Heart Failure: What's New, What's Different, and What Matters

Educational Objectives

The goal of this program is to improve treatment of heart failure. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate wild-type senile amyloidosis from hereditary type.
2. Compare stage C heart failure from other stages of disease.
3. Administer intravenous iron in patients with heart failure with reduced ejection fraction and iron deficiency anemia.

Summary

Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (EF): now includes 4 medication classes, including sodium-glucose cotransporter-2 (SGLT2) inhibitors; blocking an ion channel in the proximal nephron involved with absorption of sodium and glucose results in increased excretion of glucose and sodium; SGLT2 inhibitors have been found to be effective decongestants that reduce hospitalization and improve mortality; hold an angiotensin-converting-enzyme (ACE) inhibitor for 2 days before starting sacubitril-valsartan (Entresto); the goal is to get patients on all 4 medications by discharge; avoid beta-blockers in patients with reduced EF during acute HF exacerbations (may initially decrease contractility and worsen HF); beta-blockers can be started after the first day or 2; challenges include continuing medications after discharge and titrating medications to their maximum doses in outpatient settings

Treatment considerations: patients with mildly reduced or low normal EF in HF may benefit from SGLT2 inhibitors; ACE inhibitors, angiotensin 2 receptor blockers (ARBs), spironolactone, calcium-channel blockers, and beta-blockers are not beneficial in diastolic HF; SGLT2 inhibitors may help (benefits seen within weeks of therapy), especially for those with EF 40s or low 50s (do not benefit patients with preserved EF [70%]); class 2b recommendations can be used (if safe for the patient) and monitored for kidney and other issues, which include angiotensin receptor-neprilysin inhibitors (ARNIs); mostly used for patients with mildly reduced EF (40%-49%) but rarely used for EF >70%; new recommendations emphasize the importance of treating hypertension

Treatment of atrial fibrillation (Afib): Afib lowers EF; a high rate (>90 bpm) can trigger HF exacerbations in patients with congestive HF; more aggressive rate control strategies are being used; atrioventricular (AV) nodal ablations are sometimes recommended; AV nodal ablation cuts the connection between the upper and lower heart, preventing Afib stimuli from reaching the ventricle; cardiac resynchronization therapy (CRT) may be recommended for some patients; a biventricular device can augment EF; small pacemakers (Micra) are commonly implanted through the internal jugular vein; it is functionally a ventricular demand (VVI) single-lead pacemaker, which can benefit patients with chronic Afib; AV nodal ablation and pacemaker may be a viable option for patients with chronic afib; in patients that cannot tolerate ARNIs, ARBs are recommended; avoid routine use of phosphodiesterase inhibitors

Stopping medications: overmedicating patients is a concern; can consider discontinuation when EF is restored, but the EF often decreases again; women who experience peripartum cardiomyopathy are recommended not to get pregnant again, but discontinuation of medication is controversial because of lack of data; HF management can benefit from the concept of remission rather than cure

Value: ARNIs, ACE inhibitors, ARBs, beta-blockers, mineralocorticoid receptor antagonists, hydralazine, and nitrates have high value; SGLT2 inhibitors have intermediate value; transplants are expensive but beneficial; tafamidis for amyloid has a low value

Amyloid heart disease: falls under 2 categories, AL and ATTR; light-chain amyloidosis (AL) is mnemonic (L for leukemia, lymphoma), a type of plasma cell dyscrasia that causes problems in amyloid deposition; transthyretin (TTR) is an important protein that carries vitamin A and thyroxine; misfolding and deterioration can lead to amyloid deposition; 2 categories; senile (wild-type) is a disease of aging affecting White men >60 yr of age more than any other group; hereditary type is the other category; important to distinguish between the 2 types for screening family members

Treatment of amyloid heart disease: beta-blockers and spironolactone are not effective; if a patient does not respond to HF medications, consider amyloid; amyloid appears to be associated with conditions like glaucoma, bilateral carpal tunnel syndrome, and Achilles tendon rupture; artificial intelligence is being used to analyze data to identify patients with potential amyloid heart disease; there is a new medication that stabilizes transthyretin and prevents breakdown and improves clinical outcomes, including hospitalizations, death, and disease progression; it does not improve amyloid heart disease but can prevent further progression; early diagnosis provides an opportunity to prevent worsening of the condition; patients with end stages of disease receive various types of circulatory support, which saves lives in the short term, but long-term value is uncertain; screening monoclonal light chains can identify plasma cell dyscrasia; tafamidis is recommended; anticoagulation is appropriate for patients with low CHADS2-VASc score but have Afib and amyloid

Diagnosis: obtain evidence supporting increased filling pressures before diagnosing HF; echocardiography can be used to confirm HF; Afib prevents a reliable assessment of diastolic dysfunction; B-type natriuretic peptide (BNP) is better than clinical assessment for diagnosing HF; elevated BNP in patients with equivocal signs can point to the diagnosis; early and frequent BNPs are beneficial, especially when making an initial diagnosis of HF

Stages and classes of HF: stage A — increased risk for HF; can clarify the subtle processes that occur in HF as hypertension is the greatest risk factor; framing blood pressure medication as HF prevention can help patients understand the importance of taking it; stage B — pre-heart failure; there is some evidence of structural heart disease, but the patient is asymptomatic; may have elevated BNP or increased filling pressures on echocardiography; stage C — symptomatic HF; stage D — advanced HF; class I — the patient has no limitations; class II — slight limitations; class III — marked limitations; class IV — symptoms at rest

HF with reduced EF and iron deficiency anemia (IDA): research shows intravenous (IV) iron helps, while oral iron does not; IDA affects 50% of the HF population; IV iron lowers hospitalization by 25%; however, patients with HF are not routinely evaluated for IDA; continuous positive airway pressure (CPAP) is used for sleep apnea but there is no evidence supporting it as an intervention to decrease afib and improve HF outcomes; direct oral anticoagulants (DOACs) are better than warfarin

Patient referral: some patients with advanced HF should be referred to specialized teams; a specialized HF team has more time, a smaller patient panel, and more resources than general cardiologists; palliative care reduces anxiety and depression and improves quality of life; should not refer to advanced HF physicians too early or too late (eg, multiorgan failure, severe cardiac cachexia); a referral is not necessary if a patient is well and has minimal symptoms without hospitalization; since HF is progressive, advanced directives are helpful

Final points: new sodium restriction targets liberalize salt intake without causing hospitalizations or bad outcomes in patients with HF; educate patients and involve dieticians; psychosocial and financial need assessments are important; cardiopulmonary exercise stress testing can sometimes provide objective measurements of a patient’s limitations and symptoms; a multidisciplinary approach is beneficial; percutaneous valve therapies and pulmonary artery pressure sensors can help; refer patients to advanced HF team who require inotropes, increasing New York Heart Association class, high BNP, end-organ dysfunction, low EF, defibrillator shocks, hospitalizations within the past year, escalating diuretics or edema, low blood pressures limiting GDMT, and prognostic medications; evaluate and treat reversible pathologies; consider devices, particularly if there is a permanent pacemaker; evaluate noncardiac comorbidities; people with low EFs qualify for cardiac rehabilitation; encourage weight loss; educate patients and counsel them that HF is a long-term issue

Readings

Desai AS, Maclean T, Blood AJ, et al. Remote optimization of Guideline-Directed Medical Therapy in patients with heart failure with reduced ejection fraction. JAMA Cardiology. 2020 December;5(12):p1430–1434. DOI: 10.1001/JAMACARDIO.2020.3757. View Article; 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. Circulation. 2022 May 03;145(18):e895–e1032. DOI: 10.1161/CIR.0000000000001063. View Article; Mei Z, Chen J, Luo S, et al. Comparative efficacy of intravenous and oral iron supplements for the treatment of iron deficiency in patients with heart failure: A network meta-analysis of randomized controlled trials. Pharmacological Research. 2022 August;182:106345. DOI: 10.1016/J.PHRS.2022.106345. View Article; Ruberg F, Maurer MS. Cardiac amyloidosis due to transthyretin protein: A review. JAMA. 2024 March 5;331(9):778–791. DOI: 10.1001/JAMA.2024.0442. View Article; Verma A, Kalman JM, Callans DJ. Treatment of patients with atrial fibrillation and heart failure with reduced ejection fraction. Circulation. 2017 April 17;135(16):p1547–1563. DOI: 10.1161/CIRCULATIONAHA.116.026054. View Article.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Beckerman was recorded at Riding the Waves of Primary Care 2023, held November 6-10, 2023, on Kohala Coast, HI, and presented by Amedco LLC and Providence Regional Medical Center Everett. For information on future CME activities from these presenters, please visit amedcoedu.com and providence.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.00 CE contact hours.

Lecture ID:

NP240805

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.