goals of HF therapy

  • Survival
  • Morbidity
  • Exercise capacity
  • Quality of life
  • Neurohormonal changes
  • Progression of CHF
  • Symptoms
• Goals of therapy


  • Achieve euvolemic status
  • Improve functional capacity
  • Proactive clinical care
  • Reduce heart failure-related hospitalizations
  • Improve symptoms and health status
  • Improve survival
• Nonpharmacological treatment of HF

  • Maintenance of fluid balance
  • Sodium restriction < 3 grams/day
  • Fluids to < 2 L/day
  • Daily weight measurement
  • Tobacco and alcohol cessation
  • Management of cardiac comorbidities
  • Exercise
  • Patient and family counseling
  • Immunizations
  • Coronary revascularization
  • Biventricular pacing (Cardiac Resynchronization Therapy, CRT)
  • Enhanced external counterpulsation therapy
  • Surgical ventricular restoration
  • Left ventricular assist devices (VAD) /Heart transplant
  • Compassionate end of life care/hospice

  
• Therapeutic Objectives


  • Protect/Preserve myocardium
  • Improve hemodynamics
  • Prevent ischemic events
  • Prevent sudden arrhythmic death

  
• Pharmacologic treatment of HF

  • Diuretic (if evidence of fluid retention)
  • ACE inhibitor or ARB (assuming no CI)
  • β-blocker
  • ARNI (angiotensin-receptor-neprilysin inhibitor)
  • Digoxin
  • Aldosterone antagonist
  • Nitrates/Hydralazine
  • Sodium-glucose cotransporter type 2 (SGLT2)
  • Calcium Channel Blockers
  • Anticoagulation
  • Antiarrhythmics
• RAAS


  Renin-angiotensin-aldosterone system
• SGLT2


  Sodium-glucose cotransporter type 2
• HFpEF


  Heart failure with preserved ejection fraction

  
• HFrEF


  Heart failure with reduced ejection fraction

  
• Treatment algorithm for patients with ACC/AHA Stage A and B heart failure

  1. Assess etiology

  2. Plan treatment strategy

  
• Guideline-directed medical therapy (GDMT)


  • ARNI or ACE inhibitor or ARB
  • Evidence-based β-blocker
  • Aldosterone antagonist
  • Sodium-glucose cotransporter-2 (SGLT2) inhibitor
• ARNI


  Angiotensin receptor II receptor blocker/neprilysin inhibitor
• ACE inhibitor


  Angiotensin-converting enzyme inhibitor
• ARB


  Angiotensin II receptor blocker
• β-blockers


  • Carvedilol, Metoprolol succinate, and Bisoprolol prolong survival, decrease hospitalizations, reduce the need for transplantation, and promote "reverse remodelling" of the left ventricle

  
• β-blockers are recommended for all patients with HFrEF unless contraindicated
• Therapy must be instituted at low doses, with slow upward titration to the target dose
• Recent evidence suggests that ARNI sacubitril/valsartan is preferred over ACE inhibitors (or ARBs) for HFrEF unless other circumstances (eg, affordability) are present in individual patients
• The ARNI, sacubitril/valsartan, is approved to treat patients with HFrEF and many with HFpEF
• In patients with HFrEF, ARNI is preferred over either ACE inhibitors or ARBs to improve survival, slow disease progression, reduce hospitalizations, and improve quality of life
• Patients receiving ACE inhibitors or ARBs can be switched to ARNI or ARNI can be used as initial treatment in patients with newly detected HFrEF without previous exposure to ACE inhibitors or ARBs
• The doses for these agents should be targeted at those shown in clinical trials to improve survival
• SGLT2 inhibitors dapagliflozin or empagliflozin reduce the risk of cardiovascular death, hospitalization, and worsening HF in patients with HFrEF
• In addition, dapagliflozin and empagliflozin improve complex outcomes in patients with HFpEF
• In both HFrEF and HFpEF, these benefits were demonstrated in patients with and without type 2 diabetes
• SGLT2 inhibitors require assessment of renal function prior to initiation

  
• Chronic loop diuretic therapy frequently is used in patients with HFrEF or HFpEF, but it is not mandatory
• Diuretic therapy is required only in those patients with peripheral edema and/or pulmonary congestion

  
• Many patients will need continued diuretic therapy to maintain euvolemia after fluid overload is resolved
• Step 1 medications for HFrEF Stages C and D

  • ARNI or ACE inhibitor or ARB
  • Evidence-based β-blocker
  • Aldosterone antagonist
  • Sodium-glucose cotransporter-2 (SGLT2) inhibitor
• Diuretics


  Decrease Na and water retention to reduce preload, decrease signs/symptoms of fluid retention, improve exercise tolerance, quality of life, and cardiac function, reduce HF hospitalizations
• Diuretics do not alter disease progression or prolong survival
• Diuretics should not be used alone in patients with HF
• All patients with evidence of fluid retention require diuretics

  
• Many patients require chronic diuretic therapy to maintain euvolemia
• Body weight changes are a sensitive marker of fluid retention/loss
• Patients should report weight gain of > 0.25-0.5 kg/day over several days
• Thiazide diuretics


  Weak diuretics with more persistent antihypertensive activity than loop diuretics, infrequently used alone in HF, can use with loop diuretics to promote diuresis, preferred in some patients with mild fluid retention & elevated BP
• Loop diuretics


  Furosemide, bumetanide, toresmide, mainstay of HF therapy, efficacy reduced by competitors of the organic acid transport pathway, excess dietary Na+, co-administration with NSAIDs, efficacy maintained in impaired renal function