Heart Failure Flashcards
Diagnostic Algorithm for Heart Failure
Basics tests for all suspected chronic heart failure
ECG
Normal ECG makes HF unlukel
Look for AF, LVH, LBBB
Natriuretic Peptides
BNP <35 pg/ml
NT pro-BNP <125pg/ml
MR-proANP <40pmol/l
Bloods
Exclude other causes, prognostic information and guide therapy
FBC, U+E, LFT, TFTs, TSATs and Ferritin, Fasting Glucose
Echo
LVEF, RVEF, Atrial size, Valves, Pulmonary HTN, Diastolic function
CXR
Investigate other causes of SOB
Supportive evidence (pulmonary oedema)
Chronic HF - CMR
- Use in patients with poor echo windows
- Use to characterise myocardial tissue patients with suspected infiltrative disease, Fabry’s, LV non-compaction, amyloid, sarcoid, haemochromatosis, inflammatory disease (myocarditis)
- Use CMR with LGE to distinguish ischaemic from non-ischaemic scar in DCM
Chronic HF - Coronary Angiography
- Recommended in patients with angina despite medical therapy or symptomatic ventricular arrythmias
- Consider in patients with intermiediate to high pre-test probability of CAD and postive stress test
Chronic HF - Non Invasive Imaging
- CTCA in patients with low to intermiediate pre-test probability of CAD or equivocal stress test
- Stress imaging (stress MRI, stress echo, SPECT, PET) may be considered to assess ischaemia and viability in patients suitable for revascularisation
- Can consider ETT to diagnose ischaemia and investigate dyspnoea
CPEX
Recommended as part of the evaluation for transplant or MCS
Consider to help optimise exercise prescriptions
Consider to investigate unexplained dyspnoea
Chronic HF - RHC
- Recommended for transplant or MCS assessment
- Consider where constrictive pericarditis, restrictive CM, congenital or high output states thought to be the cause
- Consider when probable pHTN by echo to establish diagnosis and reversibility prior to correction of valve/structural heart disease
- May be considered in HFpEF to confirm diagnosis
EMB
* Consider in rapidly progressive HF where particular diagnosis saught that can only be made on myocardial samples
HFrEF (LVEF≤40%) - Management Algorithm
HFrEF (LVEF≤40%) Target Doses
HFrEF - ARNI
- PARADIGM-HF - reduced all cause mortality, CV mortality and HF hospitalisations compared with Enalapril in patients with LVEF ≤40%, raised NPs and eGFR ≥30
- Reduced symptoms, reduced eGFR decline rate, reduced hyperkalaemia, reduced loop diuretic requirement and reduced incidence of diabetes requiring treatment
- Increased symptomatic hypotension compared with enalapril
- ARNI is recommended to replace ACEi or ARB when remain symptomatic despite optimal therapy
- ARNI can be considered in ACEi niave patients
- If starting ARNI - need adequate BP, eGFR ≥30 and 36 hor ACEi washout (to reduce risk of angioedema)
HFrEF - SGLT2i
- DAPA-HF - SGLT2i reduced CV mortality, HF hospitalisation and all cause mortality in NYHA II-IV, LVEF ≤40% despite OMT, eGFR >30ml, raised NP patients
- Consisent large ARR in diabetic and non-diabetic patients
- Emperor-Reduced - SGLT2i reduced composite primary endpoint of CV death and HF hospitalisation (not CV death alone). Consistent effect in DM and non-DM. NYHA II-IV, LVEF ≤40% despite OMT, eGFR ≥20ml
- Recommended (Ia) for patients with HFrEF
- Small eGFR reduction after initiation is reversible and should not lead to cessation
- Increased genital infections
HFrEF - Lower Class Recommendation Drugs
- Loop Diuretics (1c) - to reduce HF hospitalisations and symptoms
- ARB - (1b) to reduce HF hospitalisations and CV death in patients unable to tolerate ACEi or ARNI
- If-channel inhibitor (Ivabradine) - (IIa) if LVEF ≤35%, SR, HR >70bpm despite maximum tolerated or guideline level beta-blocker to reduce CV death and HF hospitalisation. Or instead of betablocker if not tolerated (IIb)
- Soluble guanylate cyclase stimulator (Vericugat) - consider if worsening HF despite ACE/ARNI, BB and MRA to reduce CV death and HF hospitalisation (IIb)
- Hydraliazine and isosorbide dinitate - (IIb) consider in Black patients in NYHA II-IV with LVEF ≤35% or ≤45% and dilated LV, despite ACE/ARNI, BB and MRA or who can tolerate ACI/ARNI/BB
- Digoxin - consider in patients with HFrEF, sinus rhythm, with symptoms despite ACE/ARNI, BB, MRA to reduce hospitalisations
HFrEF - ICD recommendations
**Secondary prevention **
1a - recovered form a ventricular arrhythmia causing haemodynamic instability, life expectancy > 1year, good funtional status, absence of reversible cause and absence of MI in last 48 hours
Primary Prevention
1a - HFrEF of ischaemic aetiology (except in 40 days post MI), LVEF ≤35% despite 3 months of OMT, life expectancy with good functional status >1 year
IIa - As above but for non-ischaemia aetiology
IIa - Re-evaluate patient by experienced cardiologist before box change as need for device may have changed
IIb - Consider wearable defibrillator as a bridge to implantable device or for patients with transient arrhythmia risk
IIIa - do not implant ICD in 40 days post MI
IIIc - do not implant ICD in NHYA IV unless candidate for CRT, VAD or HTx
HFrEF - CRT recommendations
1a - Symptomatic HFrEF, sinus rhythm and LBBB QRSd ≥150ms, LVEF ≤35% despite OMT.
Consider (IIa) in the above but non LBBB morphology. Consider (IIa) in the above but LBBB QRDs 130-149ms. IIb for non LBBB QRSd 130-149ms.
1a - Any HFrEF with AV block, CRT preferred to RV pacing, irrespective of QRSd, any NYHA class, including AF patients
IIa - Consider CRT upgrade in previously implanted PPM or ICD if LVEF ≤35% and worsening HF despite OMT and significant proportion of RV pacing
IIIa - CRT NOT recommended if QRSd <130ms and no AV block pacing indication
HFmrEF (LVEF 40-49%) - Medications
Ia - Diuretics for symptoms
IIb - ACE, ARB, BB, MRA
No recommendation for ICD or CRT
HFpEF - Diagnosis
- Symptoms or signs of Heart Failure
- LVEF ≥50%
- Objective evidence of cardiac structural or functional abnormalities consistent with LV diastolic dysfunction or riased LV filling pressures, including raised natriuretic peptides
If previously LVEF overtly reduced (LVEF ≤40%) but now ≥50% they have HF with improved EF, not HFpEF, and should stay on HFrEF therapy.
Confirmatory tests if uncertan (CPEX, exercise stress test, haemodynamic)
Invasive exercise haemodynamics are confirmatory test if ongoing uncertainty:
* PCWP ≥15mmHg at rest
* PCWP ≥25mmHg on exercise
* LVEDP ≥16mmHg at rest
Advanced Heart Failure - Criteria
- Severe symptoms - NYHA III (advanced) or IV
- Severe cardiac dysfunction:
-LVEF ≤30%
-Isolated RV failure (i.e. ARVC)
-Non-operable severe valvular abnormalities
-Non-operable severe congenital abnormalities
-Persistently high or increasing NPs and severe diastolic dysfunction or structural abnormalities according to HFpEF definition
- Episodes of pulmonary or systemic congestion requiring high dose diuretics OR episodes of low output states requiring inotropes OR malignant arrhythmias requiring >1 visit to hopsital in past year
- Severe impairment of exercise capacity
- 6MWT <300m
- pVO2 <12ml/kg/min OR <50% expected
- Of cardiac origin
-
Heart Transplant Criteria
Acute Heart Failure - Clinical Presentations
Acute Decompensated Heart Failure - Management
Acute Pulmonary Oedema - Management
Isolated RV failure - Management
Cardiogenic Shock - Management
Acute Heart Failure - Diuretic Management
Heart Failure - Rhythm Management
AF
* * AF, unstable, DCCV
* Consider DCCV if relationship between AF and HF symptoms
* Consider LA ablation if clear relationship between AF and HF symptoms despite OMT
* Rate control - Beta blockers first line
* If inadequate rate control and SR - add digoxin
PVCs
* Check for precipitants (electrolytes, thyroid)
* Optimise HF medical therapy
* Consider amiodarone
* Consider PVC ablation
Symptomatic Bradycardia
* HFrEF, if pacing required, CRT over RV pacing
HFrEF - Chronic Coronary Syndrome
Angina
* * Beta-blockers first line
* If HR >70 on BB, SR and need further AA -> Ivabradine
* If HR <70 on BB or AF and need further AA -> trimetazadine OR ranolazine OR nicorandil OR nitrates OR felodipine OR amlodipine (all IIb)
* AVOID nonDHP CCBs
Revascularisation
* CABG first line revascularistion strategy, particularly if DM or multivessel disease
* Consider revascularisation in HFrEF if CCS, persistent angina on OMT, anatomically suitable
* if LVAD candidate and needs revascularisation, avoid CABG
* Consider revascularisation for prognosis in HFrEF, CCS and suitable anatomy after considering risk benefit ratio (including coronary anatomy) and patient perspectives
* Consider PCI over CABG based on anatomy, comorbidites and surgical risk
HFrEF - TEER Criteria
- Could have MV surgery if low risk*
- NYHA II-IV despite OMT
- Moderate to severe MR (EROA ≥30mm2)
- Favourable anatomy
- LVEF 20-50%
- LVEDD <70mm
- Absence of: severe TR, mod-sev RV dysfunction, haemodynamic instability
Heart Failure - Iron Deficiency
- Regular screening for Iron deficiency in HF patients with FBC, Ferritin, TSats
- Consider IV ferric carboxymaltose in HF with LVEF ≤45% and ferritin <100ng/ml or 100-299ng/ml and T sats ≤20% to improve HF symptoms and exercise capacity
- Consider IV ferric carboxymaltose with LVEF≤50% and iron deficiency as above in recently hospitalised patients to reduce rehospitalisation risk
Heart Failure - CKD
- If starting ACE/ARNI/SGLT2i - Creatinine increase <50% from baseline acceptable as long as <266umol/L, or eGFR decrease <10% from baseline as long as eGFR ≥25ml
Heart Failure - Cancer Drugs Causing HF
If high risk for cardiotoxicity (CV risk factors, cardiotoxic medication or previous cardiotoxicity) - assessment by cardiologist prior to chemo
If LVEF drops by ≥10% or to ≤50% on anthracycline therapy, consider ACEi and BB
Dilated cardiomyopathy and Hypokinetic Non Dilated Cardiomyopathy
- DCM: LV dilatation and systolic dysfunction in the absence of abnormal loading conditions or significant CAD
- HNDC: LV or biventricular systolic dysfunction (LVEF ≤45%) in the absence of abnormal loading conditions or significant CAD
- Familial if two or more first or second degree relative has DCM/HNDC or first degree relative has SCD and autopsy proven DCM <50 years
- Genetic testing for all new diagnosis DCM and first degree adult relatives. Evaluation in adult relatives every 5 years (echo, ecg, consider CMR) where <50 or non-diagnostic abnormalities
Endomyocardial Biopsy
* When giant cell myocarditis, eosinophilic myocarditis, sarcoidosis, vasculitis, SLE, other autoimmune disorders or storage disorders suspected
* Minimum 5 samples, probably 7 (3 for pathology, 2 for infection (DNA PCR), 2 for RNA/viral replication
* Search for common cardiotropic viruses (parvovirus B19, HHV4, HHV6, enteroviris, adenovirus, coxsakie) where viral aetiology suspected. Viral mRNA for active replication where possible
* Further assessment may include CMV, HIV, Borriella Burgdorferi (Lyme), Coxiella Burnetti (Q fever), Trypanasoma Cruzi (Chagas), SARS-CoV2
* Quantify CD3,4,8,45 lymphocytes and CD-68 marcophages per mm2, anti-HLA-DR
* H&E staining, Massons Trichrome and Picrosirius Red for fibrosis, Congo red for amyloidosis
Therpauetic Options
* As for HFrEF
* LMNA, RBM20, PLN or FLN mutations - higher risk of SCD
* TTN mutation - higher rate of reverse remodelling but higher rate of atrial and ventrcular tachyarrhythmias
* Lyme - doxycycline
* Eosinophilic myocarditis, giant cell myocarditis, vasculitis, sarcoid and highly selected patients with inflammation of unknwn origin after MDT -> immunosuppressive therapy
