MANAGEMENT UPDATE OF HEART

FAILURE
DR.DIPTTA BHATTACHARJEE
Trainee medical officer
Department of medicine , CIMCH
 CONTENT

• Definition
• HFrEF
• HFmrEF
• HFpEF
• Acute Heart failure
• Comorbidities
• Management
 WHAT’S NEW

• A change of the term ‘heart failure with mid-range ejection fraction’ to

heart failure with mildly reduced ejection fraction’ (HFmrEF).
• A new simplified treatment algorithm for HFrEF.
• The addition of a treatment algorithm for HFrEF according to phenotypes.
• Modified classification for acute HF.
• Updated treatments for most non-cardiovascular comorbidities
including diabetes, hyperkalemia, iron deficiency anemia .
• Primary prevention ICD in non ischemic cardiomyopathy now IIa
• Emphasis on broad LBBB in selecting patients for CRT
 • Prevalence of heart failure in developed countries has
increased over time .
• 26 million number of heart failure patients worldwide
• 8 /1000 people aged 50-59 years are affected By HF
PREVALANCE
• 66/1000 men aged 80-89 years affected by HF
• 79/1000 women aged 80-89 years are affected by HF
• 74% heart failure patients suffering from at least 1
comorbidity .
 DEFINITION OF HEART FAILURE

According to ESC
• Heart failure is not a single pathological diagnosis, but a clinical syndrome
consisting of
Cardinal symptoms ( e.g. breathlessness , ankle swelling and fatigue that may
be accompanied by signs ( e.g. elevated jugular venous pressure , pulmonary
crackles and peripheral oedema .

• It is due to a structural and or functional abnormality of the heart that results

in cardiac function is insufficient to meet the metabolic needs of the tissues at
rest and/or during exercise .
 T ER MI N O L OG Y

• Heart failure with reduced ejection fraction , mildly

reduced ejection fraction and preserved ejection fraction .
 SYMPTOMATIC
SEVERITY OF HF
CLASSES OF RECOMMENDATION
 ↑Heart failure

↑Oxygen
consumption ↓Cardiac
/myocardial output
remodeling

↑Sympathetic
activation of
↑Afterload
adrenergic
system/rass

↑Vasoconstri
↑Peripheral ction/sodium
resistance and water
retention

VICIOUS CYCLE OF HEART FAILURE

DIAGNOSTIC
ALGORITHM
FOR HEART
FAILURE
 12-lead ECG

R E CO MME N D E D Chest radiography

D I A G N O S T I C T ES T S
I N A L L PAT I E N T S
W I T H S U S P E CT E D
H E A RT FA I L U R E BNP/N-terminal –proBNP

Transthoracic echocardiography

Routine blood tests for comorbidities including full

blood count , urea ,electrolytes , thyroid function ,
fasting glucose and HbA1c , lipids , iron status
 GENERAL MEASURES IN HF
MANAGEMENT

It is recommended that HF patients are enrolled in a multidisciplinary HF management

programmed to reduce the risk of HF hospitalization and mortality (IA)

• Education : Explanation of nature of disease , treatment and self-help strategies

• Diet : good general nutrition salt and fluid restriction & weight reduction for the obese
• Smoking cessation
• Alcohol : elimination of alcohol consumption specially in alcohol induced
cardiomyopathy .
• Exercise : regular moderate aerobic exercise within the limit of symptoms
• Vaccination :Consideration of influenzas and pneumococcal vaccination
THE FIVE PILLARS OF
H E A RT FA I L U R E
PHARMACOTHERAPY

•There are three major goals

of treatment for patents with
HFrEF
 Reduction in mortality .
 Prevention of recurrent
hospitalization due to
worsening HF and,
 Improvement in clinical
status functional capacity
and quality of life .
 MANAGEMENT
A L G O R I T H M O F H E A RT
FA I L U R E
WITH REDUCED
EJECTION FRACTION
 D R U G S R E C O M M E N D E D I N A L L PAT I E N T S W I T H H E A RT
FA I L U R E W I T H R E D U C E D E J E C T I O N F R A C T I O N

 Pharmacological treatments indicated in patients with (NYHA class II–IV)

heart failure with reduced ejection fraction (LVEF <_40%)

An ACE-I is recommended for patients with HFrEF to reduce the risk of HF

hospitalization and death. (IA)
A beta-blocker is recommended for patients with stable HFrEF to reduce the
risk of HF hospitalization and death. (IA)
An MRA is recommended for patients with HFrEF to reduce the risk of HF
hospitalization and death. (IA)
Dapagliflozin or empagliflozin are recommended for patients with HFrEF to
reduce the risk of HF hospitalization and death. (IA)
Sacubitril/valsartan is recommended as a replacement for an ACE-I in patients
with HFrEF to reduce the risk of HF hospitalization and death. (IB)
 ARNI
(SACUBITRIL/VALSARTAN)
• In the paradigm –HF trial , sacubitril/valsartan , an ARNI , was shown to be superior to enalapril in
reducing hospitalization for worsening HF, CV mortality , and all cause mortality in patients with
ambulatory HFrEF with LVEF ≤40%
 Additional benefits of sacubitril/ valsartan includes….
Improvement in symptoms and quality of life
Reduction in the decline in eGFR
Reduced rate of hyperkalemia
 Patients being commenced on sacubitril/valsartan should have
• Adequate blood pressure (SBP>90mmHg)
• eGFR > 30ml/min/1.73m2
• A washout period of at least 36 hours after ACR-I therapy is required in order to minimize the risk of
angioedema ,
 SGLT2 INHIBITORS
• THE DAPA-HF trial & Emperor –reduced trail found that Dapagliflozin and empagliflozin
reduced the combined primary endpoint of CV death or HF hospitalization by 26% & 25%
respectively in patients with NYHA class II-IV symptoms , and an LVEF <40% despite
OMT(optimal medical therapy)
• Therefore , dapagliflozin or empagliflozin is recommended , in addition to OMT with an
ACE-I/ARNI . A beta blocker and an MRA , for patient with HFrEF regardless of diabetes
status .
 Contraindicated in
• Pregnancy/risk of pregnancy and breastfeeding period
• eGFR <20 ml /min
• Type 1 DM is not an absolute contraindication , but an individual risk of ketoacidosis should
be taken into account when starting this therapy .
• Glycosuria may predispose to fungal Genito-urinary infection .
 H E A RT FA ILU R E W ITH M ILD LY
R ED U C E D EJ EC TIO N FR A C TIO N

• Diuretics are recommended in patients with congestion and

HFmrEF in order to alleviate symptoms and signs.
• An ACE-I may be considered for patients with HFmrEF to
reduce the risk of HF hospitalization and death.
• An ARB may be considered for patients with HFmrEF to
reduce the risk of HF hospitalization and death .
• A beta-blocker may be considered for patients with
HFmrEF to reduce the risk of HF hospitalization and death.
• An MRA may be considered for patients with HFmrEF to
reduce the risk of HF hospitalization and death .
• Sacubitril/valsartan may be considered for patients with
HFmrEF to reduce the risk of HF hospitalization and death .
 H E A RT FA I L U R E W I T H
P R E S E RV E D E J E C T I O N
FRACTION

• HFpEF differs from HFrEF and

HFmrEF in that HFpEF patients are
older and more often female . AF ,
CKD and non-CV comorbidities are
more common in patients with
HFpEF that in those with HFrEF .
• To date , no treatment has been
shown to convincingly reduce
mortality and morbidity in patient
with HFpEF .
  Implantable cardioverter defibrillator : An ICD is
recommended to reduce the risk of sudden death and all-cause
mortality in patients with symptomatic HF (NYHA class II-III)
of an ischemic aetiology and an LVEF<_35% (IA)
• An ICD should be considered to reduce the risk of sudden death
and all-cause mortality in patients with symptomatic HF (NYHA
classII-III) of a non-ischaemic aetiology, and an LVEF<_35%
(IIa-A)
NON-
• ICD implantation is not recommended within 40 days of a MI as
PHARMACOLOGICA implantation at this time does not improve prognosis (III A)
L MANAGEMENT  Cardiac resynchronization therapy : CRT is recommended for
symptomatic patients with HF in SR with a QRS duration >_150
ms and LBBB QRS morphology and with LVEF <_35% despite
OMT in order to improve symptoms and reduce morbidity and
mortality. (IA)
 Cardiac contractility modulation
 Cardiac Surgery
 • AHF refers to rapid or gradual onset of symptoms and or
signs of HF , severe enough for the patient to seek urgent
medical attention , leading to an unplanned hospital
admission or an emergency department visit .
ACUTE HEART  Major clinical presentation
FAILURE • Acute pulmonary edema
• Acutely decompensated heart failure
• Isolated right ventricular failure
• Cardiogenic shock
 MANAGEMENT OF AHF
• Propped up position
• Oxygen & /mechanical ventilation : Oxygen therapy is recommended in patients with AHF
and SP02 <90% or PaO2 <60 mmhg to correct hypoxemia
• Diuretics : Intravenous loop diuretics are recommended for all patients with AHF admitted
with signs/symptoms of fluid overload to improve symptoms.
• Vasodilators : intravenous vasodilators may be considered to relieve AHF symptoms
when SBP is > 110mmhg
• Vasopressors : Norepinephrine may be preferred in patient with severe hypotension .
• Opiates : routine use of opiates in AHF is not recommended although they may be
considered in selected patients particularly in case of severe /intractable pain or anxiety or
in the setting of palliation
• Thromboembolism prophylaxis : with heparin or another anticoagulant is
recommended , unless contraindicated or unnecessary
 COMORBIDITIES

 Atrial fibrillation :The management of patients with concomitant HF and AF includes

• Identification and treatment of possible causes of triggers of AF
• Management of HF
• Prevention of embolic events by anticoagulation (NOACs rather than warfarin should be
considered for anticoagulation)
• Rate control if hemodynamically stable
• Rhythm control if hemodynamically unstable

 Diabetes : Treatment of HF is similar in patients with and without diabetes . SGLT2 inhibitors (canagliflozin,
dapagliflozin,empagliflozin, ertugliflozin, sotagliflozin) are recommended in patients with T2DM at risk of
CV events to reduce hospitalizations for HF, major CV events, end-stage renal dysfunction, and CV death.
 Iron deficiency & anemia :
• Iron deficiency , which can be present independently of anemia , is present in up to
55% of chronic HF patients and in up to 80 % of those with AHF
• It is recommended that all patients with HF are regularly screened for anemia and
iron deficiency with full blood count , serum ferritin concentration , and TSAT
• Iron supplementation with i.v ferric carboxymaltose is safe and improves symptoms
exercise capacity and QOL of patients with HFrEF and iron deficiency .
• Erythropoietin stimulating agents are not indicated for the treatment of anemia in HF.

Renal disease :CKD and hf frequently coexist . They share common risk factors , such as diabetes
or hypertension .
• When RAAS inhibitors , ARNI or SGLT2 inhibitors are started , the initial decrease in glomerular
filtration pressure may decrease GFR and increase serum creatinine . However , these changes are
generally transient .
• There is little direct evidence to support any recommendation for treatment of AF patients with
severer CKD as to date .
Lung disease
• COPD affects about 20% of patients with HF and has a major impact on symptoms and
outcomes
• Due to overlap in symptoms and signs , the differentiation between HF and COPD may be
difficult .
• Treatment of HF is generally well tolerated in COPD
• Beta-blockers can worsen pulmonary function in individual patients but are not
contraindicated in either COPD or asthma, as stated in the (GOLD) and(GINA), respectively,
use of cardioselective beta-blockers (bisoprolol, metoprolol succinate, or nebivolol) with
consideration of relative risks and benefits.
 Patients with HF are classified based on their LVEF.
Those with LVEF between 41% and 49% are defined
as ‘mildly reduced LVEF’(HFmrEF).
Measurement of NPs and echocardiography have
key roles in the diagnosis of HF.

ACE-I or ARNI, beta-blockers, MRA, and

SGLT2 inhibitors are recommended as cornerstone
KEY MASSAGES therapies for patients with HFrEF.
ICDs are recommended in selected patients with
HFrEF of an ischemic aetiology and should be
considered in those with a nonischemic aetiology.
ACE-I/ARNI, beta-blockers, and MRA may be
considered in patients with HFmrEF.
 It is recommended that patients with type II diabetes are
treated with SGLT2 inhibitors.

Patients should be periodically screened for anaemia and

iron deficiency and i.v. iron supplementation with ferric
carboxymaltose should be considered in symptomatic
patients with LVEF <45% and iron deficiency, and in
patients recently hospitalized for HF and with LVEF
KEY MASSAGES <_50% and iron deficiency.
Exercise is recommended for all patients who are able, to
improve exercise capacity and QOL, and reduce HF
hospitalization .

Treatment of acute HF is based on diuretics for

congestion, inotropes, and short- term MCS for peripheral
hypoperfusion .
 • Dr. Akhtarul Islam Chowdhury
ACKNOLEDGEMENT
Assistant Professor & HOD of Cardiology
THANK YOU
 DOSAGE OF THE DRUGS
Starting dose Target dose
carvedilol 3.12 mg b.i.d 25 mg b.i.d
ACE-I
Ramipril 2.5mg b.i.d 5mg b.i.d Nebivolol 1.25 mg o.d 10 mg o.d
MRA
Enalapril 2.5mg b.i.d 10-20mg b.i.d Eplerenone 25 mg o.d 50 mg o.d
ARNI Spironolactone 25 mg o.d 50 mg o.d
Sacubitril/ 49/51 mg. b.i.d 97/103 mg b.i.d SGLT2 inhibitor
Valsartan
Dapagliflozin 10 mg . Od 10 mg.o.d
Beta-blockers
Empagliflozin 10mg od 10 mg od
Bisoprolol