CHF Update 2018

Peter M. Lewis, DO FACC

 Which of the following is true?

A. CHF incidence/prevalence is decreasing

B. Incidence of CHF is the same in all populations

C. Mortality has significantly decreased with

newer treatment modalities

D. HfpEF has similar mortality risk to HFrEF

 Which of the following is true?
A. ECHO is a simple, easily obtainable test in the
workup of CHF

B. Provides significant data on systolic/diastolic

parameters, valvular disease, pericardial
disease

C. Worse outcome in patients when not utililized in

diagnosis and follow up

D. All of the above

 CHF Update 2018
Definition
Types
Epidemiology
Etiology
Pathophysiology
Treatment strategies
 CHF Update 2018

 5.8 million prevalence

 Men > women

 1970s-1990s epidemic decreasing

Majority >65 years and older accounting for

>80% of mortality
 CHF Update 2018

$ 31 billion in 2012 (80% direct costs from

hospitalizations)
Accounts for 1-2% of all health care cost in
developed countries
Costs expected to double by 2030 to over $70
billion
 CHF Update 2018
 Incidence higher and earlier in AA men/women

 Higher incidence of CAD, DM, HTN

 Obesity and CKI

 More prevalent before age 50

 CHF Update 2018
 Incidence higher and earlier in AA men/women

 Higher incidence of CAD, DM, HTN

 Obesity and CKI

 More prevalent before age 50

Update CHF 2018
 CHF Update 2018
 Systolic and Diastolic

 HFrEF and HFpEF

CHF Update 2018
 HFpEF

Now accounts for >50%of all CHF cases

More prevalent in females

Diastolic abnormalities invariably noted on ECHO

Similar mortality compared to HfrEF

No proven therapies to date to alter course

 Major Risk Factors

Age
Male
HTN/LVH
CAD/MI
Valvular heart disease
Obeisity
DM
 Minor Risk Factors

Smoking
Hyperlipidemia
CKI
Albumimuria
OSA
Anemia
Tachycardia
 CHF 2018 Update
 Immune-mediated
 Peripartum cardiomyopathy, hypersensitivity
 Infectious
 Viral, parasitic (Chagas disease), bacterial
 Toxic risk precipitants
Chemotherapy (anthracyclines,
cyclophosphamide, 5-FU), targeted cancer
therapy (trastuzumab, tyrosine kinase inhibitors),
cocaine, NSAIDs, thiazolidinediones, doxazosin,
alcohoSNP (e.g. α2CDel322-325, β1Arg389),
family history, congenital heart
 CHF Update 2018
Reduced Contractility------> decreased CO

Increased preload/LAP

BP maybe be decreased but SVR is increased

Increased HR ( CO=HR x SV )
CHF Update 2018
CHF Update 2018
CHF Update 2018
CHF Update 2018

ECHO with depressed LVEF

CHF Update 2018

ECHO with LVH

 CHF Update 2018

Biomarkers BNP and proBNP

Utility in diagnosis and following response to

treatment

BNP levels responsive to ARNI Rx but not

proBNP
 CHF Update 2018

BNP
32 amino acid peptide (134 AA NT-pro BNP)

Secreted by cardiac myocytes

Predominant cardiac/renal effects

Decrease in SVR and CVP

 CHF Update 2018

Other causes for BNP elevations:

ACS
Atrial fibrillation
Myocarditis
Cardiac surgery
 CHF Update 2018

Secondary causes of increased BNP:

● Age
● Anemia
● Renal failure
● Sepsis
● Pulmonary hypertension
● Toxic/metabolic
 CHF Update 2018

ACC/AHA Classification

– Class A
– Class B
– Class C
– Class D
 CHF Update 2018

Stage A
Asymptomatic but with significant risk

Risk factor modification to include BP control

Rx of lipids/DM

Reduction/abstinence from alcohol

 CHF Update 2018

Stage B

Documented low EF but asymptomatic:

ACEI/ARB
Beta blocker
Surgery for any correctable disease
 CHF Update 2018

Stage C
Symptomatic with signs/symptoms of CHF
Standard Rx
Aldosterone antagonists
Nitrates/hydralazine
 CHF Update 2018

Stage D

Continued standard Rx
Transplant
Resynchronization therapy
LVAD
Inotropic Rx
 CHF Update 2018

NYHA Classification

Class I asymptomatic
Class II symptoms with significant activity
Class III symptoms with minimal activity
Class IV symptoms at rest
 CHF Update 2018
CBC
UA
CMP
Fasting blood glucose levels
Lipid profile
Thyroid stimulating hormone (TSH) levels
B-type natriuretic peptide levels/pro BNP N-terminal
natriuretic peptide levels
Electrocardiography
 CHF Update 2018

Electrocardiography
Chest radiography
Two-dimensional (2-D) echocardiography
Nuclear imaging
Maximal exercise testing
Pulse oximetry or arterial blood gas
 CHF Update 2018

Diet/exercise

Dietary consult

Routine daily weights

 CHF Update 2018

Standard Medical Therapy

Diuretics
ACEI/ARB
Aldosterone antagonists
Hyralazine/nitrates
ARNI
CHF Update 2018
 CHF Update 2018

Digoxin

Spironolactone

Neseritide
CHF Update 2018
CHF Update 2018
CHF Update 2018
 CHF Update 2018

Cardiac Resynchronization Therapy (CRT)

Based on LVEF
NYHA functional class
QRS duration
Concomitant need for ventricular pacing
 CHF Update 2018

CRT
Simultaneous pacing of the RV/LV

Acute hemodynamic benefits:

Increased SBP
Increased CO/CI
Increased contractility
 CHF Update 2018

CRT

Anatomic benefits:
• Decreased adverse LV remodeling
• Decreased LV size/spherical shape
• Increased LVEF
 CHF Update 2018

Device/ cardiac resynchronization therapy

Class IA

NYHA II-IV class patients

LVEF < 35%
LBBB
Other with QRS >140 msec
 CHF Update 2018

CRT

Class IIB

Non LBBB with QRS > 150 msec and NYHA

III/IV
QRS 130-149msec and NYHA II-IV
 CHF Update 2018

CRT

CLASS III
LVEF > 50%
QRS <120 msecs
Non-ambulatory NYHA Class IV
Patients on inotropic Rx
CHF Update 2018
Device Therapy
Summary Treatment Guidelines