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Basics of Heart Failure

General

  • Definition: Any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or to eject blood
    • Inability of the heart to adequately perfuse the body leading to congestion
    • Any condition that leads to an alteration in LV dysfunction (structure or function) can predispose one to developing HF
    • HF preferred over CHF because Congestive Heart Failure fails to include high-output states

Physiology

Etiology

  • CAD is MCC in US (>50%)
  • 20% of Americans ≥40 y/o develop
    • AA males have highest risk and highest 5-year mortality

Types

  • Acute
  • Chronic
  • Generally, 3 Classes of HF:
    • Left Ventricular Ejection Fraction (LVEF)
      • Important in classification
      • Acute is classified based on:
        • Congestion (wet vs. dry) and Perfusion (warm vs. cold)
  • A) HFrEF
    • Systolic Dysfunction, EF ≤40%
    • Mcly due to ischemic heart disease (MC) and dilated cardiomyopathy
  • B) HFpEF
    • Diastolic Dysfunction, EF ≥50%
  • C) High-output Failure
    • Occurs in the setting of existing systolic or diastolic dysfunction

Classification Systems

  • NYHA Classifications
    • Class I
      • Cardiac Disease but without restriction
    • Class II
      • Slight limitation of physical activity
      • Comfortable at rest
      • Fatigue, palpitation, dyspnea, or anginal pain
      • 5-10% of NYHA class II die yearly
    • Class III
      • Marked limitation of physical activity
      • Comfortable at rest
      • Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain
    • Class IV
      • Inability to carry on any physical activity without discomfort
      • HF symptoms or anginal syndrome may be present even at rest
      • Physical activity makes it worse
      • 30-70% of NYHA class IV die yearly
  • ACC/AHA Staging
    • Stage A
      • High risk for HF but no structural heart disease, including:
        • HTN, Atherosclerotic disease, diabetes, obesity, metabolic syndrome, cardiotoxins, FH of cardiomyopathy
        • Means having HTN you have Stage A HF
      • Treatment
        • Treat the disorder
        • Exercise can decrease all cause death or hospitalization (HF-ACTION Trial) up to 11%
        • ACEIs/ARBs in select patients
    • Stage B
      • Structural heart disease w/o symptoms, including:
        • Previous MI, valvular disease, and LVH or low LVEF
      • Treatment
        • ACEIs/ARBs
        • BBs + Statins if MI/ACS
        • ICD if indicated
    • Stage C
      • Structural heart disease with current or prior HF symptoms
      • Treatment
        • NYHA II-IV
          • Loop diuretics
        • NYHA III-IV + AA
          • Hydralazine/Isosorbide Dinitrate
        • NYHA II-IV + Cr >30 and K <5
          • Aldosterone antagonists
        • Stage A and B drugs
    • Stage D
      • Marked symptoms at rest
      • Treatment
        • As above + ICD, heart transplant

Symptoms

  • Fatigue and SOB
  • Progressive Dyspnea with Exercise
    • Origin: Most important mechanism is pulmonary congestion with accumulation of interstitial or intra-alveolar fluid
      • Stimulate the rapid, shallow breathing characteristic of cardiac dyspnea
      • Pulmonary compliance reduction, Increased airway resistance, Anemia
      • Less frequent with onset of RV failure and TR
    • JVD, Paroxysmal Nocturnal Dyspnea, peripheral edema, S3, orthopnea
    • Cough if present is productive

Diagnosis: Clinical

  • Best Test: Get Echocardiogram (Transthoracic Echocardiogram)
    • To distinguish between Systolic and Diastolic HF
  • Cardiomegaly on CXR
  • Labs: CXR, EKG, CBC w/Diff, UA, UM, Electrolytes + Calcium and magnesium
    • BUN/Cr, Glucose, Lipids, LFTs, TSH, BNP or NT-proBNP
    • Troponin-I

Prognosis

  • On GDMT of ARNI/BB/MRA/SGLT2i
    • Estimated 7.9, actual 4.9 years gained for a 50 y/o with HFrEF
    • Estimated 5.0, actual 3.3 years gained for a 70 y/o with HFrEF