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Primary Care
CMECNE

Management of Heart Failure

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the key elements in the work up for patients with heart failure
2. Describe the various treatment approaches for patients with heart failure

Estimated time to complete activity: 0.5 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.


The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 12/01/2022 through 12/01/2024, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours.

Designated for 0.25 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

Heart failure (HF) is a broad term that encompasses many different etiologies and degrees of cardiac dysfunction, but generally refers to impairment of blood flow through the heart. Americans over 40 have a 20% lifetime risk of developing HF. It is associated with considerable morbidity and mortality, and accounts for approximately 1M hospitalizations annually; it is also a major cause of hospital readmission. The 2013 ACC/AHA Guideline for the Management of Heart Failure (with focused updates in 2016 and 2017) offers a comprehensive guide to treating this common condition.

  • Risk Factors
  • Diagnosis of HF
  • Workup at Time of Diagnosis
  • Key Points
    • Terminology
    • Stages and Classes of HF
    • Treatment Considerations – GDMT
    • HFpEF Management
    • Dietary Recommendations
    • Other Considerations
  • Learn More – Primary Sources

Risk Factors

  • Hypertension is the primary modifiable risk factor
  • Treating chronic hypertension leads to 50% reduction in risk of developing HF
  • Other risk factors
    • Coronary artery disease (CAD) | Diabetes | Metabolic syndrome | Smoking | Alcohol | Illicit drug use (cocaine, amphetamines)

Diagnosis of HF

  • Primarily a clinical diagnosis
  • Cardinal symptoms
    • Shortness of breath | Exercise intolerance | Fatigue | Edema

Workup at Time of Diagnosis 

  • Imaging
    • Basic: EKG | Chest X-ray | Echocardiogram
    • New HF with high suspicion for CAD: Coronary angiography +/- revascularization
    • New HF with known CAD: Non-invasive imaging to detect myocardial ischemia (e.g. nuclear myocardial perfusion scan)
  • Labs
    • CBC | Tests of kidney and liver function | Electrolytes | Lipids | TSH | Urinalysis | BNP
    • New evidence suggests screening BNP in patients at risk for HF (i.e. with ≥1 risk factors) “can be useful” in preventing clinical HF

KEY POINTS:

Terminology

  • HF with reduced EF (HFrEF or ‘systolic’ HF) vs. HF with preserved EF (HFpEF or ‘diastolic’ HF)
    • HFrEF: EF≤40%
    • HFpEF: EF>40% | Accounts for half of all HF

Note: HFrEF and HFpEF are not mutually exclusive | Patients often have combined systolic and diastolic dysfunction

Stages and Classes of HF

Guideline-directed medical therapy (GDMT) Is Tailored According to Severity of Disease

  • ACC/AHA stages of HF: Considers symptoms as well as structural cardiac abnormalities
    • A: At risk for HF, no structural heart disease
    • B: Structural heart disease, no symptoms of HF
    • C: Structural heart disease with symptoms of HF
    • D: Refractory HF (not responding to standard medical therapy)
  • New York Heart Association (NYHA) classes of HF: Subjective, based on symptomatology
    • I: No limitation of physical activity
    • II: Slight limitation of physical activity (OK at rest, symptomatic with “ordinary” activity)
    • III: Marked limitation of physical activity (OK at rest, symptomatic with “less than ordinary” activity)
    • IV: Symptomatic at rest or with any level of physical activity

Treatment Considerations – GDMT

  • GDMT recommendations based on large RCTs showing morbidity and mortality benefit for Stages B-D HFrEF only
    • Little evidence of benefit in HFpEF
  • GDMT
    • Reduces morbidity and mortality
    • Improves symptoms and quality of life (QOL)
    • Decreases hospitalizations
  • Some therapies limit cardiac remodeling and lead to improvements in ejection fraction (EF) over time

ACE inhibitors (ACEI): Associated with mortality benefit

  • Examples
    • lisinopril, enalapril, fosinopril        
  • Switch to ARB (losartan, valsartan) if chronic cough develops (20% of patients)
  • Reassess renal function and electrolytes within 1 to 2 weeks after initiation of ACEI or ARB
  • Do not combine ACEI and ARB
  • In NYHA class II to III patients tolerating ACEI/ARB, switch to Entresto (valsartan/sacubitril)

Beta blockers:  Associated with mortality benefit

  • Examples
    • Carvedilol | Bisoprolol | Metoprolol succinate (not tartrate)
  • General rule for dosing
    • ‘Start low, go slow’ | Titrate up to maximum tolerated dose

Aldosterone antagonists: Mortality benefit for NYHA II-IV with EF≤35%

  • Examples
    • Spironolactone, eplerenone
  • Major risk is hyperkalemia
    • Start only if GFR >30 ml/min and K+ <5
    • Reassess renal function and electrolytes 3 and 7 days after starting

Loop diuretics: Indicated for Stages C-D for relief of symptoms due to fluid overload; no known effect on mortality

  • Examples
    • Furosemide | Bumetanide | Torsemide
  • Titration
    • Largely based on symptoms and clinical assessment of volume status (weight, urine output, BNP)
    • Most patients will require chronic fixed doses to maintain euvolemia

Other medications

  • Digoxin
    • For persistent symptoms despite GDMT | Shown to decrease hospitalizations
  • Hydralazine + isosorbide dinitrate: For persistent symptoms despite GDMT in NYHA III-IV African American patients
  • Ivabridine
    • Can reduce HF hospitalizations in a small subset of patients: NYHA class II-III with EF≤35% on GDMT and sinus rhythm with resting HR≥70 bpm
    • Omega-3 fatty acids: “reasonable to use as adjunctive therapy” for NYHA II-IV HFrEF or HFpEF

Drugs to avoid

  • Calcium channel blockers
    • Can worsen HF (particularly non-dihydropyridines due to their negative inotropic effect); amlodipine may be OK
    • NSAIDs: Cause sodium and water retention
    • Thiazolidinediones: Increased incidence of HF events

HFpEF Management

  • Recommendations are limited to BP control
    • First line: ACEI or ARB
    • Diuretics for symptom management
  • Mortality benefit of GDMT for HFrEF when applied to HFpEF has not been convincingly demonstrated

Dietary Recommendations

  • Sodium restriction
    • Stages A and B: <1.5 g/day
    • Stages C and D: <3 g/day
  • Fluid restriction: <1.5-2L/day only recommended in Stage D (refractory) HF

Other Considerations

  • Indications for CABG
    • HFrEF or HFpEF with angina despite GDMT or significant multivessel disease
  • Indications for ICD placement for primary prevention of sudden cardiac death
    • EF≤35% (NYHA II-III) or EF≤30% (NYHA I)
    • On GDMT
    • Expected survival ≥1 year
  • Repeat echocardiogram in a patient with ≥1 of the following
    • Significant change in clinical status
    • Experienced or recovered from a clinical event
    • Received treatment, including GDMT, with potentially significant effect on cardiac function
  • HF and obstructive sleep apnea
    • CPAP “can be beneficial” to improve EF and functional status
  • HF and anemia
    • NYHA II-III and iron deficiency (ferritin<100 ng/mL), IV iron “might be reasonable” to improve functional status and quality of life

Learn More – Primary Sources:

2013 ACCF/ACA Guideline for the Management of Heart Failure

2016 ACC/AHA/HFSA Focused Update on New Pharmacologic Therapy for Heart Failure

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/ACA Guideline for the Management of Heart Failure

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Related ObG Topics:

Are Optimal Doses of Heart Failure Medications the Same for Men and Women?
ACC/AHA Blood Pressure Treatment Guideline: Lifestyle Modification and Drug Therapy

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Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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