Definition
What is the definition of CHF?
Heart can't pump enough oxygen-rich blood to meet your body's needs
Two types of remodeling in CHF?
Concentric and Eccentric
Common signs of HF
Exercise intolerance
Unintentional weight loss
Refractory volume overload
Worsening Renal Function
Recurrent ventricular arrhythmias
Hypotension
Signs of inadequate perfusion (eg, low pulse pressure)
GDMT is what class recommendation?
ALL GDMTs are Class 1 recommendations
What are the NYHA Functional Classifications?
New York Heart Association (NYHA) Classification of Heart Failure
I: No limitation of physical activity. Ordinary physical activity does not cause sxs of HF
II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in sxs of HF.
III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes sxs old HF.
IV: Unable to carry on any physical activity w/o sxs of HF or sxs of HF at rest.
Reduced EF vs Preserved EF?
Reduced Ejection Fraction: EF≤40%
• Systolic HF
Preserved Ejection Fraction: EF≥50%
•Diastolic HF
•HFpEF, mildly reduced EF 41-49%
What is HFpEF?
Remodeling that affects the LV and left atrial (LA) chambers, the right ventricle (RV), the cardiomyocytes, and the extracellular matrix
Concentric pattern of LV remodeling and a hypertrophic process
Right-sided HF can cause {blank} congestion.
Hepatic congestion called congestive hepatopathy
If the patient cannot tolerate an ACEi or ARB, which medication can they replace it with?
ARNi = ARB + neprilysin inhibitor, sacubitril/valsartan (i.e. Entresto)
How many stages of HF? (AHA/ACC/HFSA)
American Heart Association/American College of Cardiology/Heart Failure Society of America
There are 4 stages
What is improved HFpEF?
EF previously was less than or equal to 40% and now its great than 40%
What is HFrEF?
Progressive chamber dilation and eccentric remodeling
If you suspected CHF, what would you order?
Labs (CBC, CMP), BNP, EKG, Echo, CXR
In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate ACEi or ARB, which medication is recommended to replace them to reduce morbidity and mortality further?
Replacement by an ARNI is recommended to reduce morbidity and mortality further. (Class I)
Inhibition of neprilysin results in natriuretic, vasodilatory, and anti-proliferative effects.
Combination reduces hospitalization, CV death, all-cause mortality.
Allow 36h between stopping ACEI and starting ARNI (concern for angioedema)
Stage A?
At-risk HF
Hx of HTN, CVD, DM, obesity, cardiotoxic agents exposure, family hx, genetics
What does GDMT mean in HF?
Guideline-Directed Medical Therapy (GDMT)
Why does eccentric remodeling occur vs concentric remodeling?
Eccentric hypertrophy typically occurs in response to chronic volume overload, leading to increased myocyte length and a dilated ventricle (volume overload)
Concentric hypertrophy results from chronic pressure overload, causing wall thickening with normal or small chamber size. (pressure overload)
What finding would you see on EKG in an advanced CHF patient?
Advanced HF (eg, Q waves, ST and T wave abnormalities in patients with prior myocardial infarction or with cardiomyopathy).
What medications are in GDMT?
1. ARNI; ACEi or ARB
2. Beta blocker
3. Mineralocorticoid receptor antagonist
4. SGLT2i
Stage B?
Pre-Heart Failure
No HF sxs, but has structural disease, evidence of filling pressure or RF plus increased BNP or peristently elevated trops
What is BNP?
BNP (brain natriuretic peptide) is secreted from the ventricles in response to ventricular volume expansion and pressure overload
How is BNP removed from the body?
BNP undergoes partial renal excretion; levels are inversely proportional to creatinine clearance.
What findings are seen on the chest X-ray in a CHF patient?
Pulmonary edema, pleural effusions, and/or pulmonary vascular congestion
Is exercise recommended in HF patients?
CLASS 1 RECOMMENDATION
Exercise-based cardiac rehabilitation or preserved ejection fraction
Reduced hospital admissions and improved quality of life without affecting all-cause mortality
Stage C and D?
Symptomatic HF: Current or previous signs/sxs of HF
Advanced HF: Marked HF sxs that interfere with daily life, recurrent hospitalizations despite attempts to optimize GDMT