HEART FAILURE: Current Concepts, Diagnosis and Management

Geetha Pinto, MD, FACC

Medical Director, Heart Failure Program

Roper St. Francis HealthCare

Coastal Cardiology, PA

Objectives● Etiology and Diagnosis of Heart Failure● Pathophysiology of Heart Failure ● Pharmacological Considerations ● Current Guidelines about Treatment of

Comorbidities (2017 Focused Update)● Cardio-Onclogy

Facts About Heart Failure ● About 5.7 million U.S. adults have heart failure

● 50% of those patients will die in the next 5 years

● Heart failure costs about $30.7 BILLION EACH YEAR

● About 50% of these patient costs are related to HFpEF

● The prevalence of HFpEF is increasing over that of HFrEF due to aging population with accumulation of risk factors

Definition of Heart Failure

● Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiovascular disorder causing systemic perfusion inadequate to meet the body’s metabolic demands without excessively increasing left ventricular filling pressures.

● It is characterized by symptoms, such as dyspnea and fatigue, and signs, such as fluid retention.

● There are many ways to assess cardiac function. However, there is no diagnostic test for HF, since it is largely a clinical diagnosis that is based upon a careful history and physical examination.

Heart Failure can exist along the ENTIRE SPECTRUM of Ejection Fractions

Elevated Cardiac Filling Pressures is the issue at heart

Classification and Types of Heart Failure

● Based on Ejection Fraction/Ventricle ○ Ejection Fraction

■ Systolic, diastolic, mid-range (EF 41-49%)○ High-Output Heart failure

■ Anemia, hyperthyroidism, AV fistula, sepsis, Paget’s

○ Right-sided, left-sided, combined ○ Classes of HF (NYHA 1-4) = symptoms ○ Stages of HF (A-D)

Etiologies of Heart Failure

VALVULAR DISEASE● Stenosis and Regurgitation ● Diastolic and systolic

HEART FAILURE

HIGH OUTPUT STATES● Anaemia● Sepsis● Thyrotoxicosis● Paget‘s disease● Arteriovenous fistula

VOLUME OVERLOAD● Renal failure● Iatrogenic (e.g. post-

operative fluid infusion

CONGENITAL HEART DISEASE

ARRHYTHMIA● Tachyarrhythmia● Atrial● Ventricular● Bradyarrhythmia● Sinus node dysfunction

CONDUCTION DISORDERS● Atrioventricular block

MYOCARDIAL DISEASE● Coronary artery disease● Hypertension● Cardiomyopathy

ENDOCARDIAL DISEASE● With/without

hypereosinophilia● Endocardial fibroelastosis

PERICARDIAL DISEASE● Constrictive pericarditis● Pericardial effusion

HEART FAILURE WITH PRESERVED EJECTION FRACTION

Goel S, Miller A, Sharma A, Gidwani U, Shani J (2015) Treatment Modalities for Heart Failure with Preserved Ejection Fraction (HFpEF) - Current State of Evidence and Future Perspective. J Clin Exp Cardiolog 6:383. doi:10.4172/2155-9880.1000383

DIAGNOSIS OF HEART FAILURE

● Signs and symptoms ● Cardiac Biomarkers ○ BNP/NT-BNP ○ Troponin

● Evidence of elevated LV filling pressures○ Echo/Stress Echo○ Right heart cath

Signs and Symptoms of Heart Failure

Pathophysiology of Heart Failure- Neurohormonal Activation

June 2016Br J Cardiol 2016;23(suppl 1):S1–S16doi:10.5837/bjc.2016.s01

↑ Sympathetic Tone/SNS activation

↑ RAAS Activity

Counterbalanced by:

↑ but weaker Natriuretic peptide system (NPS)

=Increased inflammation

Increased Oxidative StressIncreased cardiac tissue fibrosis

Goal of Management Strategies

● Prevention ● Improve symptoms/hospitalization/complications/quality of

life (Morbidity)

AND

● Improve Life Span (Mortality)

Management of Acute SYSTOLIC Heart Failure

Pharmacological Management of Chronic SYSTOLIC Heart Failure

Inhibit Sympathetic Tone

Inhibit RAAS Activation

Augment Natriuretic Peptide System Activity and Other Mechanisms

Volume Removal

● BETA BLOCKERS- Carvedilol

- Metoprolol Succinate

- Bisoprolol

- Nebivolol

● ACEi- Enalapril et. al

● ARB - Candesartan/Valsar

tan/losartan

● MRA- Spironolactone- Eplerenone

● Furosemide

● Torsemide

● Bumetanide

● Ethacrynic Acid

● Metolazone/HCTZ

● ARNI (sacubitril-valsartan)

● SGLT2 inhibitors (gliflozins)

AFTERLOAD REDUCERISDN/Hydralazine

(Bidil)

WHAT ABOUT HFpEF?

HFpEF Therapeutic Strategies

Heart failure with preserved ejection fraction: A systemic disease linked to multiple comorbidities, targeting new therapeutic options - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Cardiac-and-extracardiac-factors-involved-in-the-pathophysiology-of-heart-failure-with_fig1_326036459

TOPCAT Trial (2014) Spironolactone vs. Placebo in HFpEF

Heart Failure and Glycemic Control Medications (SGLT-2 Inhibitors)

SGLT-2 INHIBITORS

● Empagliflozin ● Canagliflozin ● Dapagliflozin

2017 Focused Update on HF Guidelines(Management of Comorbidities)

● Sacubitril-valsartan (Class I indication over ACEi, ARB in HFrEF)● Ivabradine (Class IIa indication in HFrEF)● Spironolactone in HFpEF● Anemia /iron deficiency without anemia ● Hypertension ● Sleep disordered breathing

CARDIO-ONCOLOGY

Dr. W. Blount Ellison