HEART FAILURE
MAKERERE UNIVERSITY
CARDIOLOGY INTEREST
GROUP LECTURE SERIES
WILLINGTON
AMUTUHAIRE, MBCHB,
MPH
CARDIOLOGY FELLOW,
YALE
Definition of Heart failure
Discuss the clinical presentation of heart failure
Review different classifications of heart failure
Review the etiology of heart failure
Discuss heart failure workup
Management of acute and chronic heart failure
OBJECTIVES
WHAT IS HEART FAILURE
A 56-year-old male with history of anxiety and hypertension
presents to your outpatient clinic with complaints of
shortness of breath. He has a normal weight and physical
examination is normal
Cardiac Echo shows a normal left ventricular function ( EF
56%) with moderate left ventricular Hypertrophy. Serum
BNP is 80
Does he have heart failure?
UNIVERSAL DEFINITION
Combination of 3 things:
[Link] and or signs of heart failure
[Link] or functional cardiac abnormality
[Link] of congestion ( Elevated BNP, Filling
pressures on SWAN, Pulm edema on CXR)
Symptoms of heart failure
Breathlessness
Orthopnea
Paroxysmal nocturnal dyspnea
Reduced exercise tolerance
Fatigue or tiredness
Ankle swelling or body swelling
Bendapnea
Signs of heart failure
Elevated jugular venous pressure
Third heart sound
Summation gallop
Cardiomegaly ( displaced apical impulse)
Hepatojugular reflux
Structural or functional cardiac abnormality
Reduced Ejection fraction <50%
Cardiac chamber enlargement e.g severe dilation of RA/LA
Diastolic dysfunction E/E’>15
Moderate or severe ventricular Hypertrophy
Moderate or severe Stenotic or regurgitant valvular lesions
e.g severe AS or MR
Heart failure Classifications
Stages and trajectories
Left ventricular ejection fraction
Chamber involvement ( LV, RV, Bi-V)
Symptomatology/New York Heart Association
Etiology ( Ischemic VS non-ischemic)
Stages and Trajectories
Stage Stage
A B Stage C Stage D
Symptomatic Advanced
At risk for Pre-Heart Heart failure heart failure
heart
failure failure
Stages
Stageand Trajectories
A: Much larger group, no signs and symptoms, no
structural or functional changes but have risk factors such
DM, HTN, obesity, FHx of cardiomyopathy, exposure to
cardiotoxicity e.g chemotherapy
Stage B: No signs and symptoms but have structural
cardiac changes e.g LVH, Low EF with no symptoms,
dilated LA, Elevated BNP
Stage C: Patients you will meet in the clinic or on wards
with signs and Symptoms of heart failure
Stage D: End stage HF, refractory to medical therapy,
need advanced HF therapies ( LVAD, Heart transplant, End
LV EJECTION FRACTION CLASSIFICATIONS
HF with reduced EF( HFrEF): LVEF<40%
HF with mildly reduced EF (HFmrEF): LVEF: 41-
50%
HF with preserved EF(HFpEF): LVEF: ≥50%
HF with improved EF (HFimpEF): Baseline EF
<40, ↑10%
HF DIAGNOSIS
A 56-year-old male with history of anxiety and hypertension presents
to your outpatient clinic with complaints of shortness of breath. He has
a normal weight and physical examination is normal.
Cardiac Echo shows a normal left ventricular function ( EF 56%) with
moderate left ventricular Hypertrophy. Serum BNP is 80
Does he have heart failure?
Yes:
Signs and symptoms: Breathlessness
Cardiac abnormality: Left ventricular Hypertrophy
Congestion: Elevated BNP ( >35)
DIAGNOSIS OF HF
Does he have heart failure?
Yes!!
[Link] and symptoms: Breathlessness
2. Cardiac abnormality: Moderated Left ventricular
Hypertrophy
3. Evidence of congestion: Elevated BNP ( >35)
What is the cause: Hypertensive cardiomyopathy
What is the stage: C
Classification: HFpEF (EF≥50%)
CHF Classification based on symptoms/function status
(NYHA)
Class I: No symptoms of heart failure.
Class II: Symptoms of heart failure with moderate
exertion.
Class III: Significant limitations due to symptoms
with mild activity.
Class IV: Symptoms at rest, worsened with any
physical activity
Terminologies to avoid: Diastolic heart failure, CHF
etc
ETIOLOGY OF HEART FAILURE
A: Ischemia e.g large MI, leading to ischemic
cardiomyopathy
B: Hypertension: Likely the leading cause in Uganda:
Leads to diastolic dysfunction initially followed by systolic
dysfunction
C: Advanced Valvular heart disease.
D. Others ( Cardiomyopathy not due to HTN, IHD, VHD)
OTHER CAUSES OF HEART FAILURE
[Link]: mostly viral ( Adeno, Coxsackie, HIV, EBV, CMV, Hep B, influenza,
Covid 19)
2. Toxic Cardiomyopathy: Alcohol, Cocaine, chemotherapy ( Adriamycin,
cyclophosphamide, Trastuzmab), immunotherapy e.g pembrolizumab
[Link] cardiomyopathy: HOCM, LV Noncompaction
[Link]/infiltrative cardiomyopathy: Sarcoidosis, amyloidosis, Endomyocardial
fibrosis, hemochromatosis
[Link] mediated cardiomyopathy: Tachyarrhythmia faster than 120 bpm for
> 2wks e.g uncontrolled atrial fibrillation
[Link]: Hypo or hyperthyroidism, beri-beri, Anemia
[Link] cardiomyopathy ( Takatsubo/Apical ballooning syndrome)
8. Peripartum Cardiomyopathy: Heart failure in last month of pregnancy or within 5
months of delivery
8. Sepsis associated cardiomyopathy: Up to 50% of patients with severe sepsis
HEART FAILURE WORKUP
What are you looking for in your heart failure workup?
[Link] of heart failure: Blood pressure, CBC, Hemoglobin
A1C, iron levels, lipid panel, TSH, Respiratory viral panel, HIV,
Thiamine levels, CXR, EKG, Ischemia evaluation (stress test,
coronary angiogram), Cardiac MRI, PYP scan, Endomyocardial
biopsy
[Link] and severity of congestion: BNP, CXR, SWAN
[Link] or severity of heart failure: EKG, TTE,
RFP, LFTs, lactate
4 PILLARS FOR IDEAL HEART FAILURE MANAGEMENT
[Link] congestion
2. Optimize guideline directed medical therapy (GDMT)
3. Exercise
4. Timely referral for Heart failure therapies and or
palliative care ( Pacemakers, ICD, revascularization,
Valve replacement, LVAD, Heart transplant)
DEFINITION AND BURDEN OF CONGESTION IN HF
What is congestion in HF: Fluid accumulation in the intravascular
compartment and the interstitial space, resulting from increased cardiac
filling pressures caused by maladaptive sodium and water retention by
kidney
Burden
8/10
In a large long term European registry, 83% of the patients admitted to the
hospital with acute heart failure had clinical signs or symptoms of congestion
Chioncel, o. et al. Clinical phenotypes and outcome of patients hospitalized for acute heart failure: the ESC heart failure long term registry. Eur. J.
Heart fail, 19, 1242-1254 (2017)
Congestion = Poor outcomes
More symptoms
Arrhythmias
Poor Sleep
Poor Appetite
Hospitalization
Mortality
3 TREATMENT GOALS FOR HF PATIENTS
[Link] out of hospital
2. Improved quality of life: Feel well
3. Increase their survival
Congestion impairs all of these goals
TREATMENT FOR CONGESTION
Diuretics in patient
-We mainly use loop diuretics ( furosemide, torsemide, bumetanide)
-Thiazide diuretics: Weak, used mainly for chronic HTN
-For Diuretic naïve patients, you can start with the lowest dose and up titrate prn
-For the patients on outpatient diuretics ( use Dose trial: 2.5x outpatient dose)
What to monitor inpatient
-Kidney function, electrolytes ( K, Mg), when kidney function worsens or patients become alkalotic,
you may be close to euvolemia
-intake and output ( urine output). At least Goal net negative 1-2L daily
-Weight
-Symptoms, oxygen requirements
At discharge
-determine patient’s dry weight, transition to oral stable dose of diuretics, HF education ( salt, diet,
volume)
-Followup in clinic outpatient in 1 week reduces re-admission
GDMT FOR HFrEF
Medications that improve survival ( Mortality benefit)
A. ACE-I/ARB/ARNI ( e.g Lisinopril, losartan, Entresto respectively)
B. Beta blockers: Only 3 ( Carvedilol, Metoprolol XL, Bisoprolol)
C. SGLT-2 inhibitors: Empagliflozin, Dapagliflozin
D. Aldosterone antagonists: Spironolactone, Eplerenone. GFR>30, K<5
E. Hydralazine and nitrates combination ( Isosorbide dinitrate)
Guidelines recommend that patients with HFrEF be on these 4 medications at the same time.
Key Concepts
-Start Low and Slow
-Use Entresto first
-Quadruple therapy saves life
GDMT FOR HFpEF
1.SGLT2 ( class 2a recommendation)
[Link] receptor antagonists/Aldosterone inhibitors ( Class
2b recommendation)
[Link]( Entresto): Class 2 b recommendation
[Link] diabetes, hypertension, Atrial fibrillation, OSA
BARRIERS TO GDMT
[Link]
[Link], electrolyte abnormalities, Kidney
dysfunction
[Link] effects ( Hypotension, AKI, Hyperkalemia, DKA
for SGLT2i, Brady arrythmias for beta blockers)
[Link] pill burden
ACUTE DECOMPENSATED HEART FAILURE
Patients who acutely develop symptoms of heart failure in hours to days and come
to the hospital
Dietary indiscretions, medicine noncompliance
Acute HTN
Acute ischemia/ACS
Arrhythmias such as Afib
Infectious causes
PE
Anemia
Idiopathic: 40-50% have no known precipitant
REFERENCES
1. ACC/AHA HF guidelines
2. ESC Heart failure guidelines
3. Key concepts in heart failure care in 2022, by Erian Gorodeski
[Link] Handbook for clinicians, Elias Hanna
THOUGHTS AND/OR QUESTIONS?
