Heart Failure with Reduced Ejection Fraction Etiology 1) Ischemic Heart Disease/Cardiomyopathy (Impaired Contractility) IHD/CAD = 60-75% of HF cases in developing world Decreased cardiac output due to impaired contractility A compensatory rise in NE, Renin, and ADH Increases SVR Coronary Artery Disease (CAD) Chronic Volume Overload (MR, AR, Shunting) Chronic Lung Disease (Cor pulmonale, Pulmonary vascular disorders) 2) Dilated Cardiomyopathies (Impaired Contractility) 30%, Defect in force generation, transmission, myocyte signaling Genetic (20-50%) (Cytoskeleton mutation) Non-Genetic (Myocarditis, Peri-partum, Toxic (alcohol), Idiopathic) Infiltrative Disorders 3) Valvular Heart Disease 15% Toxic/drug-induced damage (Metabolic disorder, Viral) Chagas disease Rate and Rhythm disorders (Chronic Arrythmias) 4) Hypertension General 80% die from Cardiovascular Causes (MC Cause of death) Worsening HF (Cardiogenic Shock, Low Output State) 40% Sudden Cardiac Death (VTach (most common), Bradyarrhythmia) Hypertension contributes to 75% of patients, also DM Valvular heart disease also contributes (EtOH, Hypertension, Drugs) Systolic Heart Failure (Contractile Failure) Compliance (C) = EDV/EDP EDV not easily measured, thus use EF = SV/EDV measured via TTE Characterized by decreased CO/CI, increased SVR, and increased LVEDV Decreased CO (insufficient ventricular contractility, EF will be low) Decrease in SV and Increase in EDP Decreased CO, increases A-a O2 and decreases renal perfusion Increased EDP associated with Increase in EDV Decreased Compliance (EF ≤40%), Increased HR Poor Prognostic Factors for HFrEF 30-40% die within 1 year of diagnosis and 60-70% die within 5 years Higher NYHA functional Class Exam Resting Tachycardia Presence of an S3 gallop Elevated JVP Hypotension: BP <100/60 Labs: Hyponatremia Elevated pro-BNP levels, high NE and catecholamines, elevated troponins Renal insufficiency Low maximal oxygen consumption (peak VO2) ECG: QRS >120ms, LBBB pattern Echocardiography Moderate to severe mitral regurgitation Severe LV dysfunction Concomitant diastolic dysfunction Reduced RV function Pulmonary Hypertension Other: Anemia Atrial Fibrillation Diabetes Mellitus Treatment to improve long-term survival Initial Optimized Therapy ARNI/ARB/ACEI NHYA I-IV with LVEF ≤40% Either Entresto OR BB (3 specific ones) Diuretics Entresto Step 2 of Optimized Therapy Aldosterone antagonist NYHA II-IV with LVEF ≤35% Reduces hospitalization and improves mortality Effect of spironolactone on morbidity and mortality in severe HF Step 3 of Optimized Therapy SGLT-2 Inhibitors NYHA II-IV Reduces symptoms and improves mortality Supplementary Agents Isosorbide Dinitrate + Hydralazine (Bidil) Additional therapy if asymptomatic or RAS Blocker Intolerance Also, in worsening systolic CHF, reduce mortality in AA Improves symptoms and may improve mortality Digoxin Persistent symptoms despite other therapy Reduces hospitalizations, no mortality benefit (0.5-0.8) Avoid CCBs Add Amlodipine/felodipine if high BP (no mortality improvement) No anticoagulation unless AFib or prior VTE 40% complicated by Afib Aggressive rhythm control Catheter ablation of AF (improves morbidity and mortality) Persistent Severe HF symptoms on maximal GDMT Heart Transplant Evaluation 1 year survival is near 90%, 12 year median survival Generally 65-70 w/o T2DM w/End organ damage, Cancer in the past 5 years, GFR >30, No other survival decreasing illnesses, good social support and adherence LVAD (Left Ventricular Assist Device) EF <25% and NYHA IV symptoms on maximal therapy with either 1-2 year predicted mortality or inotrope dependency who still want aggressive restorative care Other Management Heart Failure GDMT