Heart Failure, Chronic

Heart failure (HF) results from inability of the heart to fill and/or pump blood sufficiently to meet tissue metabolic needs. HF may occur when adequate cardiac output can be achieved only at the expense of elevated filling pressures. It is the principal complication of heart disease. For acute HF, see “Heart Failure, Acutely Decompensated.”

HF is the preferred term over congestive HF as patients are not always congested (fluid overloaded). HF may involve the left heart, the right heart, or be biventricular. It is progressive—manifested by the remodeling (altered heart geometry) process.

The New York Heart Association (NYHA) classification is a subjective grading scale used for classifying a patient's functional status: NYHA I: asymptomatic; NYHA II: symptomatic with moderate exertion; NYHA III: symptomatic with mild exertion and may limit activities of daily living; NYHA IV: symptomatic at rest.

The American Heart Association (AHA)/American College of Cardiology (ACC) stages are a system to delineate the progression of HF: stage A: at risk for HF, no structural disease; stage B: structural disease, no HF symptoms; stage C: structural disease, HF symptoms; stage D: end-stage disease. 

An estimated 23 million individuals have HF worldwide. ~6.5 million people in the United States have HF; <1% in those age <50 years, increasing to 10% of those age >80 years

Primarily a disease of the elderly; 75% of hospital admissions for HF are for persons >65 years of age.

HF with reduced ejection fraction (HFrEF) or systolic HF: an inotropic abnormality, often from myocardial infarction (MI) or dilated cardiomyopathy (CM), resulting in diminished systolic emptying (ejection fraction [EF] ≤40%)

HF with preserved EF (HFpEF) or diastolic HF: a compliance abnormality, often due to hypertensive CM, in which the ventricular relaxation is impaired (EF ≥50%)

Borderline HFpEF (EF 41–49%): mild systolic dysfunction, clinically behaves like HFpEF

Improved HFpEF (EF >40%): previously HFrEF, with improvement in systolic function

Myocarditis and CM: alcoholic, viral, drugs, muscular dystrophy, infiltrative (e.g., amyloidosis, sarcoidosis), postpartum , infectious (e.g., Chagas disease, HIV), hypertrophic CM (HCM), inherited familial dilated CM

Valvular and vascular abnormalities: valvular stenosis or regurgitation, rheumatic heart; renal artery stenosis, usually bilateral, may cause recurrent “flash” pulmonary edema.

Chronic lung disease and pulmonary HTN

Arrhythmias (atrial fibrillation and other tachyarrhythmias, high-grade heart block, frequent PVCs)

Other: high-output states: hyperthyroidism, anemia; cardiac depressants (β-blocker overdose), stress induced; Iatrogenic volume overload (extreme overload in patients with normal hearts and kidneys); Idiopathic: 20–50% of idiopathic dilated CM are familial.

Dyspnea on exertion: cardinal sign of left-sided HF. Deteriorating exercise capacity: easy fatigued, general weakness

Nocturnal nonproductive cough, orthopnea, and paroxysmal nocturnal dyspnea; sometimes frothy or pink sputum. Wheezing, especially nocturnal, in absence of history of asthma or infection (cardiac asthma); Cheyne-Stokes respirations

Anorexia and/or fullness or dull pain in right upper quadrant (hepatic congestion). Nausea and poor appetite may indicate advanced HF.

Increased filling pressures: rales and sometimes wheezing, peripheral edema, S₃ gallop, hepatomegaly, jugular venous distention, hepatojugular reflux, ascites

Remodeling: enlarged or displaced point of maximal impulse

Poor cardiac output: hypotension, pulsus alternans, tachycardia, narrow pulse pressure, cool extremities, cyanosis

β-Type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-BNP): helpful in acute setting to differentiate the cause of dyspnea ( <100 essentially rules out HF). A BNP level in those with risk factors for developing HF or with structural heart disease but no symptoms of HF can help predict the development of symptomatic HF (1)[A]. Pulmonary embolism, renal failure, and acute coronary syndromes may elevate BNP.  Sacubitril/valsartan can raise BNP levels but has less impact on NT-proBNP levels. Obesity may lower BNP levels. The use of BNP-guided therapy in chronic HF and acutely decompensated HF is not well established, although a predischarge BNP can predict risk of readmission and survival (1)[A]. 

Lab findings: respiratory alkalosis, azotemia, decreased erythrocyte sedimentation rate, proteinuria, elevated creatinine (cardiorenal syndrome), dilutional hyponatremia (poor prognosis), hyperbilirubinemia.

Chest x-ray (changes lag clinical symptoms): increased heart size, vascular redistribution (cephalization) with “butterfly” pattern of pulmonary edema, interstitial and alveolar edema, Kerley B lines, and pleural effusions. Findings of pulmonary edema may be absent in long-standing HF.

Echocardiogram: most useful test to determine LVEF, which is critical for proper diagnosis and management of HF, as well as RV function, diastolic dysfunction, ventricular size, wall thickness, and valvular abnormalities; repeated if change suspected in underlying cardiac status.

Other tests: Nuclear imaging to estimate ventricular size, assess for ischemia or infarction, amyloidosis, and systolic function. Cardiac MRI in select circumstances: suspicion of cardiac sarcoidosis, arrhythmogenic RV CM, acute myocarditis, amyloidosis, and hemochromatosis. Cardiac catheterization is important for excluding CAD as an etiology in the setting of risk factors. Endomyocardial biopsy only in special circumstances (e.g., suspected giant cell myocarditis)

ACE-I: used to decrease afterload, increase survival, improve symptoms, and exercise capacity in all NYHA classifications; benefit greatest for patients with systolic dysfunction and post-MI. Number needed to treat (NNT) ~25 per year for mortality. All ACE-Is are considered equally effective. Initiate at low doses and titrate as tolerated to target doses.

• Starting dose: captopril: 6.25mg PO TID; enalapril: 2.5mg PO BID; lisinopril: 2.5-5mg daily; ramipril: 1.25mg daily

Angiotensin receptor blockers (ARBs): indicated if intolerant to ACE-Is. Avoid combination of ACE-I and ARB.

• Starting dose: candesartan: 4-8mg PO daily; losartan: 25-50mg PO daily; valsartan: 40mg PO BID

β-Blockers: used in systolic or diastolic HF; Initiate in hemodynamically stable/compensated patients at low dose and titrate upward slowly.); NNT = 25/year for mortality. Mortality decreased in systolic HF; evidence for titration to heart rate (HR) rather than specific dose.

• Starting dose: carvedilol: 3.125mg PO BID; metoprolol succinate ER: 12.5mg/day PO; bisoprolol: 1.25 to 10mg once daily

Sacubitril/valsartan (Entresto): an angiotensin receptor and neprilysin inhibitor (ARNI), shown to reduce the risk of CV death and HF hospitalizations in patients with HFrEF. Recommended dose: 24/26mg or 49/51mg PO BID to a target of 97/103 PO BID. Patients with HFrEF and NYHA class II and III who tolerate an ACE-I or ARB with CrCl >30, replacement by an ARNI is recommended to reduce morbidity and mortality (NNT to prevent one CV death over 3.5 years: 31). ACE-Is should be discontinued at least 36 hours prior to starting ARNIs. Most common adverse effects: hypotension, angioedema, renal insufficiency​​​​​​

Serum glucose cotransporter-2 (SGLT-2) inhibitors, Dapagliflozin and Empagliflozin, medications used for type 2 diabetes mellitus, showed improvement in worsening HF or CV death in patients with EF≤40% and NYHA II/IV, irrespective of diabetes, and may decrease overall death (NNT 50 to 60/year) based on randomized clinical trials, DAPA-HF and EMPEROR-Reduced. Recommended dose for both is 10 mg PO daily. Based on evidence, FDA approved the use of SGLT-2 inhibitors for the treatment of HFrEF. Adverse effects: urogenital infections, ketoacidosis, reduced blood pressure, enhanced diuresis  (2)[A]​

Vericiguat, a guanylate cyclase simulator, shown to reduce the risk of death from CV causes or hospitalization for HF with a hazard ration of 0.9 (95% CI 0.82–0.98). FDA approved in patients with an EF≤45%, recent HF hospitalization, or need for IV diuretics based on the VICTORIA trial  (1)[B]

Diuretics are helpful to manage volume overload/reduce preload.

• Furosemide (Lasix): 40-120 mg/day PO divided dose; bumetanide (Bumex): 0.5mg-10 mg/day IV/PO divided dose; torsemide (Demadex): 10-200 mg/day PO divided dose

• Metolazone (Zaroxolyn): 2.5 to 20 mg/day PO divided dose; hydrochlorothiazide: 12.5 to 100 mg/day PO divided dose; chlorothiazide (Diuril): 250 to 2,000 mg/day IV/PO divided dose

• Spironolactone, eplerenone (improve mortality when added to standard therapy in NYHA class II to IV + EF <35%): spironolactone 12.5-25 mg/day PO; maximum 50 mg/day PO; eplerenone 25-50 mg/day; caution regarding hyperkalemia and chronic kidney disease (CKD)

Digoxin: reduces symptoms, without positive effect on mortality. In patients with preserved renal function (CrCl >50 mL/min), the recommended dose is 0.125mg/day.

Combination of isosorbide dinitrate and hydralazine  (20 mg/37.5mg PO TID) is effective for improving survival and reducing hospitalizations in African Americans and can be used if the patient is unable to take an ACE-I/ARB.

Ivabradine (Corlanor) can be considered in NYHA II and III HF, EF ≤35%, on maximally tolerated β-blockers with HR >70 to reduce hospitalization  (1)[B]. Contraindication: ADHF, hypotension (<90/50 mm Hg), severe hepatic impairment, pacemaker–dependence, bradyarrhythmias, or strong CYP3A4 inhibitors. Do not administered to patients currently in atrial fibrillation (AF) and discontinued if AF develops.

In HFpEF, no therapy has improved survival. ARBs and spironolactone can be used to potentially reduce hospitalizations (1)[A].

CRT recommendation: sinus rhythm with a QRS width ≥150 ms due to left bundle branch block (LBBB), LVEF ≤35%, persistent mild to moderate HF despite goal directed medical therapy (GDMT), reduced LVEF and chronic RV pacing or with bradyarrhythmias and an anticipated need for a pacemaker.

CRT consideration: LVEF ≤35%, sinus rhythm, QRS width >150 ms, non-LBBB pattern, and NYHA II or ambulatory NYHA IV symptoms. If QRS width >150 ms due to LBBB pattern, consider CRT in ambulatory NYHA class IV patients. If QRS width is between 120 and 150 ms with LBBB pattern, consider CRT in NYHA II to IV, despite GDMT.

ICDs recommendation: primary prevention in patients with nonischemic and ischemic CM, at least 40 days post-MI; LVEF ≤35%, NYHA class II or III HF, or LVEF ≤30%, NYHA I HF; and on optimal medical therapy and >1 year estimated survival; generally not indicated in end-stage HF

Heart valve surgery for defective heart valve; mitral valve repair if mitral regurgitation (MR) is the primary issue and not functional

Advanced therapies such as cardiac transplantation and LV assist device (LVAD) implantation can be considered in patients with HF refractory. Cardiac transplantation: considered for patients ≤70 years old with a predicted 1-year survival worse than that afforded by transplantation. ILVAD implantation indications are similar but evolving.

Admission: hemodynamic/respiratory compromise, mental status change, acute renal injury, significant volume overload, electrolyte abnormalities (e.g. hyponatremia).

Discharge: subjective improvement, euvolemia on assessment, improved vitals, , outpatient education performed

I50.9 Heart failure, unspecified

I50.1 Left ventricular failure

I50.22 Chronic systolic (congestive) heart failure

I50.32 Chronic diastolic (congestive) heart failure

I50.42 Chronic combined systolic and diastolic hrt fail

48447003 chronic heart failure (disorder)

111283005 Chronic left-sided heart failure (disorder)

10335000 Chronic right-sided heart failure (disorder)

88805009 Chronic congestive heart failure

424404003 decompensated chronic heart failure (disorder)

441481004 Chronic systolic heart failure

441530006 Chronic diastolic heart failure

153941000119100 Chronic combined systolic and diastolic heart failure (disorder)

Have patients weigh themselves and report weight gains of >2lb in a day or 5lb above dry weight.

β-Blockers, ACE-I, and aldosterone antagonists are the core medications for management.