heart%20failure%20-%20chronic
HEART FAILURE - CHRONIC
Treatment Guideline Chart
Heart failure is a clinical syndrome due to a structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood in order to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues.
Symptoms are caused by ventricular dysfunction secondary to abnormalities of the myocardium, pericardium, endocardium, valves, heart rhythm and conduction.
Chronic heart failure is a state where patient's signs and symptoms have been unchanged (stable) for at least a month but may decompensate suddenly or slowly when stable chronic heart failure deteriorates leading to hospitalization.

Heart%20failure%20-%20chronic Management

Prevention

Immunization

  • Pneumococcal vaccination and annual influenza vaccination are recommended in all patients with HF in the absence of known contraindication
  • Pulmonary congestion and pulmonary hypertension increase the risk of respiratory infections (one of the major causes of acute decompensation, especially in the elderly)

Prognosis

  • Assessment of prognosis provides better information for the patients and their families to plan for their futures
  • Helps in the identification of patients in whom cardiac transplantation or mechanical device therapy should be considered
  • Referral to a HF specialist should be considered in patients needing chronic IV inotropes, NYHA Class IIIB/IV symptoms or persistently elevated natriuretic peptides, end-organ dysfunction, EF ≤35%, defibrillator shocks, multiple hospitalizations, edema despite dose escalation of diuretics, low BP/high heart rate, and progressive intolerance or down-titration of GDMT 
    • Other indications for referral include a new-onset HF regardless of EF, chronic HF with high-risk features, HF etiology requiring a second opinion, yearly review of patients with confirmed advanced HF and patient assessment for possible clinical trial inclusion

Conditions Associated with a Poor Prognosis in Heart Failure

  • Decreasing LVEF
  • Worsening NYHA functional status (Class III-IV)
  • Chronic hypotension
  • Widened QRS >120 msec on 12-lead ECG
  • Tachycardia and Q waves
  • Resting tachycardia
  • LVH and complex ventricular arrhythmias
  • Marked elevation of brain-type natriuretic peptide (BNP)/N-terminal-pro-BNP (NT-proBNP)
  • Elevated biomarkers of myocardial fibrosis (soluble ST2 receptor, galectin-3, high sensitivity cardiac troponin) and neurohormonal activation
  • Iron deficiency with or without anemia
    • Anemia is independently associated with the severity of HF and iron deficiency seems to be uniquely associated with a reduction in exercise capacity
      • Iron deficiency in HF patients is associated with a worse prognosis
  • Hyponatremia
  • Decreasing peak exercise O2 uptake
  • Renal insufficiency or failure
  • Intolerance to therapy
  • Refractory volume overload
  • Advanced age
  • Ischemic etiology
  • Resuscitated sudden death
  • Prior HF hospitalization
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