Mount Carmel Health Partners Clinical Guidelines Heart Failure

Heart Failure Clinical Guideline
Definition: Heart failure (HF) is a complex clinical syndrome resulting from a structural or functional cardiac disorder that impairs the ability of
the ventricle to fill with or eject blood.
Causes: The most common causes of heart failure after 40 years of age are: Atherosclerosis, HTN, Diseases of the heart valves, Lung disease,
general heart muscle damage from viruses or toxins.
Heart Failure
At Risk for Heart Failure
Stage A
At high risk for developing heart
failure but has no structural
disorder
Patients with:
• Hypertension
• Atherosclerotic disease
• Diabetes mellitus
• Obesity
• Metabolic syndrome
Or
• With family history of
cardiomypathy
• Cardiotoxin use
(e.g., cocaine,chemotherapy)
Stage C
Structural heart disease but
without symptoms of heart
failure Structural heart disease with
prior or current symptoms of
heart failure
Patients with:
• Previous MI
• LV remodeling including LV
and low EF
• Asymptomatic valvular
disease
Patients with:
• Known structural heart disease
• HF signs and symptoms
• Shortness of breath
• Fatigue
• Reduced exercise tolerance
HFpEF
Therapy
Therapy
Goals
• Heart healthy lifestyle
• Prevent vascular, coronary
disease
• Prevent LV Structural
abnormalities
Goals
• Prevent HF symptoms
• Prevent further cardiac
remodeling
Drugs (pages 3-4)
• ACEI or ARB as appropriate
patients for vascular disease or
DM
• Statins as appropriate
Testing
• BNP or NT-pro BNP screening
Stage D
Stage B
Drugs (pages 3-4)
• ACEI or ARB as appropriate
• Beta blockers as appropriate
In selected patients
• ICD
• Revascularization or valvular
surgery as appropriate
Testing
• BNP or NT-pro BNP screening
Therapy
Therapy
Goals
• Control symptoms
• Improve HRQOL
• Prevent hospitalization
• Prevent mortality Goals
• Control symptoms
• Patient education
• Prevent hospitalization
• Prevent mortality
Strategies
• Identification of comorbidities Drugs for routine use (pages 3-4)
• Diuretics for fluid retention
• ACEI or ARB or ARNI
• Beta blockers
• Aldosterone antagonists
• Inotropes
• Ivabradine
(see page 4)
Stages in the development of HF and recommended therapy by stage. ACEI indicates angiotensin-converting enzyme
inhibitor; AF, atrial fibrillation; ARB, angiotensin-receptor blocker; CAD, coronary artery disease; CRT, cardiac
resynchronization therapy; DM, diabetes mellitus; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF,
heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction;
HRQOL, health-related quality of life; HTN, hypertension; ICD, implantable cardioverter-defibrillator; LV, left ventricular;
LVH, left ventricular hypertrophy; MCS, mechanical circulatory support; and MI, myocardial infarction. Adapted from
Hunt et al.3Yancy CW et al., ACCF/AHA Guideline for the Management of Heart Failure, Circulation, 10/15/13.
Patients with:
• Marked symptoms at rest
despite maximal medical
therapy
• Recurrent hospitalizations
despite GDMT
HFrEF
Therapy
Treatment
• Diuresis to relieve
symptoms
• Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
• Revascularization or valvular
surgery as appropriate
Testing
• BNP or NT-pro BNP screening
(Refractory HF)
End-stage disease requiring
specialized interventions
Drugs for use in selected patients
• Hydralazine/isosorbide dinitrate
• ACEI and ARB
• Digitalis
In selected patients
• CRT
• ICD
• Revascularization or valvular
surgery as appropriate
Testing
• BNP or NT-pro BNP screening
Goals
• Control symptoms
• Improve HRQOL
• Reduce hospital readmissions
• Establish patient’s end-of-life
goals
Options
• Advanced care measures
• Heart transplant
• Temporary or permanent
MCS
• Experimental surgery or drugs
• Palliative care and hospice
• ICD deactivation
Testing
• BNP or NT-pro BNP screening
Evaluation
Treatment
NYHA Classification Table
Class
Patient Symptoms
Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause
undue fatigue, palpitation, dyspnea (shortness of breath) or anginal pain.
Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary
physical activity results in fatigue, palpitation, dyspnea or anginal pain.
Class III (Moderate)
Class IV (Severe)
Marked limitation of physical activity. Comfortable at rest, but less
than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain.
Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency or
anginal syndrome even at rest. If any physical activity is undertaken, discomfort is increases.
February 2018