Heart Failure Management

Introduction

• Heart failure is a clinical syndrome characterized by typical symptoms (breathlessness, fatigue, ankle swelling) and signs (elevated jugular venous pressure, pulmonary crackles, peripheral edema) caused by a structural and/or functional cardiac abnormality, resulting in reduced cardiac output and/or elevated intracardiac pressures, as defined by the European Society of Cardiology 1

Classification and Diagnosis

• Heart failure is classified based on ejection fraction, with heart failure with reduced ejection fraction (HFrEF) defined as EF ≤40% and heart failure with preserved ejection fraction (HFpEF) defined as EF ≥50% 2
• The New York Heart Association (NYHA) classification system is used to classify heart failure patients into four classes based on their symptoms and physical activity limitations, as reported by the American Heart Association 3
• Natriuretic peptides (BNP, NT-proBNP) have a high negative predictive value for diagnosing heart failure, and are useful for diagnosis when clinical uncertainty exists 1, 4, 5

• Diagnostic criteria include:

  Diagnostic Test	Threshold
  BNP	>100 pg/mL
  NT-proBNP	>300 pg/mL

Pharmacological Therapy

• The American College of Cardiology recommends a comprehensive approach to heart failure management, including pharmacological therapy with ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors as cornerstone treatments, along with diuretics for symptom management, device therapy when indicated, and structured patient education and follow-up 7
• ACE inhibitors or ARBs are recommended for all patients with heart failure with reduced ejection fraction (HFrEF), with a strength of evidence level of I (high) 8, 1, 9, 7
• Beta-blockers are recommended in addition to ACE inhibitors for stable symptomatic heart failure patients with reduced ejection fraction (HFrEF), with a strength of evidence level of I (high) 8, 1, 9, 4, 10
• Diuretics are essential for symptomatic treatment of fluid overload in heart failure patients, and should be administered in combination with ACE inhibitors when possible, with a strength of evidence level of I (high) 8, 9, 4
• Mineralocorticoid receptor antagonists (MRAs) are recommended for patients with HFrEF who remain symptomatic despite ACE inhibitor and beta-blocker therapy, with close monitoring of potassium and renal function, and a strength of evidence level of I (high) 1, 9, 11
• SGLT2 Inhibitors are recommended for patients with heart failure regardless of ejection fraction, to reduce the risk of heart failure hospitalization and cardiovascular death 12

Device Therapy

• Cardiac Resynchronization Therapy (CRT) may be considered for patients with left ventricular ejection fraction (LVEF) <35% and QRS duration ≥150 ms or 120-149 ms with mechanical dyssynchrony, with a strength of evidence level of I (high) 9, 13
• Implantable Cardioverter-Defibrillator (ICD) therapy may be considered for patients with LVEF <35% (or <30% with QRS ≥120 ms) for primary or secondary prevention of sudden cardiac death, with a strength of evidence level of I (high) 9, 13

Lifestyle Modifications

• Sodium restriction is reasonable for patients with symptomatic heart failure to reduce congestive symptoms, with moderate restriction being better than strict reduction 14
• Addressing obesity is important as it is a risk factor for heart failure progression 5
• Smoking cessation is strongly advised for patients who smoke 5
• Moderate dynamic exercise, such as walking or recreational bike riding, should be encouraged, while avoiding isometric exercise, and supervised exercise-based rehabilitation programs are beneficial for stable patients, with a strength of evidence level of IIa (moderate) 8, 4, 13

Patient Education and Self-Care

• Patient education should facilitate self-care, including explanation of heart failure pathophysiology, symptom recognition, and medication adherence, as well as teaching self-monitoring of weight and symptoms 7
• Patients with symptomatic heart failure should receive specific education to facilitate self-care, including weight and symptom monitoring 14
• The American College of Cardiology recommends patient education on weight monitoring, sodium restriction, symptom management, physical activity, smoking cessation, medication instructions, and minimizing NSAIDs 10

Transitional Care and Multidisciplinary Care

• Patient-centered discharge instructions with a clear transitional care plan and early follow-up within 7 days of hospital discharge are recommended 7
• High-risk heart failure patients should be referred to multidisciplinary disease management programs, which may include cardiologists, primary care clinicians, heart failure nurses, pharmacists, dieticians, and social workers 7
• Disease management programs with a multidisciplinary approach and nurse case management may reduce hospitalization frequency and improve quality of life, with a strength of evidence level of I (high) 9, 15

Symptom Management and End-of-Life Care

• Symptom management, including addressing dyspnea, fatigue, pain, depression, and anxiety, is crucial for patients with advanced heart failure 7, 9
• Consideration of hospice referral may be appropriate for patients with end-stage heart failure, with a strength of evidence level of IIb (low) 7, 9
• The American College of Cardiology recommends considering advance care planning to discuss and document patients' values, goals, and preferences regarding future medical care 7