HEART FAILURE





























  • Reference [17]
AHA Heart Failure Subtypes Based on EF
HFrEF (HF with reduced EF)
  • LVEF ≤ 40%
HFimpEF (HF with improved EF)
  • Previous LVEF ≤ 40% and a follow-up measurement of LVEF > 40%
HFmrEF (HF with mildly reduced EF)
  • LVEF 41 - 49%
  • Evidence of spontaneous or provokable increased LV filling pressures (eg, elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement)
HFpEF (HF with preserved EF)
  • LVEF ≥ 50%
  • Evidence of spontaneous or provokable increased LV filling pressures (eg, elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement)


Reference [1]
NYHA class Symptoms
I No limitation of physical activity. Ordinary physical activity does not result in symptoms.
II Slight limitation of physical activity. Comfortable at rest, but ordinary activity results in fatigue, palpitations, or shortness of breath.
III Marked limitation of activity. Comfortable at rest, but less than ordinary activity results in fatigue, palpitations, or shortness of breath.
IV Symptoms at rest. Unable to carry on any physical activity without discomfort. Any physical activity results in discomfort.

  • Reference [17]
AHA Stages of Heart Failure
Stage A - At risk for HF
  • At risk for HF but without symptoms, structural heart disease, or cardiac biomarkers of stretch or injury (e.g. patients with hypertension, atherosclerotic CVD, diabetes, metabolic syndrome and obesity, exposure to cardiotoxic agents, genetic variant for cardiomyopathy, or positive family history of cardiomyopathy)
Stage B - Pre-HF
  • No symptoms or signs of HF and evidence of 1 of the following:
    • Structural heart disease (defined as any of the following):
      • Reduced left or right ventricular systolic function
      • Ventricular hypertrophy
      • Chamber enlargement
      • Wall motion abnormalities
      • Valvular heart disease
    • Evidence for increased filling pressures (by invasive or noninvasive measures)
    • Patients with risk factors and increased levels of BNPs or persistently elevated cardiac troponin
Stage C - Symptomatic HF
  • Structural heart disease with current or previous symptoms of HF
Stage D - Advanced HF
  • Marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize guideline-directed medical therapy




  • Reference [7]
Chest X-ray findings in heart failure
Finding Sensitivity Specificity
Cardiomegaly 63.6% 70.5%
Overall radiographic interpretation of HF 53.3% 86.3%
Interstitial edema 29% 92.6%
Kerley B lines 23.4% 95.8%
Bilateral pleural effusion 19.6% 94.7%
Peribronchial cuffing 16.8% 95.8%
Alveolar edema 12.1% 98.9%




  • Reference [4,12]
BNP / NT-proBNP Levels in Heart Failure
Condition BNP level NT-proBNP level
Rule in acute heart failure > 100 pg/ml
  • < 50 years: > 450 pg/ml
  • 50 - 75 years: > 900 pg/ml
  • > 75 years: > 1800 pg/ml
Rule out acute heart failure < 100 pg/ml < 300 pg/ml
Rule out chronic heart failure < 35 pg/ml < 125 pg/ml


  • Reference [1,11]
Factors that may affect BNP and NT-proBNP values
Factor Comment
Age
  • Levels increase naturally with age
Female sex
  • Women have higher levels on average
Kidney disease
  • BNP and NT-proBNP may be elevated in patients with kidney disease
  • Levels begin to rise when CrCl falls to < 60 ml/min
  • NT-proBNP levels may be more sensitive to kidney disease than BNP levels
Heart conditions
  • Heart conditions other than heart failure may cause levels to rise. Examples include acute coronary syndrome, pericardial disease, atrial fibrillation, myocarditis, cardiac surgery, and cardioversion.
Pulmonary disease
  • Pulmonary diseases including ARDS, severe COPD, pulmonary embolism, and primary pulmonary hypertension can cause levels to rise
Obesity
  • Patients with obesity tend to have lower levels on average. In one study, a BNP of > 54 pg/ml was 90% sensitive for heart failure in patients with a BMI ≥ 35.
High output states
  • BNP and NT-proBNP levels may be elevated in high output states (e.g. sepsis, cirrhosis, hyperthyroidism)



Reference [1,2]
EF value Interpretation
≥ 50%
  • Normal
  • Patients with HFpEF may have an EF in this range
41 - 49%
  • Decreased, but does not typically cause symptoms
  • Patients with HFpEF may have an EF in this range
  • Patients with HFrEF that has improved may have an EF in this range
≤ 40%
  • Decreased function that may cause symptoms
  • Patients with HFrEF have an EF in this range



  • References [14,15,16]
Echocardiographic measures of diastolic function
Finding Measurements
Normal
  • Under normal conditions, the E wave is slightly greater than the A wave
  • E/A ratio: 0.75 - 1.50
  • E/a' ratio: < 8
  • Deceleration time: 140 - 240 msec
  • IVRT: ∼ 70 ms (40 year old)
Supernormal
  • Young, physically fit people sometimes have a vigorous ventricular recoil right after systole. This can cause the E value to increase. Supernormal filling should be considered in physically fit patients without signs of heart failure.
  • E/A ratio: > 2
  • E/a' ratio: < 8
  • Deceleration time: 140 - 240 msec
  • IVRT: ∼ 70 ms (40 year old)
Grade 1 diastolic dysfunction
(Impaired relaxation)
  • In grade 1 diastolic dysfunction, ventricular wall stiffness impairs early filling, and the E value decreases. More blood is present in the atrium during late diastole, and this causes the atria to contract harder, increasing the A wave.
  • Grade I diastolic dysfunction is a common finding on echocardiography. It occurs normally with aging and has a prevalence of 25% in people ≥ 40 years old.
  • E/A ratio: < 0.8
  • E/a' ratio: < 8
  • Deceleration time: ≥ 240 ms
  • IVRT: > 100 ms
Grade 2 diastolic dysfunction
(Pseudonormal filling)
  • In grade 2 diastolic dysfunction, progressive ventricular stiffness starts to cause congestion in the atrium, and the resting atrial pressure rises. The increase in atrial pressure creates a gradient that drives early ventricular filling, and the E wave increases. This causes the E/A ratio to return to the normal range (0.75 - 1.5), hence the name "pseudonormal."
  • To distinguish grade II dysfunction from normal diastolic function, the Valsalva maneuver can be performed during echocardiography. The Valsalva maneuver decreases venous return to the left atrium, and atrial pressure drops. Patients with true diastolic dysfunction will have a drop in their E/A ratio to below 1 with Valsalva. An E/e' ratio of > 14 also indicates true diastolic dysfunction, and a ratio of 8 - 12 is suggestive.
  • E/A ratio: 0.75 - 1.5
  • E/a' ratio: ≥ 8
  • Deceleration time: 140 - 240 msec
  • IVRT: < 90 ms
Grade 3 diastolic dysfunction
(Reversible restrictive)
  • In grade 3 diastolic dysfunction, progressive congestion causes the resting atrial pressure to continue to rise. The E wave increases, and the A wave decreases.
  • Grade 3 diastolic dysfunction is distinguished from grade 4 dysfunction by the fact that it is reversible, which means that the E/A ratio returns to the pseudonormal range if the Valsalva maneuver is performed.
  • E/A ratio: ≥ 2
  • E/a' ratio: ≥ 8
  • Deceleration time: < 140 msec
  • IVRT: ≤ 70 ms
Grade 4 diastolic dysfunction
(Irreversible restrictive)
  • Grade 4 diastolic dysfunction is similar to grade 3 dysfunction except that the Valsalva maneuver does not return the E/A ratio to the pseudonormal range
  • E/A ratio: ≥ 2
  • E/a' ratio: ≥ 8
  • Deceleration time: < 140 msec
  • IVRT: ≤ 70 ms



  • Reference [1,2,3,17]
AHA 2022 HFrEF Treatment Recommendations
STEP 1 - All patients with Stage C HF and LVEF ≤ 40%
  • Medications below may be started simultaneously at low doses or sequentially, with sequence guided by clinical or other factors, without need to achieve target dosing before initiating next medication

  • RAAS inhibitor therapy (one of the following):

  • Beta blocker

  • Aldosterone antagonist
  • SGLT2 inhibitor therapy (dapagliflozin, empagliflozin)
    • Consider dapagliflozin or empagliflozin in patients who meet all of the following criteria:

  • Diuretics as needed
    • Start with a loop diuretic and titrate dose over days to weeks to relieve fluid overload. Monitor blood pressure, electrolytes, and renal function.
    • If reaching a high dose of loop diuretic (e.g. 80 mg furosemide twice daily), consider one of the following:
STEP 2 - After optimizing therapy, reevaluate patient

  • Asymptomatic with LVEF > 35%
    • Continue guideline-directed medical therapy

  • Symptomatic with LVEF > 40%
    • Continue guideline-directed medical therapy with serial reassessment and dosage optimization

  • Symptomatic with LVEF ≤ 40%
    • NYHA III-IV and Black
    • NYHA I-III, LVEF ≤ 35%, and estimated survival > 1 year
      • Evaluate for ICD
    • NYHA II-III or ambulatory NYHA IV, LVEF ≤ 35%, NSR and QRS ≥ 150 ms with LBBB
      • Evaluate for CRT

  • Other therapies that may be considered include:
Aldosterone antagonist therapy (spironolactone, eplerenone)
  • An aldosterone antagonist is recommended in patients who meet all of the following criteria:
    • NYHA class II - IV heart failure
    • GFR > 30 ml/min
    • Potassium level < 5.0 mEq/L

  • Monitoring
    • Monitor electrolytes (especially potassium), and kidney function 2 - 3 days following initiation, and at 7 days after initiation or drug titration. After that, check monthly for 3 months and then every 3 months from then on.
    • If serum potassium cannot be maintained at < 5.5 mEq/L, aldosterone antagonist should be discontinued to avoid life-threatening hyperkalemia
    • See aldosterone antagonist review and aldosterone antagonist dosing for more

  • AHA recommended dosing
    • Spironolactone
      • Starting: 12.5 - 25 mg once daily
      • Maintenance: 25 mg once daily OR 25 mg twice a day
      • Average dose achieved in trials: 26 mg once daily
      • Increase dose at intervals of 2 weeks as tolerated
    • Eplerenone
      • Starting: 25 mg once daily
      • Maintenance: 50 mg once daily
      • Average dose achieved in trials: 42.6 mg once daily
      • Increase dose at intervals of 2 weeks as tolerated
Ivabradine (Cordalor®)
  • Ivabradine may be beneficial in patients who meet all of the following criteria:
    • Normal sinus rhythm with a resting heart rate ≥ 70 bpm on maximally tolerated beta blocker therapy
    • NYHA class II - III heart failure with EF ≤ 35%

  • See ivabradine review and ivabradine dosing for more
Vericiguat (Verquvo®)
  • In selected high-risk patients with HFrEF and recent worsening of HF already on guideline-directed medical therapy, vericiguat may be considered to reduce HF hospitalization and cardiovascular death
  • Vericiguat was approved based on the results of the VICTORIA study. Main inclusion criteria were NYHA class II - IV heart failure and an EF < 45%.
  • See vericiguat review and vericiguat dosing for more
Digoxin
  • In patients with symptomatic HFrEF despite GDMT (or who are unable to tolerate GDMT), digoxin might be considered to decrease hospitalizations for HF [17]