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Principles of therapy
The use of angiotensin receptor-neprilysin
inhibitor (ARNI), angiotensin-converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB), beta-blocker, mineralocorticoid receptor agonist (MRA),
and sodium-glucose linked transporter 2 (SGLT2) inhibitor is important in
modifying the course of systolic heart failure. The use of the above drugs should
be considered in all patients with heart failure because it decreases the risk
of heart failure hospitalization and premature death. They are commonly used in
conjunction with a diuretic to relieve the symptoms and signs of congestion. There
is no optimal order of treatment initiation and/or titration. Treatment
approach should be individualized. Initiation of a beta-blocker is better
tolerated when the patient is less congested (dry), with adequate resting heart
rate, and an ARNI, ACE inhibitor, or ARB when the patient is congested (wet).
Rapid initiation and titration of
therapy to maximally tolerated or target doses doses must be done in chronic
HFrEF patients in order to achieve the maximal benefits of guideline-directed
medical therapy. Guideline-directed medical therapy should be continued,
initiated, and further optimized in hospitalized patients before discharge. To reduce
the risk of heart failure readmission or death, it is recommended that
high-intensity evidence-based treatment be started early and rapidly
up-titrated pre-discharge and during follow-up visits within the first 6 weeks
after heart failure hospitalization. It is important to reassess ventricular
function 3-6 months after achieving maximally tolerated or target doses of
guideline-directed medical therapy to determine the need for ICD and/or CRT.
Continuous intravenous
inotropes and/or vasopressors may be considered as a bridge to mechanical
circulatory support or heart transplantation in patients with advanced heart
failure with low cardiac output and evidence of organ hypoperfusion, or as
palliative therapy to control symptoms and improve functional status.
In COVID-19 infection, inhibition of
the renin-angiotensin-aldosterone system is not associated with infection risk
or disease severity and should be continued as long as hemodynamically
tolerated by the patient. Chronic heart failure patients should continue guideline-directed
medical therapy regardless of COVID-19 infection.
Pharmacological therapy
Please see the Heart Failure - Acute
disease management chart for information on intravenous drugs administered in
the hospital or healthcare facility for emergency cases of heart failure.
Angiotensin Converting Enzyme (ACE) Inhibitors
ACE inhibitors are recommended for the
prevention of heart failure in patients at risk of this syndrome. They should
be prescribed to all patients with decreased left ventricular ejection fraction
of ≤40% regardless of symptoms unless contraindicated or not tolerated.
It may be started as soon as a heart
failure diagnosis is made because of its modest effect on left ventricular remodeling
which delays the development of symptomatic chronic heart failure in patients with
asymptomatic left ventricular dysfunction and those without ventricular
dysfunction.
If a patient has a recent or current
history of fluid retention, diuretics should be started prior to ACE inhibitors
to ensure sodium balance, preventing peripheral and pulmonary edema.
An increase in creatinine and
potassium levels is expected after treatment with an ACE inhibitor (or ARB) or ARNI.
An increase in the creatinine level of up to 3 mg/dL (eGFR >25 mL/min/1.73 m2)
or up to 50% above baseline (whichever is smaller) and a potassium level of ≤5.5
mmol/L is acceptable. Administration of potassium-lowering agents (eg patiromer
and sodium zirconium cyclosilicate) may allow the renin-angiotensin-aldosterone
system (RAAS) inhibitor initiation or uptitration in a large number of patients
with hyperkalemia. Consider a specialist referral if with significant renal
dysfunction or hyperkalemia.
Angiotensin
Receptor Blockers (ARBs) or Angiotensin II Antagonists
ARBs are recommended as alternative
drugs in patients who are intolerant of ARNI or ACE inhibitors due to cough or angioedema.
Patients should also be given a beta-blocker and an MRA. ARBs can also be used
as alternatives to ACE inhibitors as first-line agents in those already on ARB
for other indications. They may also be considered in patients with systolic chronic
heart failure who remain symptomatic despite receiving an ACE inhibitor and a
beta-blocker and are intolerant of MRA.
Candesartan may be considered for
ambulatory patients with symptomatic HFmrEF to decrease the risk of heart
failure hospitalization and cardiovascular death.
Avoid the use of ARBs in patients with
recent acute myocardial infarction and decreased left ventricular ejection
fraction who are on ACE inhibitors and beta-blockers. The triple combination of
an ACE inhibitor, ARB, and MRA is not recommended due to the increased risk of
hyperkalemia.
Angiotensin
Receptor-Neprilysin Inhibitor (ARNI)
Example Drugs: Sacubitril/Valsartan
ARNI is indicated for patients with HFrEF
(ejection fraction of ≤40%), NYHA Class II-IV.
It is a recommended replacement for an
ACE inhibitor or ARB to further decrease morbidity and mortality in ambulatory patients
with HFrEF NYHA Class II-III. It reduces the risk of cardiovascular death and
heart failure hospitalization in adult patients with chronic heart failure with
benefits most evident in those with left ventricular ejection fraction below
normal.
It acts by inhibiting neprilysin which
slows down the degradation of natriuretic peptides, bradykinin, and other
peptides leading to high amounts of circulating A-type natriuretic peptide and
BNP resulting in diuresis, natriuresis, and relaxation and anti-remodeling of
the myocardium. It is important to interpret BNP values with caution as BNP
levels may rise with ARNI therapy. It is recommended as a replacement for ACE
inhibitor or ARB to further decrease morbidity and mortality in patients with
HFrEF NYHA Class II-IV.
One may consider
starting Sacubitril/Valsartan rather than an ACE inhibitor or ARB for patients
admitted with new-onset heart failure or decompensated chronic heart failure
for reduction of short-term risk of adverse events, and for simplification of
management (ie the need to initially titrate ACE inhibitor then switch to
Sacubitril/Valsartan is avoided).
Treatment should not be combined with
an ACE inhibitor or ARB or initiated within 36 hours from the last dose of an ACE
inhibitor due to a higher risk of angioedema.
Beta-Blockers
Beta-blockers are recommended in all
stable NYHA Class II-IV patients with HFrEF to relieve angina unless
contraindicated or not tolerated. It is the preferred first-line treatment to
control ventricular rate for patients in NYHA Class I-III provided that they
are euvolemic. They may also be used to control the ventricular rate in heart
failure patients with preserved ejection fraction and atrial fibrillation.
Additionally, they are also used in
patients with prior myocardial infarction to reduce mortality, recurrent myocardial
infarction, and the development of heart failure. Beta-blockers slow down
symptom onset and decrease cardiac morbidity in post-myocardial infarction
patients with asymptomatic left ventricular dysfunction. They may be considered
for ambulatory patients with symptomatic HFmrEF to decrease the risk of
all-cause and cardiovascular death.
They prevent ischemia and
inhibit the adverse effects of the sympathetic nervous system in heart failure.
It is recommended to use only evidence-based beta-blockers (eg Bisoprolol,
Carvedilol, Metoprolol succinate, or Nebivolol) in patients with HFrEF and to
initiate treatment in a “start low, go slow” approach.
Calcium Channel Blockers
Dihydropyridine calcium channel
blockers are not recommended for heart failure treatment in patients with HFrEF
but may be used to treat hypertension in patients with high blood pressure
despite optimal guideline-based medical treatment.
Non-dihydropyridine calcium channel
blockers that are negative inotropes are contraindicated in patients with HFrEF.
However, Diltiazem is sometimes used in patients with chronic heart failure and
atrial fibrillation to decrease excessive exercise-related heart rates.
Digoxin
Digoxin may be used to slow a rapid
ventricular rate in patients with symptomatic heart failure, left ventricular
ejection fraction of ≤40%, and atrial fibrillation in addition to or prior to a
beta-blocker. It is recommended as the preferred second drug, in addition to a
beta-blocker, to control the ventricular rate in patients with inadequate
response to a beta-blocker. It may also be used to decrease hospitalization in
NYHA Class II-IV patients with an ejection fraction of ≤40% in sinus rhythm and
persisting symptoms despite treatment with optimized guideline-directed medical
therapy.
Diuretics
Diuretics are recommended in NYHA
Class II-IV patients with heart failure and those with clinical manifestations
of congestion or fluid overload regardless of the ejection fraction.
Start with a low dose and titrate
accordingly until clinical improvement is achieved. Diuretic dosing may need to
be reduced with increasing doses of ARNI, ACE inhibitor, or ARB and/or
initiation of an SGLT2 inhibitor. Adjust the dose after the restoration of dry
body weight to avoid the risk of dehydration, hypotension, and renal
dysfunction.
Patients with preserved ejection
fraction are given diuretics to control volume, manage high blood pressure, and
relieve ischemia. If after the management of volume overload, the patient with preserved
ejection fraction still has persistent hypertension, ACE inhibitors or ARBs and
beta-blockers should be given to achieve a systolic blood pressure of <130
mmHg.
Diuretics may be considered to reduce
the risk of heart failure hospitalization in patients in sinus rhythm with an ejection
fraction of ≤45% who are unable to tolerate a beta-blocker.
They work synergistically when a different
diuretic is used in combination with a loop diuretic for the treatment of resistant
edema. Consider ultrafiltration in patients with refractory volume overload not
responding to diuretic therapy.
Loop Diuretics
Loop diuretics are the preferred diuretics for the treatment of heart
failure. They are used in patients with more severe volume overload or if there
is an inadequate response to thiazides. They produce a greater fractional
excretion of filtered sodium and provide a more intense and shorter diuresis.
Initial dose will depend on the patient's renal function and prior
treatment with diuretics.
If high doses of a loop diuretic are reached during
treatment (ie equivalent of Furosemide 80 mg 12 hourly), one may consider
switching to a different loop diuretic or adding a thiazide diuretic.
Potassium-Sparing Diuretics
Potassium-sparing diuretics are recommended
in patients with excessive potassium losses secondary to the use of loop
diuretics. They are also used in combination with thiazides for the treatment
of hypertension. Caution is needed if a potassium-sparing diuretic is used in
addition to an ACE inhibitor or ARB, and MRA.
Thiazide Diuretics
Thiazide diuretics may be effective as
monotherapy in heart failure patients with mild congestion and normal renal
function.
Combinations
Thiazides or Metolazone can be used in
combination with loop diuretics for a synergistic effect in patients with persistent
fluid retention despite a high-dose loop diuretic treatment. Chronic daily use
of these agents, especially Metolazone, should be avoided because of the risk
of electrolyte imbalance and dehydration.
Hydralazine + Isosorbide Dinitrate
Hydralazine and Isosorbide dinitrate are
given to NYHA Class III-IV black patients with HFrEF who remain symptomatic
despite optimal standard therapy with ARNI, ACE inhibitor or ARB, beta-blocker,
aldosterone antagonist, and SGLT2 inhibitor. They are considered an alternative
in patients who cannot tolerate ACE inhibitors, ARBs, or ARNI or in whom these agents
are contraindicated and if no other treatment options are available.
Hydralazine and Isosorbide have
complementary dilating actions. Hydralazine may interfere with the molecular
mechanisms responsible for the progression of heart failure while Isosorbide
may also inhibit abnormal myocardial and vascular growth, thus may reduce
ventricular remodeling. The dose may be increased every 2 weeks to maximum
tolerated or target dose.
Ivabradine
Ivabradine is a highly selective sinus node I(f) channel inhibitor
that is known for slowing the heart rate. It is approved for use in patients with
a heart rate of ≥75 bpm.
It may be considered to reduce
mortality and the risk of heart failure hospitalization in patients in sinus
rhythm with a left ventricular ejection fraction of ≤35%, heart rate of ≥70 bpm
at rest, with persisting symptoms (NYHA Class II-III), and with:
- Inadequate response to guideline-directed medical therapy including maximally tolerated, evidence-based dose of beta-blocker
- Intolerance or contraindication to beta-blockers or when there is treatment failure after beta-blocker therapy; the patient should also be given an ACE inhibitor (or ARB/ARNI) and MRA
Mineralocorticoid Receptor Antagonists (MRA)
or Aldosterone Antagonists
MRA or aldosterone antagonists are recommended
for NYHA Class II-IV patients with HFrEF to reduce morbidity and mortality. It
is a treatment option for patients with HFpEF (EF ≥45%, increased BNP,
estimated GFR >30 mL/min, creatinine <2.5 mg/dL, potassium <5 mEq/L)
to reduce hospitalizations. It is recommended also for NYHA Class II
symptomatic patients with a history of previous cardiovascular hospitalization
or an elevated level of natriuretic peptide.
Spironolactone and Eplerenone block
receptors that bind aldosterone and other corticosteroids and are best
characterized as MRAs. Spironolactone is recommended for patients who remain
severely symptomatic despite appropriate doses with ACE inhibitors, loop
diuretics, and Digoxin. Spironolactone may be considered for ambulatory
patients with symptomatic HFmrEF without contraindications to decrease the risk
of heart failure hospitalization and cardiovascular death. Eplerenone is
considered in patients with systolic heart failure who still have mild symptoms
despite receiving standard therapy of ACE inhibitors and beta-blockers.
Additionally, it has no antiandrogenic effects.
Renal dysfunction and hyperkalemia may
lead to the underutilization of MRA. Administration of potassium-lowering
agents may allow MRA initiation or uptitration in a large number of patients with
hyperkalemia. Serial monitoring of serum electrolytes and renal enzymes is therefore
advised.
Nitrates
A short-acting oral or transcutaneous
nitrate is an effective treatment for angina and is safe to use in patients with
heart failure.
Rivaroxaban
Rivaroxaban may be considered, in
addition to Aspirin therapy, for ambulatory patients with CAD, and chronic
heart failure in NYHA Class I/II with a left ventricular ejection fraction of >30%
to decrease the risk of stroke and cardiovascular death.
Sodium-Glucose Linked Transporter or Co-transporter
2 (SGLT2) Inhibitors
Example drugs: Dapagliflozin, Empagliflozin,
Sotagliflozin
SGLT2 inhibitors are indicated for
patients with heart failure across all ejection fraction subgroups, with or
without diabetes, NYHA Class II-IV, to decrease the risk of cardiovascular
deaths, heart failure hospitalization, and urgent heart failure visits. They reduce risk of cardiovascular death and heart
failure hospitalizations in patients with type 2 diabetes mellitus and
established cardiovascular disease or multiple cardiovascular risk factors.
Sotagliflozin is an
inhibitor of both SGLT1 and SGLT2. Its inhibition of SGLT1 decreases intestinal
absorption of sodium and glucose which may cause diarrhea. All patients with
HFpEF should be initiated on SGLT2 inhibitor if without contraindications.
Tolvaptan
Tolvaptan is a vasopressin V2
receptor antagonist that may be used for short-term treatment of resistant
hypervolemic hyponatremia despite water restriction and guideline-directed
medical therapy. It may be given during hospitalization to patients with HFrEF
who have fluid retention unresponsive to treatment with other diuretics
including loop diuretics. Tolvaptan given during hospitalization for acute
heart failure may be used by patients with HFpEF after discharge to control congestion.
Adverse effects include thirst and dehydration.
Vericiguat
Vericiguat is an oral soluble guanylate cyclase
stimulator that may be considered to decrease the risk of heart failure
hospitalization and cardiovascular death following a heart failure
hospitalization or outpatient intravenous diuretic therapy in select high-risk
patients with HFrEF NYHA Class II-IV and left ventricular ejection fraction of
<45% with worsening heart failure despite guideline-directed medical
therapy.
Adjunctive Therapy
Coenzyme Q10 (CoQ10)
Coenzyme Q10 is a lipid-soluble
cofactor found in the mitochondrial inner membrane that has antioxidant
properties and a bioenergetic role. It is predominantly located in the
myocardium.
The Q-SYMBIO trial, a double-blind
trial on Coenzyme Q10 as adjunctive therapy for chronic heart failure, found
that supplementation with Coenzyme Q10 was safe and has resulted in heart
failure symptom improvement and reduction in major adverse cardiovascular
events and mortality. As trials on Coenzyme Q10 have shown mixed results,
further evidence is needed to establish its beneficial effect.
Treatment of Comorbidity
Anticoagulation
Long-term anticoagulation should be given to
patients with chronic heart failure with permanent-persistent-paroxysmal atrial
fibrillation and a CHA2DS2-VASc score of ≥2 in men and ≥3
in women. In eligible patients, direct oral anticoagulant (DOAC) is recommended
over Warfarin. A reasonable therapy for patients with chronic heart failure with
permanent-persistent-paroxysmal atrial fibrillation in the absence of
additional risk factors.
Intravenous Iron Replacement
Intravenous iron replacement may be
given in symptomatic patients with HFrEF and HFmrEF, and iron deficiency (serum
ferritin <100 ng/mL or 100-300 ng/mL if transferrin saturation is <20%) with
or without anemia for alleviation of heart failure symptoms and improvement of
exercise capacity and quality of life. Ferric carboxymaltose or Ferric
derisomaltose should be considered in above patients to decrease the risk of
heart failure hospitalization.
Immunization
Pneumococcal vaccination, annual
influenza vaccination, as well as COVID-19 vaccination, are recommended in all
patients with heart failure in the absence of known contraindications. Pulmonary
congestion and pulmonary hypertension increase the risk of respiratory
infections (one of the major causes of acute decompensation, especially in the
elderly).
Nonpharmacological
Patient Education
General Counseling
Patient counseling tends to
improve patient compliance and outcomes. Educate the patient and caregivers
about chronic heart failure. Discuss the nature of heart failure, treatment
goals, drug regimens and side effects, dietary and activity restrictions, signs
and symptoms of worsening heart failure, what to do if these symptoms occur,
and prognosis.
Advise the patient regarding
enrollment in a multidisciplinary heart failure management program,
self-management strategies, and either home-based and/or clinic-based programs
to decrease the risk of hospitalization and mortality. Provide discharge instructions with a transitional care plan and
programs for psychological and social support. Genetic counseling and screening
may be advised to patients with first-degree relatives with inherited or
genetic cardiomyopathies.
Medications
Inform patients about the drugs’ indications, dosage, side effects, and
precautions. Emphasize the importance of treatment adherence to the patients. Assist
patients in dealing with complicated drug regimens and in accessing affordable
medications. Advise patients to avoid non-steroidal anti-inflammatory drugs (NSAIDs)
including cyclooxygenase-2 (COX-2) inhibitors since patients are at increased
risk for fluid retention and renal failure especially those with decreased
renal function or who are on angiotensin-converting enzyme (ACE) inhibitors. NSAIDs
can cause sodium retention, peripheral vasoconstriction, decrease the efficacy and
increase the toxicity of ACE inhibitors and diuretics.
Pregnancy and Contraception
Low-dose oral contraceptives have a
small risk of causing hypertension or thrombogenicity, but these risks need to
be weighed against the risk of pregnancy. Advise patients with left ventricular
ejection fraction of <30% and those in NYHA Class III-IV to not get
pregnant. If heart failure occurs during pregnancy, use beta-blockers, Digoxin,
diuretics, Hydralazine and/or nitrates judiciously. Women
with a history of heart failure or cardiomyopathy should be counseled
pre-pregnancy regarding contraception and the risks of cardiovascular status
deterioration while being pregnant.
Travel
Discuss travel plans with the
physician for patients with heart failure who are at increased risk of deep
venous thrombosis (DVT). Air travel is preferred to other means of
transportation, especially on long journeys. Long flights may predispose
patients to accidental omission of medicines, edema of the lower extremities,
dehydration, and deep vein thrombosis. Deep vein thrombosis prophylaxis with a
single injection of low-molecular-weight Heparin and/or graduated compression
stockings plus calf stretching during the flight are recommended.
Pharmacotherapy may be added if there is a significant risk of deep vein
thrombosis. Advise patients to avoid high altitude destinations of >1500
meters because of relative hypoxia.
Lifestyle Modification
Weight Monitoring
An increase in body weight is
associated with deterioration of heart failure and fluid retention. Patients
should weigh themselves regularly to monitor their weight change. If a patient
has sudden unexpected weight gain of >2 kg in 3 days, the physician should
be informed, and diuretic dose may need to be adjusted.
Patients who are obese need to lose
weight to decrease symptoms, improve well-being, and prevent progression of heart
failure. Weight reduction should not routinely be done in patients with moderate
to severe heart failure since unintentional weight loss and anorexia are common
problems in these patients.
Please see Obesity disease
management chart for further information.
Cardiac cachexia, defined as
involuntary non-edematous weight loss ≥6% of total body weight within the
previous 6-12 months, is an important
predictor of decreased survival. Possible treatments are appetite stimulants,
exercise, anabolic agents, and nutritional supplements.
Diet Modification
Restrict sodium intake to <2 g/day
(~1/4 teaspoon of table salt). Advise patients regarding a low potassium diet
since hyperkalemia and/or abnormal renal function hinders the ability to reach
target medication doses.
Fluid restriction should be
individualized, though generally patients may limit fluid intake to 1-1.5 L/day
in patients with normal renal function. Routine fluid restriction in all
patients with mild to moderate symptoms is probably not beneficial. Weight-based
fluid restriction (30 mL/kg body weight if body weight is ≤85 kg or 35 mL/kg if
body weight is >85 kg) may cause less thirst.
Excessive caffeine intake may increase
heart rate, increase blood pressure, and exacerbate arrhythmia. Advise patients
to limit caffeine beverages to 1-2 cups/day.
Limit saturated fat intake in all
patients with heart failure. Supplementation with omega-3 polyunsaturated fatty
acids is a reasonable adjunctive therapy in chronic heart failure NYHA Class
II-IV. A trial showed reduction in
mortality or hospital admission for a cardiovascular event.
High fiber diet is recommended to
prevent constipation that is secondary to relative gastrointestinal
hypoperfusion. It helps avoid straining in stool which may provoke angina,
dyspnea, or arrhythmia. Frequent small meals may prevent shunting of the
cardiac output to the gastrointestinal tract, thus decreasing the risk of
angina, dyspnea, dizziness, or bloating.
Alcohol
Alcohol is a direct myocardial toxin and
may impair cardiac contractility, may have a negative inotropic effect, may be
associated with blood pressure elevation, and increases the risk for arrhythmia.
Advise patients to abstain from or
avoid excessive alcohol consumption. Limit alcohol intake to 10-20 g/day (2
units/day in men or 1 unit/day in women). A standard drink of 14 g of pure
alcohol is equal to 12 oz of beer (5% alcohol content), 8-9 oz of malt liquor (7%
alcohol content), 5 oz of table wine (12% alcohol content), or 1.5 oz of
80-proof distilled spirits or liquor such as gin, rum, vodka, whiskey (40%
alcohol content). 1 unit is equivalent to 10 mL (8 g) of pure alcohol (1/3 pint
of beer [5.2% alcohol content], half a standard glass [175 mL] of wine [12%
alcohol content], or 1 measure [25 mL] of spirits [40% alcohol content]).
Smoking Cessation
The primary goals in
managing patients with heart failure are complete smoking cessation and
avoidance of passive smoking. Patients may be provided with counseling,
cessation programs, and pharmacotherapy (eg nicotine replacement, Bupropion) to
aid in smoking cessation.
Physical Activity
Regular physical activity or aerobic
exercise is strongly recommended in patients with chronic heart failure (NYHA
Class I-III). It should be individualized based on the patient’s capacity. Promote
adherence to an exercise goal of 30 minutes of moderate activity or exercise,
5-7 days a week with warm up and cool down exercise. When clinically stable, patients
should be encouraged to carry out daily physical activities and leisure
activities that do not induce symptoms.
Sexual Activity
Counsel patients to
defer sexual activities if they are in NYHA Class III-IV but may resume when
their cardiac condition is stabilized. Sexual activity is likely to be safe in
patients who are able to achieve approximately 5-6 metabolic equivalents of
exercise (ie can climb two flights of stairs without stopping due to angina,
dyspnea, or dizziness).
Advise patients
regarding the use of sublingual Nitroglycerin as prophylaxis against dyspnea and
chest pain during sexual activity. Drugs used in erectile dysfunction (eg
Avanafil, Sildenafil, Tadalafil) are contraindicated in patients receiving nitrates
or those who have hypotension, arrhythmias, or angina pectoris.
Other Therapy
Cardiac
Rehabilitation
Cardiac rehabilitation is considered
useful in patients who are clinically stable and able to participate in
exercise programs. This includes monitored
exercise, psychological support, and education about lifestyle changes to
reduce cardiovascular risks. Several meta-analyses demonstrated that
cardiac rehabilitation improves functional capacity, exercise duration, and
health-related quality of life. It also decreases the risk of hospitalizations
and mortality in heart failure patients. Exercise-based cardiac rehabilitation
is recommended in symptomatic patients with HFrEF who are stable to decrease
the risk of hospitalization. Consider a supervised program in patients with
frailty, more severe disease, or comorbidities.
It is helpful in monitoring symptoms, supporting
drug titration, and reduce patient anxiety and uncertainty. Following
revascularization, patients may also be referred for cardiac rehabilitation.
Depression and Mood Disorder
Screening for endogenous
or prolonged reactive depression in patients with heart failure should be done
following its diagnosis and at periodic intervals as clinically indicated. Initiate
appropriate pharmacotherapy (eg selective serotonin receptor uptake inhibitors)
and provide psychosocial support.
Sleep and Breathing Disorders
Patients with
symptomatic heart failure usually have sleep-related breathing disorders (eg
central or obstructive sleep apnea). Weight loss in obese patients, smoking
cessation, and abstinence from alcohol are recommended to decrease the risks.
Continuous positive airway pressure (CPAP) should be considered in
polysomnograph-documented obstructive sleep apnea to improve daily functional
capacity and quality of life.
Interventional Therapy
Device-based Therapy
Cardiac Resynchronization Therapy (CRT)
Cardiac resynchronization therapy is
indicated for patients with ventricular dyssynchrony from conduction
abnormalities. It is recommended if NYHA Class II-IV symptomatic patient is in
sinus rhythm with a QRS duration of ≥150 msec, left bundle branch block, and left
ventricular ejection fraction of ≤35% despite optimal guideline-directed
medical therapy for at least 3-6 months. Cardiac resynchronization therapy provides
high economic value.
It should be considered in NYHA Class
II-IV symptomatic heart failure patients in sinus rhythm with a left
ventricular ejection fraction of ≤35% and QRS duration of ≥150 msec and non-left
bundle branch block pattern or QRS duration of 120-149 msec and left bundle
branch block pattern despite optimal medical therapy. It may be performed in
patients more than 40 days post-myocardial infarction and with a reasonably
expected survival of more than 1 year.
Cardiac resynchronization therapy with
a pacemaker is recommended (instead of right ventricular pacing) in patients with
HFrEF regardless of NYHA class or QRS width with an indication for ventricular
pacing for high-degree atrioventricular block, bradycardia, and atrial
fibrillation.
Consider an upgrade to cardiac
resynchronization therapy in patients with a left ventricular ejection fraction
of ≤35% who have received a conventional pacemaker or an implantable
cardioverter-defibrillator (ICD) and subsequently experience worsening heart
failure despite optimal medical therapy and who have a significant proportion
of right ventricular pacing.
To improve symptoms and quality of life and to
reduce hospitalizations and total mortality, cardiac resynchronization therapy may also be considered in the following patients:
- With high-degree or complete heart block and left ventricular ejection fraction of 36-50%
- In sinus rhythm NYHA Class III-IV with a QRS duration of 120-149 msec, non-left bundle branch block, and left ventricular ejection fraction of ≤35% on guideline-directed medical therapy
- With an ischemic cause of heart failure, in sinus rhythm NYHA Class I with a QRS duration of ≥150 msec, left bundle branch block, and left ventricular ejection fraction of ≤30% on guideline-directed medical therapy
- On guideline-directed medical therapy with left ventricular ejection fraction of ≤35% and undergoing placement of a new or replacement of a device implant with anticipated requirement for significant ventricular pacing
Implantable Cardioverter-Defibrillator (ICD)
Implantable cardioverter-defibrillator
is indicated for patients with ventricular arrhythmias. Primary prevention or
prophylactic implantable cardioverter-defibrillator implantation to decrease
the risk of sudden cardiac death may be done in an NYHA Class II-III
symptomatic patient with a left ventricular ejection fraction of ≤35% or NYHA
Class I symptomatic patient with a left ventricular ejection fraction of ≤30%
despite optimal guideline-directed medical therapy for at least 3-6 months and
without myocardial infarction in the prior 40 days, or with dilated ischemic
cardiomyopathy, or with a reasonable expected survival for more than 1 year.
A transvenous implantable cardioverter-defibrillator
is of high economic value in the primary prevention
of sudden cardiac death.
Implantable cardioverter-defibrillator may be done for secondary
prevention in the following patients to improve survival:
- Cardiac arrest survivors (expected survival rate of >1 year with good functional status) from ventricular fibrillation or with hemodynamic instability caused by documented ventricular dysrhythmia
- Those with symptomatic chronic heart failure and left ventricular ejection fraction of ≤35% who experience syncope of unclear etiology
- Those with previous myocardial infarction and left ventricular ejection fraction of ≤40% with non-sustained ventricular tachycardia and ventricular tachycardia or ventricular fibrillation that is inducible and sustained during an electrophysiological study
Consider an implantable
cardioverter-defibrillator implantation in patients
with genetic arrhythmogenic cardiomyopathy with high-risk features of sudden
death and ejection fraction of ≤45% to decrease sudden death.
Left
Ventricular Assist Device (LVAD)
A left ventricular assist device
is a mechanical circulatory support used as a bridge to transplantation or to
recovery. It should be considered in select NHYA Class IV
patients who are deemed dependent on intravenous inotropes or temporary
mechanical circulatory support. It may be used long-term as a
transplantation alternative in patients with end-stage heart failure not
eligible for heart transplantation (destination therapy) or as a bridge to candidacy
or heart transplantation.
Surgery
Coronary Revascularization
Coronary revascularization therapy includes
coronary artery bypass grafting (CABG) or percutaneous coronary intervention
(PCI). It is considered in patients with heart failure with left ventricular
ejection fraction ≤35% and suitable coronary anatomy to relieve persistent
angina symptoms despite optimal guideline-directed medical therapy including
anti-anginal agents.
Valvular Surgery
Mitral valve repair or replacement
may be considered after optimization of guideline-directed medical
therapy in patients with left ventricular systolic dysfunction and moderate-severe
mitral regurgitation who will undergo surgical coronary revascularization.
Mitral valve repair may be done in
symptomatic patients with heart failure, severe mitral regurgitation, and a left
ventricular ejection fraction of <30%. A MitraClip may be considered in
select patients with HFrEF to decrease mitral regurgitation. In symptomatic
patients with chronic moderate-severe to severe mitral regurgitation despite guideline-directed
medical therapy at optimal doses, a transcatheter mitral valve edge-to-edge
repair may be considered if ineligible for surgery and not requiring coronary
revascularization.
Mitral valve replacement may be
considered in symptomatic patients with a left ventricular ejection fraction of
<30% and/or left ventricular end-systolic diameter of >55 mm unresponsive
to medical treatment, with comorbidities, and with a low likelihood for
successful surgical outcome.
Balloon mitral valvuloplasty (BMV) can
be considered in patients with mitral stenosis with suitable valve anatomy.
Percutaneous mitral commissurotomy
(PMC) may be considered in symptomatic patients with mitral stenosis with a
valve area of >1.5 cm2 with suitable valve anatomy at high risk
or with contraindications for surgery. It should be considered in asymptomatic
patients with high thromboembolic risk and/or high risk of hemodynamic decompensation
without contraindications to percutaneous mitral commissurotomy.
Aortic valve replacement may be
considered for patients with aortic stenosis or aortic regurgitation. It is recommended
for symptomatic patients irrespective of the left ventricular ejection fraction
value. It should also be considered in symptomatic patients with a left
ventricular ejection fraction of ≤50%, left ventricular enlargement with a left
ventricular end-diastolic diameter of >70 mm, or left ventricular
end-systolic diameter of >50 mm. Transcatheter aortic valve replacement
(TAVR) or transcatheter aortic valve implantation (TAVI) may be considered in
patients with high-risk aortic stenosis or patients who are not fit for surgery.
Aortic valve repair or valve-sparing
surgery should be considered in patients with pliable noncalcified tricuspid or
bicuspid valves with type I or type II aortic regurgitation.
Heart
Transplantation
Heart transplantation is considered in
eligible patients with poor prognosis, advanced, or end-stage heart failure, and
severe symptoms who have failed or are refractory to optimal guideline-directed
medical therapy or device therapy or surgery, and without absolute
contraindications. It significantly increases a patient’s survival and quality
of life.
Prevention
Control of Risk and Prevention of Cardiovascular Events
Hypertension and Dyslipidemia
The optimal blood pressure for heart failure patients with hypertension is recommended to be <130/80 mmHg1. A healthy diet and statin therapy are potential preventive strategies for dyslipidemia.
1Recommendations for blood pressure target goals may vary between countries. Please refer to available guidelines from local health authorities.
Please see Hypertension and Dyslipidemia disease management charts for further information.
Diabetes Mellitus (DM)
SGLT2 inhibitors significantly decrease heart failure events in type 2 diabetes patients with heart failure, established cardiovascular disease, or high risk for cardiovascular disease. Metformin may be used in type 2 diabetes patients with stable heart failure, including HFpEF.
Long-term treatment with ACE inhibitors or ARBs can prevent the development of end-organ disease, cardiovascular complications, and risk of heart failure in patients with diabetes and those without hypertension. Other agents that may also be given to patients with diabetes mellitus include a beta-blocker, MRA, an ARNI, and Ivabradine.
Please see Diabetes Mellitus disease management chart for further information.
Atherosclerotic Disease
One large-scale trial showed that long-term therapy with an ACE inhibitor decreased the risk of cardiovascular death, myocardial infarction, and stroke in patients with known vascular disease. ACE inhibitors prevent heart failure in patients who are at high risk of developing heart failure, have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors.
For the prevention of symptomatic heart failure in pre-heart failure patients, the following may be considered:
- ACE inhibitor or beta-blocker for left ventricular ejection fraction of ≤40%
- ARB in patients intolerant of ACE inhibitors and with a recent myocardial infarction and left ventricular ejection fraction of ≤40%
- Beta-blocker (left ventricular ejection fraction of ≤40%) or statins for patients with a remote or recent history of acute coronary syndrome or myocardial infarction
An implantable cardioverter-defibrillator may be placed in pre-heart failure patients who are at least 40 days post-myocardial infarction with a left ventricular ejection fraction of ≤30% and with more than 1 year expected survival.
Atrial Fibrillation
Patients with atrial fibrillation should be treated according to guideline-directed medical therapy. Beta-blocker or non-dihydropyridine calcium channel blocker plus Digoxin may be given if needed. Anticoagulation may be done if without contraindications.
Chronic Kidney Disease
SGLT2 inhibitors and RAAS inhibitors may slow renal disease progression. Finerenone reduced the risk of heart failure hospitalization in patients with type 2 diabetes mellitus and CKD.
Please see Chronic Kidney Disease disease management chart for further information.