Heart%20failure%20-%20chronic Management

Immunization

• Pneumococcal vaccination and annual influenza vaccination, as well as COVID-19 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)

• Assessment of prognosis provides better information for the patients and their families to plan for their futures
  • Validated multivariable risk scores for CHF (eg the Seattle Heart Failure Model, the Heart Failure Survival score and the Meta-analysis Global Group in Chronic Heart Failure [MAGGIC] score) have commonly been used to provide estimates of patient’s survival 
• Helps in the identification of patients in whom cardiac transplantation or mechanical device therapy should be considered  
• Patients with HF, even with stable and well-controlled symptoms, require follow-up at intervals no longer than 6 months to assess symptoms and treatment optimization
  • A follow-up visit 1-2 weeks after hospitalization (earlier [within 7 days] if admitted for worsening HF) is recommended to check for signs of congestion, drug tolerance and to initiate and/or uptitrate evidence-based therapy
• Patients with prior HFrEF who currently have an LVEF of >40% are considered to have an improved LVEF (HFimpEF) and should continue optimized GDMT, even in those who may become asymptomatic, in order to avoid LV dysfunction and relapse of HF
• Referral to a HF specialist should be considered in patients needing chronic IV inotropes, with 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 systolic BP/high heart rate, and progressive intolerance or down-titration of GDMT
  • Other indications for referral of advanced HF include a new-onset HF regardless of EF, CHF 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
• Provide palliative and end-of-life care services to patients with advanced HF

Conditions Associated with a Poor Prognosis in Heart Failure

• Advanced age
• Ischemic etiology
• Worsening NYHA functional status (Class III-IV)
• Chronic hypotension
• Resting tachycardia
• Intolerance to GDMT at optimal dose
• Increasing need for diuretics, refractory volume overload
• >1 HF hospitalization within the last year
• Resuscitated sudden death, CRT non-responder clinically
• Decreasing peak exercise O₂ uptake
• 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
• Progressive deterioration of hepatic or renal function
• Persistent hyponatremia
• 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
• Widened QRS >120 msec on 12-lead ECG
• Tachycardia and Q waves
• LVH and complex ventricular arrhythmias
• Decreasing LVEF