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Heart Failure

William Chavey, MD, MS

Associate Professor

Department of Family Medicine

University of Michigan

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Heart Failure Terms

Heart failure (HF) may be divided into two categories --- preserved ejection fraction and reduced ejection fraction

Systolic dysfunction (reduced ejection fraction) is defined by a reduced EF (< 40 - 45%), typically measured via echo, ventriculogram, radionuclide scan, or CT

Diastolic dysfunction is an echocardiographic finding representing poor filling. Heart failure with reduced ejection fraction is not necessarily the same as diastolic dysfunction and patients may have simultaneous systolic and diastolic heart failure

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HF Classification

NYHA Class NYHA Symptom Description

NYHA Class I Asymptomatic

NYHA Class II Mildly symptomatic

NYHA Class III Moderately symptomatic

NYHA Class IV Symptoms at rest

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BNP

Prognosis Diagnosis Titration of therapy --- mixed results when

compared to symptom management Levels increased by age, female, renal

insufficiency Levels decreased by obesity

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BNP Concentration for theBNP Concentration for thePrediction of Clinical EventsPrediction of Clinical Events

Maisel A, et al. Annals of Emergency Medicine 2001 (in press)

0 20 40 60 80 100 120 140 160 1800%

5%

10%

15%

20%

25%

30%

35%

40%

45%

BNP < 230 pg/ml

BNP 230-480 pg/ml

BNP > 480 pg/ml

Death or Heart Failure Hospitalization

Days

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ROC Curves for BNP and ED

Diagnosis Using All 250 Patients

0 10 20 30 40 50 60 70 80 90 100

0102030405060708090

100

1 - Specificity (%)

Sen

siti

vity

(%

)

82118

205

--- BNP --- ER diagnosisAUC 0.8840.9790

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Identifying Heart Failure Using BNP

Treatment Recommendations for Heart Failure Patients with Left Ventricular Systolic Dysfunction

ACC/AHA B C D

NYHA Classification

I II – III IV

Symptoms 1 Symptoms, Current or Prior

Asymptomatic Never Hospitalized History of

Hospitalization Recurrent or Ongoing

Rest Dyspnea

ACE Inhibitor2 Yes Yes Yes Yes

Beta Blocker Yes1 Yes Yes Yes3

Aldosterone antagonist

Yes Yes Yes

Isosorbide dinitrate-hydralazine

Selected patients4 Selected patients4 Selected patients4

Diuretic PRN congestion PRN congestion Yes

ARB PRN5 PRN5 PRN5

Digoxin PRN5 PRN5 PRN5

Consider AICD/Bi-V pacemaker

Selected patients6 Yes Yes Yes

HF Disease Management

Yes Yes

Referral to Advanced Heart Failure Program

Yes Yes7

Device Referral Algorithm

Heart Failure with Preserved EF

Few clinical trials

Diuresis in decompensated state

Rate reduction can improve diastolic filling

BP control important

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Case 1

73 y/o male with h/o AF on verapamil, metoprolol, and warfarin; o/w healthy and active and travels the world performing

Presents with DOE What is in differential diagnosis? How would you work this up?

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Case 1 points

Role of BNP in assessing etiology of symptoms

Management of systolic vs diastolic dysfunction

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Case 1 points

Management of systolic vs diastolic dysfunction. If systolic dysfunction would:- d/c verapamil- add ACE

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Case 2

50 y/o AA female with EF 20% and dyspnea at rest plus h/o AFib, CVA, Type II DM, RA plus other co-morbid conditions

What is the appropriate medical regimen for her?

Is she eligible for a device?

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Case 2

ACE inhibitor? Beta blocker? Diuretic? Aldosterone antagonist? ARB? Vasodilators? Dig?

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Case 2

ACE inhibitor? Yes Beta blocker? Yes Diuretic? Yes Aldosterone antagonist? Yes ARB? Probably not Vasodilators? If tolerated by BP Dig - probably