HF Sally Cahan Flashcards
Definition of HF
HF is a clinical syndrome with current or prior symptoms and or signs caused by a structural and/or functional cardiac abnormality and corroborated by at least one of the following:
- elevated natriuretic peptide levels
- objective evidence of cariogenic, pulmonary or systemic congestion
Heart failure is a clinical syndrome with typical symptoms (breathlessness, ankle swelling, and fatigue) and signs (elevated jugular venous pressure, basal crepitations, and peripheral oedema). Heart failure is caused by a structural and/or functional abnormality that produces raised intracardiac pressures and/or inadequate cardiac output at rest and/or at exercise (NICE)
Stages of HF
Stage A (at risk) - patients at risk for HF, but without current or prior symptoms or signs of HF and without structural cardiac changes or elevated biomarkers of heart disease
Stage B (pre-HF) - patients without current or prior symptoms or signs of HF with evidence of one of the following:
-structural HD
- abnormal cardiac fn
- elevated natriuretic peptide or cardiac trop levels
Stage C (HF) - patients with current or prior symptoms and/or signs of HF caused by a structural and/or functional cardiac abnormality
Stage D (Advanced HF) - Severe symptoms and/or signs of HF at rest, recurrent hospitalisation despite GDMT (guideline-directed medical therapy), refractory or intolerant to GDMT, requiring advances therapies; transplantation, mechanical circulatory support, or palliative care
Classification by EF (NICE,ACC)
Heart failure is classified by measurement of the left ventricular ejection fraction (LVEF).
- HF with reduced EF (LVEF<40%)
- HF with mildly reduced EF HFmrEF (41-49%)
-HF with preserved EF (LVEF>50%) People who have symptoms of heart failure, cardiac structure or function abnormalities, and/or raised levels of natriuretic peptides with a preserved LVEF of 50% or more, have heart failure with preserved ejection fraction (HF-PEF):
What is acute vs chronic HF?
Acute and chronic heart failure are terms used to define the rate of onset and duration of symptoms:
Acute heart failure may be a new presentation of heart failure or, may be, deterioration or ‘decompensation’ in a person with existing chronic heart failure.
The overall prognosis has improved over recent decades but remains poor — often with a poor quality of life.
Symptomatic severity:
The New York Heart Association (NYHA) has a functional classification of heart failure based on severity of symptoms and limitation of physical activity [Yancy, 2017; ESC, 2021]:
Class I — no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness, or palpitations.
Class II — slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.
Class III — marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.
Class IV — unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken discomfort is increased.
Chronic heart failure can be classified according to:
- EF
- Symptom severity
- the time-course of HF
What is the role of echo in HF?
NICE guidelines advocate echo if clinical suspicion of HF and NTpBNP > 400ng/L
Aetiology – ischaemic, dilated, restrictive, valvular heart disease, pulmonary hypertension, congenital abnormalities
Surveillance: bicuspid valves, familial CM, cardio-oncology
Follow up
What is dilated cardiomyopathy?
Dilated/impaired contraction or LV (and/or RV)
Aetiology: idiopathic, ischaemic, familial, genetic, viral, immune, toxins, pregnancy
What are the 4 pillars of HF?
- ACE-i/ ARNI
- BB
- MRA
Dapagliflozin/ Empagliflozin - Loop diruetic for fluid retention
For HFrEF
What is valve disease?
Thickened or leaky valves
Causes of valve disease
ageing
congenital
MI - causes ischaemic damage to heart muscle
rheumatic fever
endocarditis
hypertension
cardiomyopathy
Management of patients with aortic regurg
-> Significant enlargement of ascending aorta?
Y -> surgery
N -> Severe AR - Y - Symptoms -> Y -> Surgery
N -> LVEF <50% -> Surgery
N -> Follow up
Aortic regurgitation surveillance
Asymptomatic severe AR + normal LV: annual echo
Asymptomatic severe AR + LV dilation/EF abnormal: 3-6 monthly echo
Mild to moderate AR: annual review, 2 yearly echo
BNP monitoring
If the ascending aorta is dilated (>40mm) this should also be monitored with echo/mri
Management of patients with sever aortic stenosis
Symptoms -> Y -> Intervention likely to be of benefit? (frailty, comorbidity) -> Heart team evaluation -> TAVI or open repair/ replacement
Symptoms -> N-> LVEF <50% -> Y - open repair/TAVI
-> N-> physical active -> Y -exercise test -> symptoms or sustained fall in BP below baselines -> open repair/tavi
Not physically active and high procedural risk -> educated patient and reassess in 6 mo
ADVANCED HEART FAILURE
All the following criteria must be present despite optimal medical treatment:
1. Severe and persistent symptoms of heart failure [NYHA class III (advanced) or IV].
*2. Severe cardiac dysfunction defined by at least one of the following:LVEF ≤30%
*Isolated RV failure (e.g., ARVC)
*Non-operable severe valve abnormalities
*Non-operable severe congenital abnormalities
*Persistently high (or increasing) BNP or NT-proBNP values and severe LV diastolic dysfunction or structural abnormalities (according to the definitions of HFpEF).
3. Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned visit or hospitalization in the last 12 months.
4. Severe impairment of exercise capacity with inability to exercise or low 6MWT distance (<300 m) or pVO2<12 mL/kg/min or <50% predicted value, estimated to be of cardiac origin.
ADVANCED HEART FAILURE MANAGEMENT
Transplant NHS Blood and Transplant Heart Allocation Policy:
Super-urgent (days – weeks)
Urgent (months)
Non-urgent (years)
Long term mechanical circulatory support (bridge)
LVAD
Short term mechanical circulatory support (bridge)
ECMO ( central / peripheral)
Impella / IABP
Centrimag BiVAD
Temporary RVAD
