Congestive heart failure with preserved EF pharmacotherapy

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Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure with preserved EF pharmacotherapy On the Web

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Congestive heart failure with preserved EF pharmacotherapy in the news

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Directions to Hospitals Treating Congestive heart failure with preserved EF pharmacotherapy

Risk calculators and risk factors for Congestive heart failure with preserved EF pharmacotherapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Seyedmahdi Pahlavani, M.D. [3] Edzel Lorraine Co, DMD, MD[4]

Overview

Heart failure has been divided into three subgroups including heart failure reduced ejection fraction, heart failure mildly reduced EF, heart failure preserved EF. HFrEF is defined when LVEF≤ 40% and significant LV systolic dysfunction. Patients with a LVEF between 41% and 49% have mildly reduced LV systolic function or HFmrEF. Patients with ejection fractions between 40-50% may benefit from similar therapies to those with LVEF≤ 40%. HFpEF is explained in the presence of symptoms and signs of HF, and evidence of structural and/or functional cardiac abnormalities and/or raised natriuretic peptides (NPs), and LVEF≥ 50%. Patients with non-cardiovascular disease including anaemia, pulmonary, renal, thyroid, or hepatic disease may mimic symptoms and signs of HF, but in the absence of cardiac dysfunction, they are not diagnosed for HF. Neverthless, these disorders can coexist with HF and exacerbate the HF syndrome.

Heart failure mildly reduced ejection fraction (HPmrEF), EF (41-49%)

The diagnosis of heart failure with mildly reduced ejection fraction

Clinical characteristics

Treatment

Angiotensin-converting enzyme inhibitors

Angiotensin receptor II type 1 receptor blockers

Beta-blockers

Mineralocorticoid receptor antagonists

Angiotensin receptor-neprilysin inhibitor

Other drugs

Devices



Medications indicated in patients with New York Heart Association (NYHA class II–IV) HFmrEF (heart failure with mildly reduced ejection fraction) (LVEF41-49%)

Recommedation for patients with NYHA class 2-4 heart failure with mildly reduced ejection fraction
Diuretics (Class I, Level of Evidence C):

Diuretics are recommended in patients with congestion and HFmrEF in order reduce symptoms and signs

ACEI (Class IIb, Level of Evidence C):

ACE-I may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death
ARB may be indicated for patients with HFmrEF to reduce the risk of HF hospitalization and death
Beta-blocker may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death,
MRA may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death
Sacubitril/valsartan may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death

The above table adopted from 2021 ESC Guideline

[4]



Class IIa
"1. In patients with HFmrEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality. [5] (Level of Evidence: B-R) "
Class IIb
"2. Among patients with current or previous symptomatic HFmrEF (LVEF, 41%-49%), use of evidence-based beta blockers for HFrEF, ARNi, ACEi, or ARB, and MRAs may be considered to reduce the risk of HF hospitalization and cardiovascular mortality, particularly among patients with LVEF on the lower end of this spectrum. [6][7][8][9][10][1][11][12] (Level of Evidence: B-NR) "
The above table adopted from 2022 AHA Guideline

[13]

Heart failure With Improved Ejection Fraction (HFimpEF)

Class I
"1. In patients with HFimpEF after treatment, medical therapy should be continued to prevent relapse of HF and LV dysfunction, even in patients who may become asymptomatic. [8] (Level of Evidence: B-R) "
The above tables adopted from 2022 AHA Guideline

[13]

Heart failure preserved ejection fraction (HFpEF)

Clinical characteristics

The diagnosis of heart failure preserved ejection fraction

  • Echocardiographic criteria:
  • LA size (LA volume index >32 mL/m2)
  • Mitral E velocity <90 cm/s
  • Septal e' velocity <9 cm/s
  • E/e' ratio >9
    The diagnosis is made when there are the following:

(1) Symptoms and signs of HF
(2) An LVEF ≥ 50%
(3) Evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/ raised LV filling pressures, including raised NPs

  • In the presence of AF, the threshold for LA volume index is >40 mL/m2
  • Exercise stress thresholds include E/e' ratio at peak stress ≥ 15 or tricuspid regurgitation (TR) velocity at peak stress >3.4 m/s
  • LV global longitudinal strain <16%


 
 
 
 
 
 
 
 
 
 
 
 
 
Diuretic as needed (class1)
 
 
 
 
 
 
 
 
 
 
 
SGLT2i (class 2a)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MRA (class 2b)
 
 
 
 
 
Symptomatic heart failure with LVEF ≥ 50%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ARNi (class 2b)
 
 
 
 
 
 
 
ARB class 2b
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The above tables adopted from 2022 AHA Guideline

[13]




Recommedation for treatment of patients with HFpEF (heart failure preserved ejection fraction)
(Class I, Level of Evidence C):

❑ Screening, treatment, investigation of underlying etiologies, and cardiovascular and non-cardiovascular comorbidities is recommended in patients with HFpEF
Diuretics are recommended in congested patients with HFpEF to improve symptoms and signs

The above table adopted from 2021 ESC Guideline

[4]



Class I
"1. Patients with HFpEF and hypertension should have medication titrated to attain blood pressure targets in accordance with published clinical practice guidelines to prevent morbidity. [17][18][19] (Level of Evidence: C-LD) "
Class IIa
"2. In patients with HFpEF, SGLT2i can be beneficial in decreasing HF hospitalizations and cardiovascular mortality. [5] (Level of Evidence:B-R) "
"3. In patients with HFpEF, management of AF can be useful to improve symptoms. (Level of Evidence: C-EO) "
Class IIb
"4. In selected patients with HFpEF, MRAs may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum. [20][21][10] (Level of Evidence:B-R) "
"5. In selected patients with HFpEF, the use of ARB may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum. [2][22](Level of Evidence: B-R) "
"6. In selected patients with HFpEF, ARNi may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum. [7][11](Level of Evidence: B-R) "
Class III (No Benefit)
"7. In patients with HFpEF, routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QOL is ineffective. [23][24] (Level of Evidence:B-R) "
The above tables adopted from 2022 AHA Guideline

[13]

External Link

References

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