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HEART FAILURE - CHRONIC
Treatment Guideline Chart
Heart failure is a clinical syndrome due to a structural or functional cardiac abnormality 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 in spite of normal filling pressures or only at the expense of elevated filling pressures.
Symptoms are caused by ventricular dysfunction secondary to abnormalities of the myocardium, pericardium, endocardium, valves, heart rhythm or conduction.
Chronic heart failure is a chronic 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 or outpatient IV diuretic therapy.

Heart%20failure%20-%20chronic Treatment

Interventional Therapy

Device-based Therapy

Cardiac Resynchronization Therapy (CRT)

  • May be performed in patients >40 days post-MI and with reasonable expected survival of >1 year
  • Recommended if NYHA Class II-IV symptomatic patient is in sinus rhythm with a QRS duration of ≥150 msec, left bundle branch block (LBBB) and LVEF ≤35% despite optimal GDMT for at least 3-6 months; CRT provides high economic value     
  • Should be considered in NYHA Class II-IV symptomatic HF patient in sinus rhythm with LVEF ≤35% and QRS duration of ≥150 msec and non-LBBB pattern or QRS duration of 120-149 msec and LBBB pattern despite optimal medical therapy   
  • CRT with a pacemaker is recommended (instead of a right ventricular pacing) in patients with HFrEF regardless of NYHA class or QRS width with an indication for ventricular pacing for high-degree AV block, bradycardia, and AF   
  • Consider an upgrade to CRT in patients with LVEF ≤35% who have received a conventional pacemaker or an ICD and subsequently experience worsening HF despite optimal medical therapy and who have a significant proportion of right ventricular pacing  
  • To improve symptoms and quality of life and to reduce hospitalizations and total mortality, CRT may also be considered in the following patients: 
    • With high-degree or complete heart block and LVEF of 36-50%
    • In sinus rhythm NYHA Class III-IV with a QRS duration of 120-149 msec, non-LBBB and LVEF ≤35% on GDMT
    • With ischemic cause of HF, in sinus rhythm NYHA Class I with a QRS duration of ≥150 msec, LBBB and LVEF ≤30% on GDMT
    • On GDMT with LVEF ≤35% and undergoing placement of a new or replacement of a device implant with anticipated requirement for significant ventricular pacing

Implantable Cardioverter Defibrillator (ICD)

  • Primary prevention or prophylactic ICD implantation to decrease the risk of sudden cardiac death may be done in a NYHA Class II-III symptomatic patient with an LVEF ≤35% or NYHA Class I symptomatic patient with an LVEF ≤30% despite optimal GDMT for at least 3-6 months and:
    • Without an MI in the prior 40 days 
    • With dilated ischemic cardiomyopathy 
    • With reasonable expected survival of >1 year
  • A transvenous ICD is of high economic value in the primary prevention of sudden cardiac death 
  • ICD may be done for secondary prevention in the following patients to improve survival:
    • Cardiac arrest survivors (expected survival rate of >1 year with good functional status) from ventricular fibrillation or with hemodynamic instability caused by documented ventricular dysrhythmia
    • Those with symptomatic CHF and LVEF ≤35% who experience syncope of unclear etiology  
    • With previous MI and LVEF ≤40% with non-sustained ventricular tachycardia and ventricular tachycardia or ventricular fibrillation that is inducible and sustained during an electrophysiological study   
  • Consider an ICD implantation in patients with genetic arrhythmogenic cardiomyopathy with high-risk features of sudden death and EF of ≤45% to decrease sudden death

Left Ventricular Assist Device (LVAD)

  • A mechanical circulatory support used as a bridge to transplantation or to recovery  
  • Should be considered in select NHYA Class IV patients who are deemed dependent on IV inotropes or temporary mechanical circulatory support
  • May be used long-term as a transplantation alternative in patients with end-stage HF not eligible for heart transplantation (destination therapy) or as a bridge to candidacy or heart transplantation  

Surgery

Coronary Revascularization

  • Eg coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)  
  • Considered in patients with HF with LVEF ≤35% and suitable coronary anatomy to relieve persistent angina symptoms despite optimal GDMT including anti-anginal agents 

Valvular Surgery

  • Mitral valve repair or replacement may be considered after optimization of GDMT in patients with LV systolic dysfunction and severe mitral regurgitation who will undergo surgical coronary revascularization  
    • Mitral valve repair may be done in symptomatic patients with HF, severe mitral regurgitation and LVEF <30%
      • A MitraClip may be considered in select patients with HFrEF to decrease mitral regurgitation 
      • In symptomatic patients with chronic moderate-severe to severe mitral regurgitation despite GDMT at optimal doses, a transcatheter mitral valve edge-to-edge repair may be considered if ineligible for surgery and not requiring coronary revascularization
    • Mitral valve replacement may be considered in symptomatic patients with LVEF <30% and/or LV end-systolic diameter >55 mm unresponsive to medical treatment, with comorbidities, and with low likelihood for successful surgical outcome
    • Balloon mitral valvuloplasty (BMV) can be considered in patients with mitral stenosis with suitable valve anatomy
    • Percutaneous mitral commissurotomy (PMC) may be considered in symptomatic patients with mitral stenosis with valve area >1.5 cm2 with suitable valve anatomy at high risk or with contraindications for surgery
      • Should be considered in asymptomatic patients with high thromboembolic risk and/or high risk of hemodynamic decompensation without contraindications to PMC
  • Aortic valve replacement may be considered for patients with aortic stenosis or aortic regurgitation
    • Recommended for symptomatic patients irrespective of LVEF value
    • Should be considered in symptomatic patients with LVEF ≤50%, LV enlargement with LV end-diastolic diameter >70 mm, or LV end-systolic diameter >50 mm
    • Transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI) may be considered in patients with high-risk aortic stenosis or patients not fit for surgery
  • Aortic valve repair or valve-sparing surgery should be considered in patients with pliable noncalcified tricuspid or bicuspid valves with type I or type II aortic regurgitation

Heart Transplantation

  • Considered in eligible patients with poor prognosis, advanced or end-stage HF and severe symptoms who have failed or are refractory to optimal GDMT or device therapy/surgery, and without absolute contraindications
  • Significantly increases patient’s survival and quality of life
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