Heart Failure Management Overview

Overview

Episode focuses on the practical management of heart failure with reduced ejection fraction (HFrEF), highlighting diagnostic evaluation, evidence-based therapy, medication titration, and non-pharmacologic considerations, featuring expert insights from Dr. Michelle Kittleson.

Case Introduction and Initial Evaluation

• Presenting patient: 62-year-old man, new HFrEF, post-hospitalization, classic symptoms, and reduced EF.
• Initial evaluation must focus on identifying the underlying cause of cardiomyopathy.
• Assess for coronary artery disease, thyroid dysfunction, diabetes, HIV, hemochromatosis, substance use, familial/genetic factors.
• Select tests that will inform management decisions; avoid unnecessary testing.

BNP Use in Heart Failure

• BNP is valuable for diagnosing or excluding heart failure and for prognosis on admission.
• Serial BNP levels should not be used to guide diuretic titration or day-to-day management.
• BNP interpretation is affected by age, obesity, and renal dysfunction; prioritize clinical examination.

Guideline-Directed Medical Therapy (GDMT)

• Four pillars: ARNI (sacubitril/valsartan), evidence-based beta-blocker (metoprolol succinate, carvedilol, bisoprolol), mineralocorticoid receptor antagonist (spironolactone/eplerenone), SGLT2 inhibitor.
• Start with ARNI, MRA, SGLT2 inhibitor before beta-blocker; sequence can vary based on patient status.
• Beta-blockers may worsen symptoms initially; introduce when patient is decongested.
• ACE inhibitors are preferred over ARBs for HFrEF if ARNI not used.
• Cost and side effects may drive therapy choices; maximize use of generics if needed.

Medication Titration and Monitoring

• Use rapid sequence titration rather than simultaneous initiation; monitor response and side effects.
• Labs (for potassium, creatinine) checked every 1-2 weeks with dose changes, then every 3 months once stable.
• SGLT2 inhibitors require minimal lab monitoring unless major changes in renal function or volume status occur.

Role and Limitations of Other Therapies

• Hydralazine/isosorbide dinitrate reserved for select patients (e.g., Black patients, persistent hypertension after all pillars).
• Ivabradine and vericiguat reserved for patients still symptomatic or hospitalized after maximized GDMT; only use in appropriate niche cases.
• Diuretics provide symptom relief but do not improve outcomes.

Advanced Therapies and Device Considerations

• ICD/CRT considered only after optimizing GDMT and re-evaluation of EF after 3–6 months.
• Secondary mitral regurgitation: re-assess after GDMT optimization before considering mitral intervention.
• Heart failure with improved EF: continue GDMT indefinitely to prevent relapse.

Non-Pharmacologic Management

• Sodium and fluid restriction should be individualized; no strong evidence for strict limits in stable outpatients.
• Educate patients on recognizing symptoms and adjusting intake based on their response.

Patient Follow-Up and Specialist Referral

• Continue primary care or cardiology follow-up if stable; repeat echo at 6 months, then annually.
• Refer to advanced heart failure specialist if patient exhibits "I NEED HELP" criteria: IV diuresis, worsening symptoms, end organ dysfunction, persistent low EF, recurrent hospitalizations, escalating edema, low BP, tachycardia, intolerance of GDMT, or ICD shocks.

Recommendations / Advice

• Optimize and titrate all four GDMT pillars for HFrEF whenever possible.
• Investigate underlying etiology of cardiomyopathy in all new cases.
• Use clinical findings, not serial BNPs, to guide heart failure management.
• Continue GDMT indefinitely even after EF improves.

Decisions

• Do not titrate diuretics based on serial BNP.
• Prioritize ARNI over ACEi/ARB if possible, given evidence for improved outcomes.
• Switch patient from metoprolol tartrate to succinate for HFrEF benefit.
• After GDMT optimization, delay ICD/CRT decisions for 3–6 months to reassess EF.
• Continue GDMT even if EF normalizes (“heart failure with improved EF”).

Action Items

• TBD – Primary care team: Complete full diagnostic workup for underlying cause of cardiomyopathy per history/physical/labs.
• TBD – Primary care/cardiology: Initiate and titrate GDMT pillars as tolerated, monitoring labs and symptoms.
• TBD – Primary care/cardiology: Recheck echocardiogram after 3–6 months of optimized GDMT.
• TBD – Primary care/cardiology: Refer to advanced heart failure specialist if patient meets “I NEED HELP” criteria.

Key Dates / Deadlines

• Follow-up labs: every 1–2 weeks with medication changes, then every 3 months when stable.
• Reassess EF by echo at 3–6 months after GDMT optimization.