Dr. Ning presents a new case of decompensated heart failure with reduced EF, most likely due to lack of access to medications vs. Afib with rapid ventricular rate.
Teaching points:
1. How and why do we classify the severity of heart failure? The patient's functional class and stage affect the choice of therapy.
Patients CAN move back and forth between NYHA classes depending on fluid status and progression of heart failure.
In contrast, they may only progress in the ACC/AHA stages.
2. What is guideline-directed medical therapy for HFrEF?
ACEi/ARB: inhibit upregulation of aldosterone pathway
-Goal: uptitrate to maximal doses (ATLAS trial) with blood pressure goal <130/80
Angiotensin receptor - neprilysin inhibitor (valsartan-sacubitril) - additional property of degradation of natriuretic peptides and bradykinin
-PARADIGM-HF trial demonstrated reduction in morbidity/mortality
-Can replace ACEi/ARB in patients with chronic, symptomatic HFrEF who tolerate ACEi/ARB well
Beta Blockers: Improve remodeling, increase EF (specifically bisoprolol, carvedilol, metoprolol)
Initiated when euvolemic, uptitrate slowly (over weeks) to target HR ~60
Loop diuretics: lowest dose that achieves euvolemia
Digoxin: indicated in HFrEF and concommitant Afib if continued symptoms despite above
Aldosterone antagonists: reduce mortality and hospitalizations in NYHA class II-IV, add after ACEi and BB are maximally uptitrated
Isosorbide Dinitrate - Hydralazine: superior to placebo, inferior to ACEi in symptomatic HFrEF
Indicated in patients intolerant of ACEi/ARBs
OR in African American patients with NYHA class III/IV symptoms
3. When should I consider device therapy?
ICDs improve survival for primary and secondary prevention of arrhythmias -- ICD placement in patients receiving guideline-directed medical therapy w/ EF </=35% and NYHA class II/III
Cardiac resynchronization therapy in patients with dyssynchrony (wide QRS interval or LBBB), EF </=35%, NYHA class II to IV heart failure symptoms despite GDMT
4. What about pulmonary hypertension? Resting mean PA pressure >/= 25 mmHg
-Five different subtypes
Group 1: Pulmonary arterial hypertension (idiopathic, drugs, toxin, connective tissue dz, HIV, schistosomiasis, portal hypertension)
Group 2: Pulmonary hypertension due to L-sided heart disease
Group 3: Pulmonary hypertension due to lung diseases and/or hypoxia
Group 4: Chronic thromboembolic pulmonary hypertension and other pulmonary artery obstructions
Group 5: Pulmonary hypertension with unclear or multifactorial causes
Why is it important? This patient had severe LV and RV dysfunction. After they are euvolemic it may be worth re-assessing PA pressure to ensure that there is nothing else contributing to development of potential cor pulmonale (OSA, obesity hypoventilation syndrome, chronic hypoxia, etc).
PH is a risk factor for death in patients with group 2 and 3 disease, and may be directly contributory to death due to RV ischemia, arrhythmias or heart failure.
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