Vignette says a 68 year old male with a history of hypertension, diabetes mellitus and coronary artery disease presents to the emergency department with progressive onset of shortness of breath over the past 2 weeks; He also reports increasing fatigue, orthopnea (i.e. difficulty breathing when lying flat), paroxysmal nocturnal dyspnea (i.e. waking up at night feeling short of breath) and bilateral leg swelling up to the knee; He also reports of unintentional weight gain of 2 kg in the past 4 weeks; He has a history of hypertension, diabetes mellitus and coronary artery disease and takes medications for hypertension, diabetes and dyslipidemia; Examination shows jugular venous distension, 2 + pitting edema; On auscultation bilateral crackles/rales along with S3 heart sound are heard; CXR shows cardiomegaly with bilateral pleural effusions; Laboratory studies show elevated BNP & NT pro BNP, elevated BUN & creatinine and hyponatremia; Echocardiogram shows dilated left ventricle, left ventricular ejection fraction (LVEF) of 35%, and enlarged left atrium; Diagnosis?
The American College of Cardiology (ACC) defines Heart Failure with Reduced Ejection Fraction (HFrEF) as a clinical syndrome characterized by:-
Diagnosis:-
1. CBC, Serum electrolytes, Troponins, BNP/NT pro BNP, RFT, and LFT; (BNP>400 pg/mL, NT pro BNP> 450mg/dL if < 50 years of age, NT pro BNP> 900mg/dL if 50-74 years of age and NT pro BNP> 1800mg/dL if > 75 years of age indicates acute heart failure).
2. Chest x ray shows pulmonary edema, cardiomegaly, Kerley B lines and pleural effusion.
3. ECG shows LVH, atrial enlargement, condition abnormalities (e.g. LBBB, RBBB), ischemic changes, and arrhythmias (e.g. atrial fibrillation, sinus tachycardia, premature ventricular ectopic, ventricular tachycardia).
4. Echocardiography shows reduced left ventricular ejection fraction, regional wall motion abnormalities, dilated LV & LA and valvular dysfunction.
5. Radionuclide ventriculography.
6. Cardiac MRI.
7. Coronary angiography.
Management of chronic HFrEF:-
1. ACE-i (e.g. Enalapril, Lisinopril) /ARBs (e.g. losartan, valsartan, telmisartan)/ ARNI (e.g. sacubitril-valsartan); The PARADIGM- HF showed that Sacubitril/valsartan is superior to enalapril in reducing mortality and HF hospitalizations.
2. Beta blockers (e.g. Metoprolol, Carvedilol).
3. MRA (e.g. Spironolactone); The RALES trial (Randomized Aldactone Evaluation Study) showed that spironolactone significantly reduced mortality and hospitalizations in patients with severe HFrEF (LVEF ≤ 35%), particularly those with symptomatic heart failure.
4. SGLT2i (e.g. empagliflozin. Dapagliflozin); The DAPA-HF trial showed that Dapagliflozin significantly improved outcomes in HFrEF patients (i.e. reduced CV death and HF hospitalization), even in those without diabetes.
5. Diuretics (e.g. Furosemide, Torsemide).
6. Hydralazine and Nitrates (decreases mortality and morbidity in HFrEF among African Americans, with NYHA class III-IV HF receiving optimal medical therapy (OMT) with ACEi and beta-blockers).
7. Adjunctive therapies:- Anticoagulation (patients with AFib); ivabradine (HR >70 bpm on maximally tolerated beta blocker therapy); Iron therapy (serum ferritin <100, TSAT<20%), and Digoxin (decrease hospitalization of HFrEF).
8. Inotropes (e.g. Dobutamine, Milrinone) as a bridge therapy for cardiac transplantation or Ventricular Assist Devices (e.g. IABP, impella, tandem heart and ECMO) in patients with stage D HF refractory to Guideline Directed Medical Therapy (GDMT).
9. CRT (EF< 35% and QRS > 130 ms).
10. ICD (EF< 35% and QRS < 130 ms).
11. Ventricular assist device (VAD).
12. Heart transplantation.
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Admit to hospital for management of acute decompensated heart failure and includes oxygen therapy via noninvasive ventilation (i.e. CPAP/BiPAP), diuretics (e.g. furosemide), vasodilators (e.g. nitroglycerin) and inotropes (e.g. dobutamine, milrinone).
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