H e a r t Fa i l u r e S p e c i a l I s s u e
Heart Failure Management and Prognosis
Jacinthe Boulet and Nadia Giannetti
About the Authors
Jacinthe Boulet is with the Division of Cardiology, Montreal Heart Institute, Montreal, Canada.
Nadia Giannetti is with the Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada. Corresponding author: nadia.giannetti@muhc.mcgill.ca
Submitted: January 29, 2020. Accepted: February 5. Published: April 8, 2020. DOI: 10.22374/cjgim.v15iSP1.420.
Abstract
Heart failure is increasing in prevalence and represents a significant burden to the Canadian Health Care System. To provide optimal care for this complex disease, a
Résumé
La prévalence de l’insuffisance cardiaque augmente et représente un fardeau important pour le système de santé canadien. Afin de fournir des soins optimaux pour cette maladie complexe, une approche à multiples facettes est nécessaire, en tirant parti de toutes les thérapies pharmacologiques disponibles, des traitements invasifs et des dispositifs. Dans le contexte canadien, les patients devraient idéalement être pris en charge en collaboration avec des programmes multidisciplinaires de gestion des maladies chroniques, et être orientés de manière appropriée vers des thérapies avancées lorsque cela est indiqué. Dans cet article, nous souhaitons fournir des conseils sur la stratification des risques pour les patients, l’application de la thérapie médicale dirigée par les lignes directrices pour l’insuffisance cardiaque avec une fraction d’éjection préservée et réduite, et fournir des conseils sur l’adéquation des patients pour les dispositifs spécifiques à l’insuffisance cardiaque et les thérapies avancées.
The morbidity and mortality of heart failure (HF) patients represent a significant and growing burden for the health care system in Canada.1 The clinical syndrome of HF, whether with preserved ejection fraction or reduced ejection fraction (HFpEF and HFrEF, respectively), has reached epidemic proportions worldwide. At least 600 000 Canadians are living with HF and the clinical burden is increasing every year as the population ages; the epidemic has reached a level that requires
action and change. Improving uptake of
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constantly evolving field of HF requires innovative approaches to delivering appropriate and optimal care within the Canadian healthcare context. In this article, we aim to provide guidance on patient risk stratification, application of
reference to their specific population, endpoints, and variables. Risk scores can be helpful for clinicians and whenever possible, should be incorporated into practice, but clinical judgment and acumen remain essential and central to decision making. The Canadian Cardiovascular Society’s (CCS) Heart Failure Guidelines incorporate these prognostic scores into their latest recommendations.21
Heart Failure Prognosis
The general HF population suffers from persistently poor outcomes despite recent therapeutic advances.9 Reported mortality rates vary according to the population studied and are also influenced by adherence to
Risk Scores and Markers of Risk in Heart Failure Patients
Markers of Risk in Patients with HF
Prognosis is challenging and variable in the HF population. Various markers of risk have been established and a number of disease- specific risk scores are available to aid clinicians in determining prognosis. One
Risk Scores for HF
As noted, several risk scores have been validated using different variables to assess
Pharmacological Therapy for Heart Failure and Reduced Ejection Fraction
Standard newer pharmacologic therapies for HFrEF, developed over the past decade, are associated with improved survival and quality of life in this population. Novel agents, angiotensin receptor neprilysin inhibitors (ARNIs) and sinus node inhibitors (ivabradine) should now be considered in addition to the usual triad of HF medications consisting of
After optimization and appropriate medication titration, persistently symptomatic patients (NYHA
Older trials looking at the use of hydralazine and isosorbide dinitrate in
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Figure 1. Risk scores for heart failure.
ACEi =
ACEIs, ARBs, or ARNIs. To further relieve moderate to severe symptoms and decrease the risk of HF hospitalization, digoxin may be considered for HFrEF patients in sinus rhythm who are persistently symptomatic.21 Digoxin confers no survival benefit and does not decrease other cardiovascular hospitalizations.42
A recent network
resulted in progressive improvement in
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involve patients as much as possible in their care to enhance medication adherence.
Pharmacological Therapy for Heart Failure and Preserved Ejection Fraction
In contrast to HFrEF, clinical trials of pharmacologic therapy for HFpEF have not shown significant mortality benefits and there are no current trials that clearly modify the natural history of this condition. Patient care is focused on treatment of comorbid conditions that might contribute to exacerbations, symptom control, and the thorough evaluation of potential etiological factors that may be implicated in the development of HF.21 While there are no drugs that reduce mortality in HFpEF, there is evidence that ARBs and MRAs reduce HF hospitalizations, as shown in the “Candesartan in HF Assessment of Reduction in Mortality and Morbidity
Associated comorbidities such has hypertension and diabetes should be treated aggressively following the Canadian Hypertension Education Program hypertension guidelines as well as the Canadian Diabetes Association guidelines. The American College of Cardiology and American Heart Association guidelines for hypertension in HFpEF patients with persistent hypertension after the management of volume overload recommended a systolic blood pressure target <130 mmHg.26 Emerging diabetes therapy will be addressed in accompanying articles of this HF series. Diuresis with loop diuretics should be used in these patients to control symptoms of volume overload and pulmonary congestion.21
Indications for Device Therapy
To frame the discussion around device therapy for HF, consider a typical clinical scenario:
A
The patient’s current medications include bisoprolol 7.5 mg daily, sacubitril/valsartan 24/26 mg BID, spironolactone
12.5mg daily, furosemide 20 mg BID, aspirin 81 mg daily, ticagrelor 90 mg BID and atorvastatin 80 mg QHS. There has been no change in the past 3 months. He is NYHA class II and
On examination, heart rate is 62 beats per minute and blood pressure is 92/65 mmHg. He is euvolemic with no lower leg edema and clear lung fields.
An electrocardiogram reveals sinus rhythm with a left bundle branch block and a QRS of 139 milliseconds.
A repeat echocardiogram performed 2 days ago showed no improvement in heart function.
Are device therapies indicated in this patient?
Implantable Cardioverter Defibrillator (ICD)
Primary Prevention
Patients with NYHA class
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Secondary Prevention
In patients with a history of cardiac arrest, sustained ventricular tachycardia, ventricular fibrillation, or unexplained syncope in the presence of an EF <35%, ICDs are indicated to prevent sudden cardiac death and reduce
Cardiac Resynchronization Therapy (CRT)
As demonstrated in systematic reviews, CRT significantly reduces mortality and HF hospitalizations in appropriately selected HFrEF patients with mild to severe
persistent or progressing functional impairment and NYHA class
The following “I NEED HELP” acronym taken from the American College of Cardiology expert consensus decision pathway for optimization of HF treatment may be used to guide referral to an HF disease program.65
I:Intravenous inotropes
N:New York Heart Association (NYHA) class III/IV or persistently elevated natriuretic peptides
E:
E:EF ≤35%
D:Defibrillator shocks
H:Hospitalizations >1
E:Edema despite escalating diuretics
L:Low systolic BP ≤90, high heart rate
P:Prognostic medication; progressive intolerance or
When to Refer for Advanced Therapies and Interventions
Mechanical Circulatory Support (MCS) and Heart Transplantation (HTx)
Appropriate timing of referrals for evaluation of MCS and HTx candidacy is crucial and the key to optimizing the benefits from advanced HF therapies. Advanced therapies also include palliative care involvement and optimization of their quality of life when appropriate.
The specific definition of advanced HF somewhat differs across international guidelines but generally considers patients on optimal medical therapy or maximally tolerated therapy with
The important
Role of Disease Management Programs
Multiple trials and
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Persistent hyponatremia |
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Figure 2. Characteristics triggering heart failure specialist consultation.
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pharmacist) for all outpatient HF clinics and disease management programs, especially for patients with recurrent hospitalizations.21 The benefits of a multidisciplinary management approach include improved symptom control, decreased mortality, and less intensive care utilization.66,68 To transform care delivery, the mandate of a disease management program in HF should be to improve both morbidity and mortality as well as the quality of life in this complex population.69 It has been shown that a multidisciplinary team can safely facilitate transitions of care (in and outpatient services) and reduce the
Additional specific roles of a disease management program as outlined in the CCS Guidelines include assessment of multimorbidity, cognitive impairment, dementia, frailty, and depression; factors that may all impact therapeutic decisions, compliance,
Furthermore, with the evolution of novel device therapies, heart transplantation and mechanical circulatory support options, shared
Remote Monitoring
Monitoring of patients’ clinical status at a distance can be performed through various methods and tools such as telephone support, standalone devices at home (e.g., blood pressure monitors), cardiac implantable electronic devices, and wearable technologies (e.g., smartwatches). A Cochrane review based primarily on small studies showed a 44% reduction of
decreased
Remote monitoring of patients with HF continues to generate interest as new strategies to improve the rapid detection of decompensation, rates of hospitalizations, as well as compliance and optimization of medical therapy have been developed.75 The Heart Failure Society of America published a white paper on remote patient monitoring in which the authors advised against the routine use of external monitoring devices, as there were no consistent benefits in large randomized trials.81 Implanted devices, including monitors of pulmonary artery pressure (CardioMems), have shown improved patient outcomes in a small number of studies and may be beneficial for carefully selected patients.82 Further studies are required to explore the role and potential benefits of novel remote monitoring technologies in practice, with particular attention to both clinical and
Future Directions
The management of HF is constantly evolving as newer therapies arise. Knowledge translation in HF care, as well as a better understanding of patients’ perspective of their disease, are persistent gaps that require further attention. Multidisciplinary recognition and management of HF comorbidities is another important aspect of care requiring better integration into disease management programs. With the advent of so many novel therapeutic strategies improving patient survival and quality of life, this is indeed an exciting time for the care of HF patients.
Conflicts of Interest
Dr. Boulet: None.
Dr. Giannetti: Honoraria: AstraZeneca, BMS/Pfizer Alliance, Medtronic, Novartis, Pfizer, Servier, Abbott Clinical Trials: Novartis, Servier, Amgen, Boehringer Ingelheim.
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