Heart Failure Management (Canadian Cardiovascular Society 2012 Guidelines)

Rational

Proper management of patients suffering from HF can have significant mortality and morbidity benefits for the patient.

Screening

Not routinely done

Diagnostic Criteria

Clinical diagnosis based on the presence of a constellation of signs and Sx including orthopnea, SOB on exertion, B/L pedal edema, respiratory crackles, ascites.  NP can be used when there is diagnostic uncertainty.  Scoring systems are commonly used.

Clinical scoring system for AHF Dx

Classification

Acute or chronic variants

Preserved (HF-PEF) or reduced ejection fraction (HF-REF)

For chronic HF, use NYHA functional classification:

  1. Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
  2.  Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
  3. Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m). Comfortable only at rest.
  4. Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Risk Factors

FHx of cardiomyopathy or sudden death, EtOH abuse, sarcoidosis, amyloidosis, HIV infection, neuroendocrinopathies, rheumatologic diseases, nutritional deficiencies, OSA, HTN, previous MI

Physical Exam

Vitals, Wt, Volume status, CVS, Resp, Abdo

Investigations

Acute:

EKG and CXR within 2 hours of presentation

Echocardiogram within 72 hours

CBC, Cr, BUN, Lytes, Trop

BNP if available can be useful for prognostication

Chronic:

EKG, CXR, Echocardiogram, CBC, Cr, Lytes, TSH, FBS, Urinalysis

If indicated: cardiopulmonary exercise testing, MRI, CT, Coronary angiography in patients who may benefit from revascularization

Management

HF-PEF:

  • treat to hypertension guidelines
  • Diuretics for Sx relief

HF-REF:

  • ACE-I (or ARB if intolerant, especially important following an MI) and a beta-blocker (bisoprolol, metoprolol, or carvedilol)
  • Use diuretics to control pulmonary congestion and peripheral edema.
  • If NYHA Class II-IV consider MRA (e.g. spironolactone) or, if intolerant consider adding an ARB.  May also use digoxin, hydralazine/nitrates.
  • To clarify: in the situation of HF-REF, an ACE-I and ARB may be used in combination, but an ACE-I or ARB abd beta-blocker is preferred.  Also, an ACE-I, ARB, and MRA should not be used all together.

Only use daily ASA in patients with clear indications for secondary prevention of cardiovascular events.

Consider ICD in patients who have a history of sustained ventricular arrhythmia, who have ischemic cardiomyopathy, or who have REF (≤35%) and NYHA class II-III.  (Simpler: if LVEF <30%, consider referral for ICD)

If QRS >120 ms, consider CRT referral.

Treatment

Use NIV only in patients with respiratory distress not responsive to medical therapy.  Oxygen supplementation only in hypoxic patients, to keep O2 sat >90%.

Oral and intravenous diuretics is the most important intervention.  Loop diuretics can be combined with thiazides and spironolactone with beneficial synergy.  High-dose bolus IV therapy of loop diuretics has been shown to be beneficial in AHF without significant adverse effects.

In HF with preserved ejection fraction (>40%) and a fib, a rate-controlling CCB can be used safely.  Also, beta-blockers may be continued in patients with AHF who are not bradycardic or hypotensive, without increased risk of adverse events.

Vasodilators, titrated to a SBP >100 can be used to relieve dyspnea in hemodynamically stable patients.  Nitroglycerin has the most evidence, followed by nesiritide and nitroprusside.

Tolvaptan can be used in patients who are hyponatremic (< 130 mmol/L) and have ongoing congestion Sx.

Prognosis

Typically a chronic, progressive disease.

References

The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Acute and Chronic Heart Failure. Society Guidelines. Canadian Journal of Cardiology, Vol XX, 2012.  http://www.onlinecjc.ca/article/S0828-282X(12)01379-7/fulltext