Congestive Heart

Failure
- Mini-Lecture-
Kristopher Huston MD, PGY2
Ali Ashtiani MD, PGY2
Arash Taghavi MD, PGY1
 Heart Failure-Definition
 “a complex clinical syndrome that can result from
any structural or functional cardiac disorder that
impairs the ability of the ventricle to fill with or
eject blood.”
 HFrEF or Systolic HF
 EF<40%
 Aim of majority of therapies

 HFpEF or Diastolic Failure

 EF>50%
 Exclusion of other noncardiac causes of symptoms
Definition
 Classification Systems
NYHA Functional Class
 I: No limitation of physical activity. Ordinary physical activity does
not cause symptoms of HF (fatigue, palpitations, dyspnea or angina)
 II: Comfortable at rest, slight limitation of physical activity
 III: Comfortable at rest. Marked limitation, less than ordinary
activity
causes discomfort
 IV: Discomfort at rest

 ACCF/AHA Stages
 A = No structural heart disease, risk factors for HF
 B = Structural heart disease, no HF symptoms
 C = Structural heart disease, with prior or current HF symptoms
 D = Refractory HF requiring frequent interventions
 The Major Causes
 CAD (~70% of cases)
 Hypertension
 Valvular disease
 Diabetes Mellitus
 cardiomyopathy and progression of CAD
 Less Common Causes
 Myocarditis
 Tachyarrhythmia
 Congenital Heart Defects (HOCM)
 Cardiomyopathy
 Stress-induced
 Toxins: Drugs (Cocaine, Methamphetamine, Chemotherapy, Radiation),
Alcohol

 Pulmonary: OSA
 Rheumatologic: Sarcoidosis, SLE
 Infiltrative: Hemochromatosis, Amyloidosis
 Chronic Disease
 DM, HIV, Thyroid Disorders
 How patients present

 Clinical Symptoms
 Dyspnea (100% sensitivity)
 PND
 Swelling/Dependent edema
 Fatigue, Weight gain

 Risk Factors:
 Obesity, smoking, physical inactivity, lower
socioeconomic status factors.
 Physical Exam
 Pulmonary: Respiratory distress, Rales
 Cardiac: Bradycardia/Tachycardia, Displaced
PMI, JVD, S3 gallop rhythm.
 Abdomen: Ascites, Hepato-jugular Reflux
 Extremities: cool, dependent edema, cyanosis,
pallor
 Diagnosis
 EKG (check for MI, PE, Arrhythmia, LVH)
 CXR
 Pulmonary venous congestion, interstitial edema
 Cardiomegaly, pleural effusions

 Labs
 CBC, CMP, Troponin, ABG, Thyroid function tests

 Echocardiography: evaluate severity, causes,

characterization
 Coronary Angiogram in setting of STEMI/NSTEMI
 Diagnosis
 BNP, NT-proBNP
 Equally good sensitivity/specificity in diagnosing CHF
 BNP = < 100 unlikely CHF and > 400 likely CHF
 Increases with age, renal disease/arrhythmia, sepsis,
CAD, Women, African-Americans
 Decreased in obesity
 In acute HF, predictor of mortality and cardiovascular
events when >200.
 Limited evidence in serial monitoring in outpatient
setting
 Support clinical decision making
 Establish prognosis and disease severity
 Management
 Lifestyle Modification
 Vaccines: Pneumococcal and Flu
 Low Sodium (<2-3 g daily)
 Alcohol and Tobacco cessation
 Medications to avoid
NSAIDs (reduce GFR, worsen response to diuretics and ACE)
Recommended to use ASA only for CAD
Thiazolidinedione (fluid retention), Metformin (increased risk for LA)
Phosphodiesterases (PDE3 and 4, data for PDE5 is not as convincing)

 MORTALITY REDUCTION!
 ACE-I/ARB, Beta-Blocker, Aldosterone Antagonist, Hydralazine plus
Isosorbide Nitrate
 Management
ACE-Inhibitors
 Decrease MORTALITY and hospitalizations
 Initial baseline treatment in all patients with heart
failure, regardless of NYHA class
 Enalapril Initial: 2.5 mg PO BID (Target:10-20 mg
BID)
 Captopril Initial: 6.25 mg PO TID (Target: 50-100mg
TID)
 Lisinopril Initial: 5 mg PO Daily (Target: 20- 40 mg
Daily)
**ARB’s have comparable mortality reduction, used
when ACE-I not tolerated**
 Management
Beta-Blockers

 These BB decrease MORTALITY in patients with heart failure who

already are taking an ACE inhibitor and/or a diuretic.
 start low and go slow (double every 2-4 weeks)
 Coreg 3.125 mg PO BID (Target: 25 to 50 mg BID)
 Metoprolol Succinate 12.5 mg PO daily (Target: 200 mg daily)
 Bisoprolol 1.25 mg PO daily (Target: 5 to 10 mg PO daily)
 COMET (2003): NYHA classes II-IV treated with Coreg had greater
reduction in mortality than those treated with metoprolol, although
hypotension was increased in Coreg group

 Relative Contraindications
 Symptomatic Hypotension or pressor requirement
 HR < 60, 2nd or 3rd degree AV block, PAD with ischemia
 Management
 Aldosterone receptor antagonist
(Spironolactone)
 NYHA Class II-IV, LVEF of 35% or less
Reduce morbidity and mortality
Monitor renal function, BMP
 Creatinine 2.5mg/dl or less
 Potassium 5.0 mEq/L or less

 Hydralazine and Isosorbide

 African Americans. NYHA Class III-IV
 Optimal ACE-I and BB
 Reduce morbidity and mortality
 Management
 Digoxin
 Symptom relief in absence of arrhythmias
 decreases hospitalization

 Diuretics
 improve the symptoms and exercise tolerance

 Anticoagulation
 In the setting of Afib and additional cardio-embolic
risk factors
 Management
 Fish Oil
 Conflicting evidence for this, however, not harmful
 Consider 1g daily supplementation with OTC

 Statins
 No evidence for benefit in CHF

 CCB
 Peripheral vasodilators (Amlodipine, Felodipine) safe
to use in HF
 No benefit, and possible harm, with Diltiazem or
Verapamil like drugs
 Management
 ICD
 Primary Prevention
Prior MI (<40 days) and EF <30%
NYHA Class II, EF <35%
Have been on maximal medical therapy > 3 months
Syncope with structural heart disease and sustained VT/VF on EP
study

 Cardiac Resynchronization
 GRADE 1A Indication
1. SR, QRS > 150 ms, LBBB, EF < 35%, NYHA > III with optimal
therapy
 GRADE 1B Indication
1. SR, QRS > 150 ms, LBBB, EF < 30%, NYHA > II with ICD placement
 Nonpharmalogic
Treatment
 Multidisciplinary Approach
 Patient education and instruction
Appropriate hospital follow-up (within 7 days)
 Management of comorbidities
 Decreases hospitalizations and quality of life

Moderate Exercise in chronic stable HF

 Decrease mortality
 Improves hospitalizations and quality of life
 References
 KING, M, KINGERY, J and CASEY, B. “Diagnosis and Evaluation of Heart Failure” Am Fam
Physician. 2012 Jun 15;85(12):1161-1168.

 MCCONAGHY, J. “Outpatient Treatment of Systolic Heart Failure” Am Fam

Physician. 2004 Dec 1;70(11):2157-2164.

 Nishimura, RA et al. “2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease:
executive summary: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines.” Circulation. 2014 Jun 10;129(23):2440-92. doi: 10.1161/CIR.0000000000000029. Epub
2014 Mar 3.
 MKSAP Question 1
A 74-year-old man is evaluated in the emergency department for a 7-day history of
progressive exertional dyspnea associated with a dry cough, increasing orthopnea
(from two to four pillows), and inability to buckle his belt. He has a 20-year history of
hypertension treated with diltiazem.

On physical exam, blood pressure is 162/86 mmHg, pulse rate is irregularly irregular
at 84/min, and respiration rate is 18/min. Estimated central venous pressure is 14 cm
H2O. Cardiac examination reveals an irregularly irregular rhythm and an S4. Bibasilar
crackles are heard on auscultation of the lungs. His liver is enlarged 2 cm below the
costal margin. His extremity examination reveals bilateral pitting edema.

Serum electrolyte levels and kidney function tests are normal. Serum B-type
natriuretic peptide level is 2472 pg/mL. ECG shows atrial fibrillation. Echocardiogram
shows a left ventricular ejection fraction of 60%, septal wall thickness of 1.5 cm, and
posterior wall thickness of 1.4 cm. Chest radiograph shows hazy bilateral infiltrates.

Which of the following is the most appropriate next step in management?

(A) B-Blocker
(B) Cardioversion
(C) Furosemide
(D) Spironolactone
 Manage heart failure with preserved ejection fraction with
diuretics.

Answer: C Furosemide

This patient should be admitted to the hospital and given IV furosemide. His
presentation is characteristic for heart failure with preserved ejection fraction
(HFpEF). He has volume overload manifested by increasing abdominal girth,
increased exertional dyspnea, and progressive orthopnea. His left ventricular
ejection fraction is normal, but he has mild left ventricular hypertrophy and a
long history of hypertension. Additionally, he has a markedly elevated B-type
natriuretic peptide level. The etiology of his acute exacerbation into heart failure
is most likely acute atrial fibrillation, but because he is already on diltiazem and
has a normal heart rate, he may have been in atrial fibrillation for some time
and not noticed it.

In contrast to patients with a reduced ejection fraction, no drugs have been

shown to reduce mortality rates in patients with HFpEF. Instead,
guidelines emphasize controlling blood pressure and volume. Patients with
HFpEF are often volume sensitive, and careful use of diuretics to maintain
euvolemia is important. This patient is not already taking a diuretic, and starting
with a low dose of furosemide is a reasonable approach. Patients with HFpEF
should be encouraged to monitor their weight closely, as small differences in
volume can quickly cause volume overload and subsequent hospital admissions.
B-blocker therapy is relatively contraindicated in this patient with acute
decompensated heart failure as it may exacerbate his heart failure. Once his
heart failure is successfully treated with diuretics, this patient may benefit
from B-blocker therapy to manage his heart rate and blood pressure.

Despite the fact that the patient is currently in atrial fibrillation,

cardioversion at this point is incorrect. Because he is hemodynamically
stable with good rate control, there is no indication for immediate
cardioversion.

Several small trials have suggested that aldosterone antagonists may

improve diastolic function in patients with HFpEF. However, a recent trial
comparing spironolactone with placebo showed a reduction in heart failure
hospitalizations but no difference in mortality rates or all-cause
hospitalizations in patients with HFpEF, and spironolactone was associated
with significant increases in serum creatinine and potassium levels.

Key point: Patients with HFpEF are often volume sensitive, and
careful use of diuretics to maintain euvolemia is important.
 Question 2
A 56-year-old man with heart failure is admitted to the hospital with a 2-week history
of increasing exertional dyspnea and fatigue. He also has type 2 diabetes mellitus.
Medications are metformin, lisinopril, carvedilol, furosemide, metolazone, and
digoxin.

On physical examination, blood pressure is 88/60 mmHg, pulse rate is 95/min, and
respiration rate is 20/min. He is somewhat confused and inattentive. Jugular venous
distension is present to the angle of the jaw while sitting. Cardiac examination
reveals an S3. There are bibasilar crackles on pulmonary examination. He has edema
to the mid-thighs. Extremities appear mottled and are cool to the touch.

Serum creatinine level is 3.1 mg/dL; baseline value was 1.1 mg/dL. Serum sodium
level is 133 mEq/L. ECG shows no evidence of ischemia. Chest radiograph shows
cardiomegaly and vascular congestion.

In addition to intravenous diuresis, which of the following is the most

appropriate management?
(A) Dobutamine
(B) Intra-aortic balloon pump
(C) Milrinone
(D) Right heart catheterization
Answer: A Dobutamine

This patient should be started on dobutamine for probable cardiogenic shock.

Cardiogenic shock is present when there is systemic hypotension and evidence
for end-organ hypoperfusion, primarily due to inadequate cardiac output.
Cardiogenic shock usually requires treatment intravenous vasoactive
medications and, in severe cases, device-based hemodynamic support.  
In this patient, initiating inotropic therapy is reasonable. Both dobutamine and
milrinone are used to increase cardiac output; however, in the setting of kidney
dysfunction, dobutamine would be the appropriate choice because milrinone is
metabolized by the kidneys. Also, milrinone is a vasodilator, which could
exacerbate his hypotension.
Mechanical therapy for cardiogenic shock should be considered in patients with
end-organ dysfunction that does not rapidly show signs of improvement (within
the first 12-24 hours) with IV vasoactive medications and correction of volume
overload. It is premature to consider mechanical therapy for this patient.
Right heart catheterization can be helpful to guide therapy if volume status or
cardiac output is uncertain. However, it has not been shown to improve
outcomes in patients hospitalized with heart failure. Placement of a right heart
catheter is not necessary prior to initiating inotropic therapy.
 Question 3
A 66-year-old woman is evaluated prior to discharge. She has ischemic cardiomyopathy
and was admitted to the hospital 5 days ago for worsening symptoms of heart failure.
She skipped taking her diuretics during a recent business trip. Today, she feels well and
is able to walk around the ward twice without any symptoms.

This was her first hospitalization in 3 years, although she has skipped her diuretics
during other business trips without apparent ill effect. She had an implantable
cardioverter-defibrillator placed 3 years ago. An echocardiogram 1 month ago showed a
left ventricular ejection fraction of 15% (stable for the past 6 years). Medications are
captopril, metoprolol succinate, digoxin, furosemide, and spironolactone.

On physical examination, blood pressure is 110/72 mmHg, pulse rate is 56/min, and
respiration rate is 14/min. She has no jugular venous distension and no S3. Lungs are
clear, and she has no edema. ECG shows sinus rhythm, a QRS interval of 90 ms, and Q
waves in V1 through V4. There are no changes compared with the admission ECG
recorded 3 years ago.

Which of the following is the most appropriate management?

(A) Discharge and schedule follow-up within 7 days
(B) Measure B-type natriuretic peptide
(C) Obtain echocardiography prior to discharge
(D) Upgrade to biventricular implantable cardioverter-defibrillator
Answer: A Discharge and schedule follow-up within 7 days

This patient should be discharged home, with a follow-up appointment

scheduled within 7 days. She has had one heart failure hospitalization in
the past 3 years and her nonadherence with her diuretic medication was
the most likely cause of the admission.

With any heart failure hospitalization, it is important to reassess several

factors before discharge. First, patients must be adequately diuresed
prior to discharge. It is important to know that measuring a serum BNP
level will not help with that assessment. Patients should be examined for
flat neck veins, resolution of peripheral or abdominal edema (if possible),
and resolution of the signs and symptoms of acute heart failure. Second,
patients should be on appropriate medical therapy for their stage of
heart failure. For this patient, appropriate medications include ACE
inhibitor or ARB, B-blocker, aldosterone antagonist, and an adequate
dosage of diuretic to prevent readmission. Third, it has been
demonstrated that a patient seen within 1 week after discharge is
associated with a reduction of future heart failure
hospitalizations.
An echocardiogram performed 1 month ago demonstrated that the
patient’s left ventricular function is stable. There is no suggestion of
ischemia or change in valvular function as a precipitant of this
hospitalization. If this patient had not had an echocardiogram in at least 6
months, it would be reasonable to repeat the echo.

Patients are candidates for a biventricular pacemaker if they have all of

the following indications: on guideline-directed medical therapy, a reduced
ejection fraction (<35%), a wide QRS interval (>150 ms) or a left bundle
branch block, and New York Heart Association functional class III or IV
symptoms. This patient has a narrow QRS interval and therefore would not
be a candidate for upgrading to a biventricular implantable cardioverter-
defibrillator.

Key point: patients hospitalized for heart failure who are

scheduled for a follow-up appointment within 1 week after
discharge have a reduced risk of future heart failure
hospitalization.
 Question 4
A 77-year-old man with a 5-year history of idiopathic cardiomyopathy is evaluated
for progressive exertional fatigue and dyspnea. He has recently stopped carrying
groceries in from the car because of his exertional dyspnea. He had an
implantable cardioverter-defibrillator placed 3 years ago. Medical history is also
significant for hypertension. Medications are lisinopril 40 mg/d; metoprolol
succinate 25 mg/d; furosemide 40 mg/d; and spironolactone 25 mg/d.

On physical examination, blood pressure is 94/60 mmHg and pulse rate is 70/min.
Estimated central venous pressure is 5 cm H2O. There is no edema.

Serum electrolyte levels and kidney function are normal. ECG shows normal sinus
rhythm, a PR interval of 210 ms, QRS duration of 160 ms, and a new left bundle
branch block. His left ventricular ejection fraction 3 months ago was 25%.

Which of the following is the most appropriate next step in

management?
(A) Cardiac resynchronization therapy
(B) Dobutamine therapy
(C) Increase furosemide dose
(D) Left ventricular assist device placement
Manage heart failure with cardiac resynchronization therapy

Answer: A Cardiac resynchronization

This patient with symptomatic heart failure and a reduced left ventricular
ejection fraction with evidence of significant conduction system disease
should undergo placement of a biventricular pacemaker (cardiac
resynchronization therapy [CRT]). He has progressive heart failure symptoms
while on appropriate medical therapy and has New York Heart Association
functional class III symptoms. With his EF less than 35% and left bundle
branch block (LBBB), he is a candidate for a biventricular pacemaker, which
has been demonstrated to reduce mortality and symptoms in patients with
NYHA functional class III and IV heart failure by improving cardiac
hemodynamics.

The 2013 American College of Cardiology Foundation/ American Heart

Association/ Heart Rhythm Society guideline recommends CRT therapy in
patients with an ejection fraction of 35% or below, NYHA functional class III
or IV symptoms on guideline-directed medical therapy, and LBBB with QRS
duration greater than or equal to 150 ms. This patient already has an
implantable cardioverter-defibrillator. Now that he has developed a LBBB and
an increase in symptoms, it is reasonable to proceed with placement of a
biventricular pacemaker as well.
Inotropic therapy, such as dobutamine, is reserved for patients with end-
stage heart failure, either as a bridge to transplantation or for palliative
care. Although this patient has progressive symptoms, he has not reached
this stage yet, and has no indication for inotropic therapy.

The patient has no evidence of volume overload on examination and a

borderline low blood pressure; therefore, increasing his diuretic dose would
not be expected to improve his symptoms and may worsen them by
lowering his cardiac filling pressures and cardiac output.

The patient is fairly symptomatic but has not yet had optimal therapy, as
he has an indication for CRT and has not yet received it. Left ventricular
assist devices (LVAD) are reserved for patients with end-stage refractory
heart failure as a bridge to heart transplantation or as destination therapy
in selected patients who are not candidates for transplantation. However,
prior to being considered for either an LVAD or heart transplantation, a
patient must be on optimal medical therapy.

Key point: Cardiac resynchronization therapy is recommended in

patients with an EF of 35% or below, NYHA functional class III or IV
symptoms on guideline-directed medical therapy, and LBBB or QRS
duration of 150 ms or greater.
 Question 5
A 72-year-old woman is evaluated for progressive heart failure symptoms. She has 10-
year history of nonischemic heart failure. She currently experiences exertional dyspnea
with climbing one flight of stairs, which she was able to do without shortness of breath 3
months ago. Medical history is significant for hypertension, and her medications are
lisinopril, carvedilol, furosemide, digoxin, and spironolactone. The patient is black.

On physical examination, blood pressure is 134/72 mmHg and pulse rate is 66/min. BMI
is 35. She has no jugular venous distension. Cardiac examination reveals a grade 1/6
holosystolic murmur but is otherwise normal. There is no lower extremity edema. The
remainder of her examination is unremarkable.

Laboratory studies are significant for normal electrolyte levels and a serum creatinine
level of 1.5 mg/dL. ECG shows normal sinus rhythm, a QRS duration of 110 ms, and
nonspecific ST-T wave changes. Echocardiogram shows a left ventricular ejection
fraction of 38% and trace mitral regurgitation.

Which of the following is the most appropriate treatment?

(A) Add hydralazine and isosorbide dinitrate
(B) Add losartan
(C) Add warfarin
(D) Cardiac resynchronization therapy
 Treat a black patient with heart failure with hydralazine and
isosorbide dinitrate in addition to usual therapy.

Answer: A Add hydralazine and isosorbide dinitrate 

This patient should have hydralazine and isosorbide dinitrate added

to her medication regimen for the treatment of her heart failure. She
has New York Heart Association functional class III heart failure and
is black. Hydralazine and isosorbide dinitrate have been
demonstrated to improve symptoms and reduce mortality in
patients who are black and who are already on maximal therapy
with NYHA class III or IV heart failure symptoms. Adverse effects of
this therapy include peripheral edema and headaches, but this
regimen should be attempted in these patients.

Optimal therapy for patients with heart failure includes treatment

with an ACE inhibitor, B-blocker, and an aldosterone antagonist. The
addition of an angiotensin receptor blocker, such as losartan, to this
combination is generally not recommended, primarily because of
concern for hyperkalemia. Additionally, no benefit to this treatment
regimen has been documented.
In patients with heart failure, warfarin treatment is
appropriate only for those with another indication, such as
atrial fibrillation meeting CHADS-VASc criteria, but not heart
failure alone. The routine treatment of patients with heart
failure with warfarin is not indicated.

Cardiac resynchronization therapy (CRT) may be an effective

therapy in patients with heart failure and a prolonged QRS
duration indicating dyssynchrony. Because this patient does
not have evidence of dyssynchrony or an ejection fraction of
35% or less, she is not a candidate for treatment.

Key point: Hydralazine and isosorbide dinitrate

improve symptoms and reduce mortality in patients
with NYHA class III or IV heart failure symptoms who
are black and are already on maximal therapy.