#45 Heart failure: update and guidelines review

June 26, 2017 | By Matthew Watto, MD

Update your management of heart failure (HF) with expert tips from Cardiologist Dr. Eric Adler, Associate Professor of Medicine and Director of Cardiac Transplant and Mechanical Circulatory Support at UC San Diego. We cover how to use BNP, a simple way to examine jugular venous distention, medical therapy for heart failure, the PARADIGM-HF trial, and how to use sacubitril/valsartan (Entresto).

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Case: 79 yo M with obesity, hypertension (HTN), osteoarthritis, low back pain on celebrex and lisinopril who presents with new onset dyspnea and lower extremity edema.

Clinical Pearls:

1. Classification: Classify as HFpEF or HFrEF, NYHA functional class I-IV, stage A-D, and whether ischemic, or nonischemic.
2. Heart failure with reduced ejection fraction (HFrEF): EF less than or equal to 40%
3. Heart failure with preserved ejection fraction (HFpEF): EF between 41-49% (borderline), or 50% and above. Challenging diagnosis. Must exclude potential noncardiac causes of HF symptoms (2013 HF guidelines).
4. NYHA Functional Classes (I-IV): These change based on control of HF. Class I = no limitations, or symptoms, Class II = slight limitations, and symptoms of HF with ordinary physical activity; Class III marked limitations, and symptoms of HF with less than ordinary activity; Class IV = symptoms at rest (2013 ACC Guidelines).
5. Stages of HF (A to D): These do not change once a stage is reached.  A = high risk for HF, w/o symptoms or structural disease; B = structural heart disease w/o signs or symptoms HF; C = structural heart disease w/prior or current symptoms HF; D = refractory HF requiring specialized interventions. (2013 ACC Guidelines)
6. Neck exam for jugular venous distention (JVD): Sit patient at 90 degrees and perform hepatojugular reflux. If JVD above clavicle, then test is positive (Dr. Adler’s expert recommendation). https://wn.com/jugular_venous_distension_example
7. Brain Natriuretic peptide: Initially identified in brain, but released primarily from heart. The prohormone (pro-BNP) is cleaved into the active hormone, BNP, and the inert N-terminal pro-BNP (NT-proBNP). (Source UptoDate)
8. BNP: Value above 100 pg/mL predicts HF. Consider using value above 200 pg/mL if afib present to improve specificity.  (Source UptoDate)
9. NT-proBNP: Longer half life than BNP. Value under 300 pg/mL excludes HF w/98% negative predictive value. Cut-off varies with age <50, 50-75, or >75 yo use 450 pg/mL, 900 pg/mL, and 1800 pg/mL respectively. (Source UptoDate)
10. Factors that affect BNP value: Obesity lowers BNP. BNP elevated by female sex, atrial fibrillation, valvular disease, acute coronary syndrome, LVH, advanced age, anemia, CKD, sleep apnea, pneumonia, pulmonary HTN, sepsis. Sacubitril, or nesiritide (recombinant human BNP) will raise BNP, but not NT-proBNP.
11. BNP (or NT-proBNP) for prognosis: Consider in asymptomatic patients at risk for HF (per 2017 ACC guidelines). Useful if Stage A or B to help risk stratify (Dr. Adler’s expert opinion)
12. BNP (or NT-proBNP) prior to hospital discharge: If BNP has not decreased despite optimal medical therapy, then may need CHF specialist or advanced HF therapy (2017 ACC guidelines and Dr. Adler’s expert opinion).
13. Counseling patients on HF: Consume less than 2 L fluid or 2 gm of salt per day. Teach patients to read labels, and correlate symptoms to high salt load (Dr. Adler’s recommendation).
14. Cardiac rehab: Useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL, and mortality (2013 ACC HF guidelines)
15. Additional testing for new HF: Check TSH, HIV. Evaluate for coronary artery disease. Screen for substance abuse (ETOH, cocaine, methamphetamine). Consider amyloidosis if HFpEF w/low voltage EKG, and hypertrophy on echo, but not on EKG.
16. Medical therapy for HFrEF*: See patients weekly for 1st month of therapy to titrate medications and assess response to therapy. Start with afterload reduction (e.g. ACEI) because patients feel better —> increased compliance (Dr. Adler’s expert opinion). *Meds discussed from here on refer to HFrEF unless otherwise stated.
17. Beta blockers: Indicated as chronic therapy for all patients w/HFrEF. Metoprolol XL, bisoprolol, and carvedilol have proven efficacy, and mortality benefit. Downside: patients feel worse in the near term so must coach them through it.
18. Loop diuretics: No mortality benefit. Agents = furosemide (lasix), bumetanide (bumex), and torsemide (demadex). Congested patients may not absorb furosemide well. Take torsemide on an empty stomach to improve absorption! Common mistake = under dosing. Starting dose of furosemide (lasix) = BUN times 2. House of God dosing = BUN + age. Joel Topf (@kidney_boy) dosing = Cr times 20. Conversion 40 mg oral furosemide = 20 mg oral torsemide = 1 mg oral bumetanide.
19. Aldosterone antagonist (only diuretic that improves mortality). Indication = NYHA Class II-IV w/CrCl >30 and K<5 (2017 ACC Guideline update). Start at 12.5 mg daily. Check potassium, Cr within 1 week.
20. Sacubitril/valsartan (Entresto): Known as “ARNI” for angiotensin receptor-neprilysin inhibitor. Adverse effects: hypotension, angioedema, hyperkalemia, elevated Cr. Has diuretic effect (through sacubitril) so lower or stop diuretic upon initiation of ARNI. Must stop ACEI for 24-36 hours prior to initiation. Start ARNI at lowest dose and titrate up every 2-4 weeks.
21. PARADIGM-HF: Randomized controlled trial w/over 8,000 patients randomized to enalapril versus sacubitril/valsartan (ARNI) after single blind run-in phase w/all patients receiving ACEI or ARNI. Primary outcome composite cardiovascular death, or hospitalization for heart failure. ARNI led to 20% relative risk reduction in primary outcome versus ACEI.
22. CCB and HF: Amlodipine is safe to use, but has downside of LE edema. Avoid diltiazem and verapamil due to further depression of cardiac function.
23. Digoxin: Consider in elderly who have afib with rapid ventricular response at low doses, or in advanced HF patients who is not candidate for transplant or other advanced therapies. Be cautious due to low therapeutic index (Dr. Adler’s expert opinion).
24. Blood pressure target in HFrEF: At least 130/80 (per 2017 ACC HF guidelines), but as low as patient can tolerate (Dr. Adler’s expert opinion).

Goal: Listeners will develop a standardized approach to the diagnosis and management of heart failure.

Learning objectives:
By the end of this podcast listeners will:

1. Consider use of palliative care for patients with heart failure
2. Appropriately classify and stage heart failure
3. Utilize BNP and NT-proBNP as tool for establishing diagnosis and prognosis of HF
4. Recall factors that alter BNP values
5. Perform an accurate neck vein exam
6. Order additional testing for patient with new diagnosis heart failure
7. Choose appropriate initial medical therapy
8. Safely titrate and monitor medical therapy
9. Discuss the PARADIGM-HF trial and its major findings
10. List medications and supplements to avoid in HF
11. Identify patients who might benefit from digoxin

Disclosures:
Dr. Adler reports no relevant financial disclosures.

Time Stamps
00:00 Intro
04:25 Rapid fire questions
06:00 Palliative care and heart failure
08:40 Book recommendation
10:20 Advice for teachers and learners
12:27 Clinical case of HF
13:38 Classification and staging of HF
17:07 Discussion of BNP
19:35 How to perform neck vein exam for JVD
21:20 BNP for prognosis
23:00 BNP at hospital discharge
26:36 Factors that affect BNP
27:25 Initial patient counseling
32:35 Exercise in HF
34:00 Additional testing at time of diagnosis
36:28 Initial medical therapy
38:30 Discussion of diuretics and dosing
42:50 Aldosterone antagonists
44:30 PARADIGM-HF and entresto
51:27 Medications to avoid in HF
54:14 Digoxin
57:30 Dr. Adler’s take home points
59:11 Stuart questions dosing conventions
60:48 Outro

Links from the show:

1. Deep Work (book) by Cal Newport
2. Dr. Adler’s Palliative Care Review Adler, E et al. Palliative Care in the Treatment of Advanced Heart Failure. Circulation 2009.
3. Breathing Not Proper Trial Maisel AS et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347(3):161.
4. Neck exam video recommended in 2013 ACC guidelines.
5. Summary of 2017 HF guideline update 2017 ACC/AHA/HFSA Focused Update Guideline for the Management of Heart Failure from JACC 2017
6. 2017 Full guideline update HF ACC Full Guideline for Management of Heart Failure JACC 2017
7. 2016 Focused HF update Heart Failure Focused Update on Pharmacological Therapy  a Focused Update from JACC May 2016
8. HFpEF Review article Margaret M. Redfield, M.D. Heart Failure with Preserved Ejection Fraction.  N Engl J Med 2016; 375:1868-1877. November 10, 2016 DOI: 10.1056/NEJMcp1511175
9. PARADIGM-HF McMurray, J et al. Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure (PARADIGM-HF). N Engl J Med 2014; 371:993-1004 September 11, 2014 DOI: 10.1056/NEJMoa1409077
10. 2013 Full guidelines HF ACC Yancy, CW et al. 2013 ACC/AHA Guideline for the Management of Heart Failure. https://doi.org/10.1161/CIR.0b013e31829e8776 Circulation. 2013;128:e240-e327 Originally published October 14, 2013