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🌱 來自: Huppert’s Notes
Heart Failure (HF)🚧 施工中
Heart Failure (HF)
• Etiology:
- Left-sided HF: Ischemic vs. nonischemic (e.g., arrhythmia or tachycardia-mediated; valvular disease; hypertension; drugs/toxins [chemotherapy, alcohol, stimulants]; infiltrative diseases [sarcoid, amyloid, hemochromatosis])
- Right-sided HF: Most often due to L-sided heart failure. Other causes: cor pulmonale (e.g., due to OSA, COPD, pulmonary arterial hypertension)
• Symptoms: Dyspnea, decreased exercise capacity, orthopnea, PND, nocturnal cough, fatigue, edema, abdominal bloating, early satiety
• Physical exam:
- Signs of congestion: S3, pulmonary crackles, Cheyne-Stokes respirations (deep/fast breathing cycling with apnea), jugular venous distention, hepatojugular reflex, hepatomegaly, pulsatile liver, lower extremity or sacral edema, IVC >2.1 cm and <50% collapsible on POCUS, B-lines on lung POCUS (Table 1.11)
TABLE 1.11 • Heart Failure: Signs of Congestion and Low Cardiac Output
- Signs of low cardiac output: Cool extremities, narrow pulse pressure, weak pulse, low SBP, altered mental status, reduced urine output (Table 1.11)
- Other notable findings: Irregular rhythm, tachycardia, displaced point of maximal impulse (PMI), murmurs (e.g., MR, AS, TR), S4, reduced EF on POCUS
• Classification:
- American College of Cardiology (ACC)/American Heart Association (AHA) stages and New York Heart Association (NYHA) functional classes:
• A – At risk of HF but no diagnosis
• B – Structural heart disease but without symptoms of HF
- NYHA I – No limitations on physical activity
• C – Structural heart disease with symptoms of HF
- NYHA II – Slight limitation on physical activity, ordinary activity does not cause symptoms
- NYHA III – Marked limitation on physical activity, ordinary activity causes symptoms
• D – Refractory HF requiring advanced therapies
- NYHA IV – Symptoms at rest and inability to participate in physical activity
• Diagnosis and work-up of heart failure:
- TTE: Do when euvolemic
• EF <40%: HF with reduced EF (HFrEF)
• EF >50% with diastolic dysfunction: HF with preserved EF (HFpEF)
• EF 40–50%: HF with mid-range EF (HFmrEF)
- CXR: Kerley B-lines, pleural effusions, prominent interstitial markings and alveolar opacities (“butterfly” pattern)
- Natriuretic peptides: Peptides released from the ventricles in response to stretch; elevated in acute and chronic HF but also increase with age, valvular disease, pulmonary hypertension, atrial arrhythmias (e.g., Afib), sepsis, CKD; false negative in obesity; useful to trend when patient’s baseline is known; has prognostic value in HF
• B-type natriuretic peptide (BNP): Uninterpretable in patients on sacubitril/valsartan (Entresto)
- Can be used to exclude diagnosis of HF (“Breathing Not Properly” Study 2003)
• <20 pg/mL = Rule out HF in asymptomatic outpatient with 96% NPV
• <40 pg/mL = Rule out HF in symptomatic outpatient with 96% NPV
• <50 pg/mL = Rule out Acute Decompensated HF (ADHF) in ED patient with 96% NPV
• <100 pg/mL = Rule out ADHF in ED with 90% NPV
- Can be used to identify HF:
• >400 pg/mL = Identify ADHF in ED with 86% PPV
• NT-proBNP: Useful in patients on sacubitril/valsartan (Entresto), <300 pg/mL useful to rule out ADHF in ED with 99% NPV (PRIDE study 2005)
- ECG: Look for signs of the cause of HF such as LVH, atrial arrhythmias, tachycardia, Q waves, active ischemia, pacing spikes; low voltage ECG with LVH on ECHO suggests infiltrative disease
- Troponin: Rule out active ischemia/ACS
- Sodium: Hyponatremia may occur due to volume retention, diuretic use, increased neurohumoral activation; Na+ <135 mEq/L associated with increased mortality in HF
- Assess severity of advanced heart failure: BUN/Cr, LFTs, lactate
- Assess for co-occurring conditions: HgA1c, lipid panel, TSH, iron studies
- Assess heart failure etiology: Stress test or coronary angiogram (depending on pre-test probability of CAD), HIV, Utox, Upreg; sometimes: SPEP/SFLC, cardiac MRI, endomyocardial biopsy
• Goals of hospitalization for ADHF:
- Decongestion: IV diuretics (see Table 1.12; typically start by doubling the patient’s home diuretic dose, ensure urination within 30 min), BID electrolytes (repletion of K >4 mmol/L and Mg >2 mg/dL), strict I/Os (goal negative >2 L daily or more if tolerated), diurese fully to euvolemia (i.e., no JVD, no crackles, IVC<2.1 cm and >50% collapsible), establish dry weight, trial on PO diuretics prior to discharge
TABLE 1.12 • Diuretics
- Define and reverse triggers: FAILURES mnemonic
• Forgetting (i.e., not taking heart failure medications)
• Arrhythmia (especially Afib)
• Ischemia
• Lifestyle (e.g., fluids, alcohol, salt, drugs)
• Up-regulation (e.g., in pregnancy, hyperthyroidism)
• Renal failure
• Embolism
• Stenosis (e.g., aortic stenosis, renal artery stenosis)
- Establish HF etiology: Reassess the reason that the patient has HF, determine if additional workup is required to define the etiology
- Initiate and up-titrate guideline-directed medical therapy (GDMT): Prior to discharge, try to get patients on the maximum tolerated ACEi/ARB/ARNI, BB, MRA, SGLT2 inhibitor as indicated (see later)
- Prevent rehospitalization: Schedule outpatient follow-up within 2 weeks to reassess volume exam, weight, labs, and medication tolerance
- Additional measures for severe ADHF:
• Noninvasive ventilation (NIV): Respiratory support for cardiogenic pulmonary edema (CPAP preferred, may trial bilevel NIV if hypercapnia present)
• Inotropes: Dobutamine or milrinone
• Pulmonary artery catheter (Swann-Ganz catheter): Continuously measures cardiac and pulmonary pressures and can calculate cardiac output; has not been shown to improve outcomes in ADHF (ESCAPE 2005), but has a role in some patients, particularly those with cardiogenic shock, mixed shock, RV failure due to pulmonary hypertension, or those with a challenging clinical assessment
- Treatment: Depends on the type of heart failure, as described below
HFrEF (EF <40%): Heart failure with reduced ejection fraction
• Lifestyle: Sodium restriction (<4 g/day), weight loss, smoking cessation, restrict alcohol, daily weights
• Symptomatic relief: Diuretics. Common recommendation for patients: If weight increases 3–5 lb, double diuretic and K+ repletion and call provider.
• Guideline-directed medical therapy for HFrEF: Medications with mortality benefit
- ACE inhibitor (ACEi) (SAVE 1992, SOLVD 1991)
• ~20% mortality reduction
• Recommended for EF <40%, NYHA I-IV
• Medications: Lisinopril (initial = 2.5–5 mg qD; goal = 40 mg qD). Alternatively, can use short-acting captopril (initial = 6.25 mg TID; goal = 50 mg TID) for easier titration inpatient then convert to once-daily lisinopril prior to discharge. Ratio captopril:lisinopril is 5:1 (captopril 50 mg TID = lisinopril 30 mg qD). Other options: benazepril, enalapril, ramipril
• Side effects: Hypotension, hyperkalemia, cough; careful in CKD, bilateral renal artery stenosis. Teratogen
- Angiotensin receptor blockers (ARBs) (Val-HeFT 2001; HEAAL 2009)
• ~15% mortality reduction
• Recommended for EF <40%, NYHA II–IV
• Medications: Losartan (initial = 12.5–25 mg; goal = 50 mg daily). Alternative for patients who do not tolerate ACEi (usually due to cough). Other options: valsartan, candesartan
• Side effects: Hypotension, hyperkalemia. Cough less common with ARBs than ACEi, but can occur. Teratogen
- Angiotensin receptor neprilysin inhibitor (ARNI) + ARB (sacubitril/valsartan [Entresto]) (PARADIGM-HF 2014)
• Up tô15% mortality reduction (over ACEi)
• Recommended for EF ≤35% and BNP ≥150 pg/mL or NT-proBNP ≥600 pg/mL or hospitalization
• Medications: Sacubitril/valsartan (initial = 24/26 mg BID; goal = 97/103 mg BID)
• Side effects: Hyperkalemia, angioedema. Do not combine with ACEi due to risk of angioedema
- Beta blockers (MERIT-HF 1999)
• ~35% mortality reduction
• Recommended for EF <40%, NYHA I–IV
• Medications: Carvedilol if hypertensive (initial 3.125 mg BID; goal = 25 mg BID) or metoprolol succinate if normotensive (initial = 12.5–25 mg qD; goal = 200 mg qD). When up-titrating can start with metoprolol tartrate q6h and then convert total daily dose 1:1 to metoprolol succinate at discharge
• Side effects: Hypotension, bradycardia
• Note: OK to continue home BB in stable patient with ADHF but do not start new BB until nearing euvolemia
- Mineralocorticoid receptor antagonists (MRAs) (RALES 1999, EMPHASIS-HF 2011)
• ~30% mortality reduction
• Recommended for EF ≤35%, NYHA II–IV
• Medications: Spironolactone (initial 12.5–25 mg qD; goal = 50 mg qD) or eplerenone (initial 25 mg qD; goal 50 mg qD, less gynecomastia)
• Side effects: Hyperkalemia. Do not use in CKD (Cr >2.5)
- SGLT2 inhibitors (DAPA-HF 2019)
• ~20% mortality reduction (over standard guideline-directed medical therapy [GDMT])
• Recommended for EF ≤40%, especially in patients with diabetes
• Medications: Dapagliflozin, canagliflozin, empagliflozin
• Less frequently used:
- Hydralazine-isosorbide dinitrate (A = HeFT 2004)
• Mortality reduction in persons who self-identified as Black (defined as of African descent). Beneficial if hypertensive and/or symptomatic despite GDMT, especially in African American patients
• Medications: Hydralazine 37.5–75 mg/Isordil 20–40 mg TID
- Ivabradine (SHIFT 2010)
• No mortality reduction
• SA node (funny current) blocker. Consider if HR<70 bpm after on maximum dose beta blocker
- Tolvaptan
• No mortality reduction
• Consider if severe hyponatremia (e.g., Na+ <120 mEq/L) despite fluid restriction. Initiated inpatient only with close sodium monitoring.
• Do not use for >30 days. Do not use in liver disease.
- Digoxin
• Unclear mortality benefit and potential for harm. Consider rarely if a patient is symptomatic despite GDMT.
• Dose 0.125 mg daily and maintain serum digoxin level <1 ng/mL
• Side effects: Dizziness, diarrhea, rash, confusion
• Procedures:
- Implantable cardioverter defibrillator (ICD): Consider if EF <35% after 3–6 months on medical therapy, for prevention of sudden cardiac death.
- Cardiac resynchronization therapy (CRT): Cardiac resynchronization (placement of a pacemaker with RV and LV leads to synchronize RV/LV contraction). Consider if EF <35%, NYHA II–IV, wide QRS (at least >120 ms; particularly with LBBB) after optimal medical therapy for 3–6 months.
- CardioMEMS: Implantable device that monitors changes in pulmonary artery pressure to allow clinicians to remotely titrate diuretics. Consider in patients with frequent hospitalizations, difficult to manage volume status.
• Advanced therapies: Consider in ACC/AHA Stage D/NYHA IV despite guideline-directed medical therapy:
- LVAD (Left Ventricular Assist Device): For bridge to transplant or destination therapy
- Heart transplant
- IV inotropic therapy: For symptom benefit/quality of life often as a bridge to transplant
- Palliative care: For symptom benefit/quality of life
HFmrEF (EF 40–50%): Heart failure with mid-range ejection fraction
• Definition: Between HFrEF and HFpEF. Recognized by most as a subcategory of HFreF
• Treatment: Unclear how exactly to manage given limited clinical trials directed at this population, but generally treated like HFrEF
HFrecEF (EF < 40% that improves to > 50%): Heart failure with recovered ejection fraction
• Definition: HFrEF that recovers over time with treatment
• Treatment: Unclear exactly how to manage but should NOT stop HFrEF therapies
HFpEF (EF > 50% + clinical symptoms of HF): Heart failure with preserved ejection fraction
• Treatment: Data less clear; unclear if standard HFrEF medications help this population, but trials have largely not shown benefit
• Mainstays of treatment:
- Management of hypertension
- Diuretics, lifestyle changes, consideration of remote hemodynamic monitoring (e.g., CardioMEMs) when difficult to control - MRAs: Spironolactone decreases hospitalizations (TOPCAT 2014; controversial study due to differences in subgroup analysis by region)
- SGLT-2 inhibitors may have benefit (trials on-going)