CHF CCS 2012 Guideline

Risk factors

1. HTN, Hyperlipidemia
2. Ischemic or valvular heart dz
3. DM
4. Heavy EtOH, Smoking
5. Chemotherapy
6. Fam Hx of heart failure

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Symptoms

1. Breathlessness, orthopnea, PND
2. Fatigue, Confusion (esp in elderly)
3. Leg swelling

Signs

1. Lung crackles, DVP, Positive HJR
2. Displaced apex, S3, S4, heart murmur
3. Low BP, HR >100

ECG

1. Q wave, tachycardia
2. LVH, LBBB

CXR

1. Cardiomegaly
2. pulmonary edema, pulmonary venous redistribution
3. Pleural effusion

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If CHF in doubt

BNP

• >500 pg/ml, HF likley

Echo

1. dec LVEF
2. inc LV end-systolic and end-diastolic diameter
3. LVH, Diastolic dysfunction, wall motion abn
4. Inc RV size & dysfunction
5. Valve dysfunction
6. Inc Pulmonary arterial Pressures

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How often to follow

1. Acute change in HF symptoms
   • in 1-2 days
2. After HF hospitalization
   • in 2 weeks
3. After addition of HF med or inc in dose
   • 1 wk if unstable, 2 wk if stable, 4 wk if asymptomatic
4. Stable on optimized Tx
   • 3-6mo
5. Check lytes, BUN, Cr if intercurrent illness (flu) could affect volume status

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What to Follow

1. HF symptoms – NYHA & new symptoms?
2. Body Wt, HR, postural BP
3. JVP, HJR, peripheral edema
4. Auscultate heart & chest
5. check meds

Only when there is clinical change:

1. ECG, CXR, Echo
2. BNP (if uncertain CHF contributes to S/Sx)
3. Lytes / Cr Q7-14d after ACEi/ARB, spironolactone, diuretic change, until stable, then q1-3mo

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Ref

1. New onset HF or recent HF hospitalization
2. HF associated with ischemia/infarction, HTN, valvular dz, syncope, renal dysfunction, multiple comorbidities
3. Unknown etiology
4. Family Hx of HF
5. Intolerance to Tx
6. Poor compliance with Tx

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Education on HF syndrome,

• Warning S/Sx:
  1. Dyspnea when flat, during sleep, w/ less exertion.
  2. Fatigue with less exertion or symptoms at rest
  3. lightheadedness/faint
  4. Prolonged palpitations or usual angina pain
  5. Wt gain >2kg in 2 days or 3kg in 7 days
  6. self monitoring, Drug Tx, prognosis
• Lifestyle
  1. Reduce CV risk: salt <2g/d, control HTN/DM, smoking cessation
  2. No need to push oral fluid
  3. Lose Wt, regular physical activity as tolerated, daily wt if fluid retention

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Tx

1. Low LVEF – Rx ACEI +/- BB
2. LVEF >40% with symptoms, Tx cause eg HTN, Ischemia – consider ACEI/ARB, BB
3. Systolic HF (symptoms + LVEF <40%)
   • Tailored diuretic
   • ACEi + BB – titrate to target doses (ARB if intolerance ACI)
     • Nitrate / Hydralazine if intolerant to ACEI & ARB
4. NYHA 2-3a (persistent symptoms, High BNP, recent HF hospitalization)
   • Add Mineralcorticoid Receptor Antagonist (MRA): Spironolactone, eplerenone
5. NYHA 3b-4
   • MRA, digoxin, nitrates, increase or combine diuretics
6. If refractory, consider transplant or palliation
7. LVEF <30% – ICD ref

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• Ramipril 1.25-2.5mg bid –> 5mg bid
• Metoprolol 12.5-25mg od –> 200mg od
• Spironolactone 12.5mg od –> 50mg od
• Hydralazine 37.5mg tid –> 75mg tid

• Diuretics, nitrates, digoxin – improve symptoms
• ACEI/ARB, BB, spironolactone/epleronone – Improve survival in pt with low LVEF
• Drug combination is required, most req dose adjustment & used long term
• Device with low LVEF or wide QRS

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Diastolic HF

1. Control Vol with min effective diuretic dose
2. Resting HR to 70 bpm, especially with A fib (anticoagulated unless C/I)
3. Determine if contributing ischemia or valvular heart dz & Tx if necessary – vigilant of AS and MR
4. Control HTN is critical
5. ARC/ARB +/- BB (CCB can be considered)
6. Loop diuretics, renal function may be vol dependant

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SOB & LVEF >50%

Cardiac causes

1. Diastolic HF, CAD
2. Valvular dz, intracardiac shunt
3. hypertrophic cardiomyopathy, restrictive cardiomyopathy
4. constrictive pericarditis

Non-Cardiac causes

1. Lung dz, pulm arterial HTN
2. Obesity, deconditioning, hyperventilation
3. Anemia, extracardiac shunt
4. thyrotoxicosis