BASICS

Description

HF results from inability of the heart to pump or fill adequately to meet metabolic demands.
Progressive disease with remodeling and stages (A to D by AHA/ACC).
NYHA functional classes I-IV describe symptomatic severity.
Can affect left, right, or both ventricles.

Epidemiology

~550,000 new US cases/year; >250,000 deaths/year
HFpEF rising, accounts for ~50% of cases
Prevalence ~23 million worldwide; primarily elderly population

Etiology & Pathophysiology

HF with reduced EF (HFrEF): EF ≤40%, systolic dysfunction (e.g., post-MI, dilated CM)
HF with mildly reduced EF (HFmrEF): EF 41-49%, clinical features similar to HFpEF
HF with improved EF (HFimpEF): prior HFrEF with EF improvement >40%
HF with preserved EF (HFpEF): EF ≥50%, diastolic dysfunction (impaired relaxation)
Common causes: CAD/MI, hypertension, myocarditis, cardiomyopathies (alcoholic, viral, inherited), valvular disease, chronic lung disease, arrhythmias, high-output states, idiopathic familial dilated CM

Genetics

Genetic mutations underlie some cardiomyopathies; genetic screening advised for HCM and arrhythmogenic RV dysplasia relatives.

Risk Factors

CAD, MI, hypertension, valvular disease, diabetes, cardiotoxic meds, obesity, older age

General Prevention

Control hypertension and other cardiovascular risk factors

DIAGNOSIS

Clinical Criteria

Framingham criteria: ≥2 major or 1 major + 2 minor criteria for HF diagnosis
Major: pulmonary edema, cardiomegaly, JVD, hepatojugular reflux, PND/orthopnea, rales, S3 gallop
Minor: ankle edema, dyspnea on exertion, hepatomegaly, nocturnal cough, pleural effusion, tachycardia (>120 bpm)
H2FPEF score aids HFpEF diagnosis

History

Dyspnea on exertion, fatigue, orthopnea, PND, nocturnal cough, abdominal fullness (hepatic congestion), wheezing (cardiac asthma), Cheyne-Stokes respiration

Physical Exam

Signs of elevated filling pressure: rales, edema, JVD, hepatomegaly, S3 gallop
Signs of remodeling: displaced/enlarged PMI
Signs of poor output: hypotension, tachycardia, narrow pulse pressure, cool extremities

Differential Diagnosis

Dependent edema, PE, asthma, COPD, constrictive pericarditis, nephrotic syndrome, cirrhosis, venous disease

Diagnostic Tests

BNP/NT-proBNP: <100 pg/mL rules out HF; >800 pg/mL confirms
Lab: azotemia, hyponatremia, LFTs, electrolytes, thyroid function
Chest X-ray: cardiomegaly, pulmonary edema signs (cephalization, Kerley B lines, pleural effusions)
Echocardiogram: assess EF, diastolic function, valve disease, chamber size
ECG: baseline and evaluation of arrhythmias, ischemia
Advanced: cardiac MRI (sarcoidosis, myocarditis), nuclear imaging, catheterization if ischemic etiology suspected

TREATMENT

General Measures

Manage comorbidities and risk factors
Lifestyle: sodium restriction, fluid management, smoking cessation, exercise

Medication

First Line (GDMT)

ACE inhibitors or ARBs: reduce mortality and morbidity; start low and titrate to target doses
β-blockers: improve survival; initiate when stable; titrate based on HR
Mineralocorticoid receptor antagonists (MRAs): spironolactone or eplerenone for NYHA II-IV and EF <35%
Sodium-glucose cotransporter-2 inhibitors (SGLT-2i): dapagliflozin, empagliflozin reduce CV death and HF hospitalization across HF phenotypes

Other

Diuretics: symptom control of volume overload
Sacubitril/valsartan (ARNI): replaces ACEi/ARB in HFrEF NYHA II-III with EF ≤40%; reduces mortality/hospitalization
Isosorbide dinitrate + hydralazine: effective in African Americans or ACEi/ARB intolerance
Vericiguat: for patients with EF ≤45% and recent hospitalization or IV diuretics
Ivabradine: HR control in EF ≤35%, symptomatic despite β-blockers, sinus rhythm with HR >70 bpm
Digoxin: symptom relief, no mortality benefit; consider in select cases

Surgery and Devices

Valve repair or replacement for significant valvular disease
Cardiac resynchronization therapy (CRT): indicated for LBBB with QRS ≥150 ms, EF ≤35%, NYHA II-IV on GDMT
Implantable cardioverter defibrillator (ICD): primary prevention in ischemic/non-ischemic CM, EF ≤35%, NYHA II-III, >40 days post-MI
LVAD and cardiac transplantation in end-stage HF

Admission and Nursing

Admit if hemodynamic instability, acute renal injury, electrolyte disturbances, or volume overload
Discharge when euvolemic, stable vitals, patient education completed

Ongoing Care

Follow-Up

Close monitoring post-discharge to reduce rehospitalization
Monitor for fluid retention via weight, edema assessment

Diet

Sodium restriction (~1,500-1,800 mg/day)
Fluid restriction as needed

Patient Education

Weight monitoring, symptom recognition, medication adherence, lifestyle modification

Prognosis

1-year survival ~75%
5-year survival <50%
10-year survival <25%
Progressive disease with risk of sudden death and pump failure

Complications

Sudden cardiac death
Progressive pump failure

Clinical Pearls

Core medications include β-blockers, ACEi/ARBs, and aldosterone antagonists
Daily weights important for early detection of fluid retention (>2 lb/day or 5 lb above dry weight)
HFpEF is increasing in prevalence, particularly among elderly

References

Kittleson MM, Panjrath GS, Amancherla K, et al. 2023 ACC Expert Consensus Decision Pathway on management of heart failure with preserved ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2023;81(18):1835-1878.
Cardoso R, Graffunder FP, Ternes CMP, et al. SGLT2 inhibitors decrease cardiovascular death and heart failure hospitalizations in patients with heart failure: a systematic review and meta-analysis. EClinicalMedicine. 2021;36:100933.
Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(17):e263-e421.