Chronic heart failure management

Diagnosis & Staging - The Heart's Report Card

• Initial Workup: H&P, ECG, CXR.
• Labs: ↑ BNP or NT-proBNP levels point to cardiac etiology over pulmonary.

⭐ BNP < 100 pg/mL has a high negative predictive value for ruling out acute HF.

• Imaging: Transthoracic Echo (TTE) is essential.
  • Measures LVEF to classify: HFrEF (≤40%), HFmrEF (41-49%), HFpEF (≥50%).

• Staging (ACC/AHA): Guides therapy.

Pharmacotherapy - The Pill Parade

• Guideline-Directed Medical Therapy (GDMT) for HFrEF (LVEF ≤ 40%) is based on four pillars to ↓ mortality.
• Diuretics (Loop & Thiazide): For symptom relief (congestion, edema) ONLY. No mortality benefit.
  • Titrate to euvolemia.

• Pillar Details:
  • ARNI/ACEi/ARB: Sacubitril-valsartan is preferred over ACEi/ARB.
  • Beta-Blockers: Use specific ones: Carvedilol, Metoprolol succinate, Bisoprolol.
  • MRAs: Spironolactone, Eplerenone. Watch for ↑ K⁺.
• HFpEF (LVEF ≥ 50%):
  • No established mortality-reducing therapy until recently.
  • Manage comorbidities (HTN, AFib, DM) and use diuretics for congestion.

⭐ SGLT2 Inhibitors (-gliflozins): Initially for diabetes, now a cornerstone of HFrEF treatment for ALL patients, regardless of diabetes status, due to significant reduction in cardiovascular death and hospitalization for heart failure. They are also showing benefit in HFpEF.

Device & Advanced Therapies - Shock & Awe

• Implantable Cardioverter-Defibrillator (ICD): Primary prevention of sudden cardiac death (SCD).
  • Indicated for LVEF ≤35% & NYHA class II-III symptoms despite optimal medical therapy (GDMT).
  • Must be >40 days post-MI.
• Cardiac Resynchronization Therapy (CRT): Improves symptoms & mortality.
  • Indicated for LVEF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms, & NYHA II-IV symptoms on GDMT.
• Advanced Therapies: For refractory end-stage HF.
  • LVAD (bridge-to-transplant/destination) & heart transplant.

⭐ CRT offers the most benefit in patients with LBBB and a QRS duration of ≥150 ms.

Lifestyle & Comorbidities - The Daily Grind

• Dietary Restriction:
  • Sodium <2-3 g/day
  • Fluid <2 L/day (especially in Stage D or with hyponatremia)
• Self-Monitoring: Daily weights to detect fluid retention early.
• Exercise: Regular aerobic activity (e.g., walking) improves functional capacity & quality of life.
• Key Comorbidities: Aggressively manage HTN, DM (SGLT2i are key!), obesity, and iron deficiency.
• Vaccinations: Annual influenza, pneumococcal vaccine.
• Avoid: NSAIDs, most antiarrhythmics, non-dihydropyridine CCBs.

⭐ Obstructive Sleep Apnea (OSA) is a common, reversible cause of HF exacerbation; screening is crucial.

High‑Yield Points - ⚡ Biggest Takeaways

• The four pillars of HFrEF therapy with mortality benefit are ARNI/ACEi/ARB, β-blockers, MRAs, and SGLT2 inhibitors.
• Loop diuretics (e.g., furosemide) manage volume overload and improve symptoms but do not reduce mortality.
• Use only proven β-blockers: carvedilol, metoprolol succinate, or bisoprolol.
• SGLT2 inhibitors (-gliflozins) are standard of care for HFrEF, even in patients without diabetes.
• An ICD is indicated for primary prevention if LVEF remains ≤35% despite optimal medical therapy.