Congestive Cardiac Failure

Heart Failure with reduced Ejected Fraction

(HFrEF)

Registrar Evidence Based Education Series

Dynamed
AAFP
 What Is? Medications

Treatment Goals Interventions

In-patient

Guideline Directed Therapy Summary

What is CCF?

What is the definition of CCF?

What are the most common
etiologies?
What are the classifications?
 Treatment goals

What are CCF treatment

goals?
Guideline Directed
Therapy

What is indicated for class

B/I?
What is indicated for class
C/II-III?
What is indicated for class
D/IV?
Medications

What medications can be used

to treat CCF?
When are each indicated?
What are the starting and
target doses?
Do the medications affect
POEMs or DOEs?
Interventions

What interventions can be

implemented with CCF?
When are those interventions
indicated?
What is? Heart failure is when the heart is unable to pump
enough oxygen rich blood to meet the metabolic
needs of the body
• Heart failure due to Reduced Ejection fraction (HFrEF) LVEF<40%

Common causes include: hypertension, ischemic

heart disease, valvular disease, a-fib, LVH, cardiotoxic
drugs/substances, viral, idiopathic and congenital

NYHA ACC/AHA
I: Asymptomatic A: At risk of heart failure without
structural disease
II: Symptoms with modest exertion B: Structural heart failure without
symptoms
III: Symptoms with minor exertion C: Structural heart failure with
current or prior symptoms
IV: Symptoms at rest D: Symptoms at rest
Treatment goals

Identify cause

Control: heart rate, blood pressure, volume status

Guideline mandated therapy

Decrease hospitalizations

Decrease mortality

Improve quality of life

 D/IV

Guideline Directed
Therapy
C/II-III

B/I
 B/I
INTERVENTIONS
STANDARD THERAPY • Implantable
• ACEI or ARB/ARNI Cardioverter
Defibrillator (ICD)
• SGLT-2 inhibitors
• Revascularization
• Valvular surgery
 C/II-III
STANDARD THERAPY
• ACEI OR ARB/ARNI
• SGLT-2 inhibitors
SELECT PATIENTS
• Beta blocker
• Aldosterone antagonists
• Diuretics
• Hydralazine/isosorbide dinitrate
INTERVENTIONS • Ivabradine
• Cardiac • Digoxin
Resynchronization
Therapy (CRT)
• ICD
• Revascularization
• Valvular surgery
 D/IV
• Advanced care measures
• Heart transplant
• Chronic inotropes
• Mechanical circulatory support
• Experimental surgery or medications
• Palliative Care
• ICD deactivation
 MEDICATONS

STANDARD MEDICATIONS IF INDICATED OTHER INDICATIONS

ACEI Aldosterone antagonist Statins
ARB or ARNI Loop diuretics Antiplatelets
SGLT-2 Vasodilator Anticoagulation
Beta blocker Diuretics
Sinus node modulator
Inotrope

Click on the class for more information

ACE inhibitor
• For all patients with HFrEF
• Improves mortality, quality of life and alters natural
history
• If intolerant can use ARB or ARNI

MEDICATION Starting dose Target dose

Lisinopril 5 mg daily 10-20 mg daily
Enalapril 2.5 mg bid 10 mg bid
Ramipril 1.25 mg bid 5 mg bid
ARB/ARNI
• For all patients with HFrEF if not on an ACEI
• Improves mortality, quality of life and alters natural
history
• ARNIs are very expensive

MEDICATION Starting dose Target dose

Valsartan 40 mg bid 160 mg bid
Candesartan 4 mg daily 32 mg daily
Sacubitril/Valsartan 49/51 mg bid 97/103 mg bid
SGLT-2 Inhibitors
• For all patients with HFrEF
• Improves mortality, quality of life and alters natural
history
• Safe to use in the absence of diabetes

MEDICATION Dose without DM Dose with DM

Empagliflozin 10 mg daily 25 mg daily
Dapagliflozin 10 mg daily 10 mg daily
Beta blocker
• For all stable patients with HFrEF and symptoms
already on ACEI/ARB/ARNI
• ACC/AHA Class C-D ○ NYHA Class II-IV
• Improves mortality, quality of life, symptoms, clinical
outcomes and alters natural history
• Important to reach target dose
MEDICATION Starting dose Target dose
Carvedilol 3.125 mg bid 25 mg bid
Bisoprolol 1.25 mg daily 10 mg daily
Metoprolol succinate (XL) 12.5 mg daily 200 mg daily
 Loop diuretics
• Used to manage volume status as needed
• ACC/AHA Class C-D ○ NYHA Class II-IV
• Only therapy that acutely helps symptoms
• No mortality benefit

MEDICATION Starting dose Target dose

Bumetanide 1mg once daily 1-10mg/dose (max 10/d)
Furosemide 40mg once daily 20-160mg/dose (max 600/d)
Torsemide 20mg once daily 20-100mg/dose (max 200/d)
Aldosterone antagonist
• Added to ACEI+BB+SGLT2 if still symptomatic
and EF < 35%
• ACC/AHA Class C-D ○ NYHA Class III-IV
• Mortality benefit only if the above are met

MEDICATION Starting dose Target dose

Eplerenone 25 mg daily 50 mg daily
Spironolactone 12.5 mg daily 25 mg daily
Vasodilators
• Option for those intolerant of ACEI or ARB
• ACC/AHA Class C-D ○ NYHA Class II-IV
• Reduces morbidity and mortality in black patients
when added to standard treatment (ACEI+BB)
MEDICATION Starting dose Target dose
Hydralazine 37.5 mg TID 75 mg TID
Isosorbide dinitrate 20 mg TID 40 mg TID
Isosorbide 20/37.5 mg TID 40/75 mg TID
dinitrate/hydralazine
Thiazides
• Used to manage volume status as needed
• ACC/AHA Class C-D ○ NYHA Class II-IV
• No mortality benefit

MEDICATION Starting dose Target dose

Hydrochlorothiazide 25 mg daily 25 - 100 mg daily
Metolazone 2.5 mg daily 2.5 – 10mg daily
Sinus node modulator
• Used in patients with persistent symptoms on
standard therapy, a HR > 70 despite beta blockers at
target dose and an EF < 35%
• ACC/AHA Class C-D ○ NYHA Class II-IV
• Reduces hospital admissions but not mortality

MEDICATION Starting Dose Target Dose

Ivabradine 5 mg bid 7.5 mg bid
Inotrope
• Used for symptom control in patients with persistent
symptoms despite optimal therapy
• Stop if there are no improvements in symptoms
• ACC/AHA Class C-D ○ NYHA Class II-IV
• Reduces hospital admissions but not mortality

MEDICATION Starting dose Target dose

Digoxin 0.125 mg daily 0.125 – 0.375 mg daily
 Statins
• Statins are not beneficial for adjunctive therapy for
the diagnosis of heart failure
• Indicated per USPSTF guidelines
• High dose for proven clinical CVD
• Low-moderate dose for ASCVD ≥ 10%

Statin Low-intensity Moderate-intensity High-intensity

Atorvastatin ---- 10 – 20 mg 20 – 40 mg
Rosuvastatin ---- 5 - 10 mg 20 - 40 mg
Simvastatin 10 mg 20 – 40 mg ----
Lovastatin 20 mg 40 mg ----
Antiplatelet
• Antiplatelet is not recommended for adjunctive
therapy for the diagnosis of heart failure
• Indicated if clinical CVD for secondary prevention
• History of MI, CVA, PAD, symptomatic carotid artery
stenosis
• Single therapy recommended over dual therapy

MEDICATION Dose
Aspirin 75-100 mg daily
Clopidogrel 75 mg daily
Anticoagulation
• Recommended with
• atrial fibrillation and additional risk factors for
cardioembolic stroke
• CHA2DS2-VASc calculator
• Left ventricular clot
• Warfarin with an INR of 2-3 for 3 months
• Direct Oral AntiCoagulant if not valvular a-fib
MEDICATION Dose
Warfarin Titrated
Dabigatran 150 mg bid
Apixaban 5 mg bid
Rivaroxaban 20mg daily
Interventions
Revascularization
• CABG or PCI/fibrinolytics with angina/significant coronary artery disease

Valvular surgery
• If valvular disease severe

Implantable cardioverter-defibrillator
• Class C/I-III with an EF < 35% and life expectancy of > 1 year
• Decreases sudden death and mortality

Cardiac resynchronization therapy (+/- defibrillator)

• Class C/III biventricular pacing if EF < 35%, LBBB, QRS > 150ms, symptoms despite max therapy
• Increases quality of life and decreases hospitalization

Mechanical circulatory support

• Improves cardiac output if refractory to medical management

Heart transplant
• Class D/IV with a life expectancy ≤ 1-2 years
• Improves functional status and quality of life
IN-PATIENT

Presentation Treatment

Work Up Discharge
Presentation

How do patients with new onset or acute

compensated heart failure present?

What are typical precipitating factors

prior to admission?

What is on the differential diagnosis?

Work Up

What laboratory investigations

are indicated?
What imaging studies are
indicated?
 Treatment
What are the foundations
of HFrEF treatment while
in-patient?
Discharge

What medications should be started

prior to discharge?

What patient education should occur

prior to discharge?

When and how should follow up occur?

Presentation

Signs and symptoms Precipitating factors Differential diagnosis

Dyspnea/ Fatigue New/worsened LV dysfunction
Asthma
Orthopnea Medication non-compliance
DOE
Diet non-compliance COPD
PND
Weight gain Volume overload
Cough Drug exposure Pulmonary infections
Increasing abdominal girth Arrhythmia
Lower extremity edema Valvular disease Pulmonary embolism
JVD
Uncontrolled HTN
Hypotension
S3 (LR +4.0) High output state
Crackles Increased metabolic demand
 Work Up
BNP if diagnosis is uncertain:
• BNP < 100 rules it out
• BNP > 400 suggests HF
• BNP > 800 LR [+] >5.0
Initial labs:
• troponins, FBC, RFTs, LFTs, TSH

Diagnostics:
• ECG: ACS, arrythmia
• CXR: pulmonary edema, heart size
• Echo: left/right systolic dysfunction, L atrial size, other
structural abnormalities
POCUS:
• Lung: ≥3 B lines in 2 b/l lung zones
• LR [+] 7.4 and LR [-] 0.16
• Cardiac POCUS with visually estimated reduced EF
• LR [+] 4.1
Treatment
• Diuretics: should be ≥ chronic daily dose to treat symptoms of overload
• IV furosemide 40mg followed by another 80mg after 1 hour if no response
• Oral furosemide 20 - 80mg initial dose, repeated every 6-8 hours increasing 20-40mg
until desired response
• IV Bumetanide IV 0.5-1mg over 1-2 minutes repeat every 2-3 hours until desired
response
• PO Bumetanide 0.5-2mg repeated every 4-5 hours until desired response
• Monitor fluid intake and output
• 02 for saturation < 90% or PaO2 < 60mmHg
• Continue home ACEI and BB unless hemodynamically unstable
• VTE prophylaxis with LMWH unless risk of bleeding outweighs benefits
Treatment with little evidence
Aggressive sodium and fluid restriction does not affect weight loss or clinical stability

If additional diuresis is needed:

• use higher doses of loop diuretics
• add a second diuretic (thiazide or spironolactone)
• add low-dose dopamine
• add vasopressin antagonist

If significant dyspnea despite O2 and aggressive diuresis consider:

• Vasodilators (IV nitro)
• Non-invasive positive pressure ventilation

If borderline or low blood pressure consider:

• Dopamine: 2-5 mcg/kg/minute IV infusion
• Can also use Dobutamine or milrinone
Discharge
Once not needing aggressive diuresis start beta
blocker

Start ACE inhibitor prior to discharge

Start aldosterone antagonist if C/II-III with an EF

≤ 35% prior to discharge

Lifestyle education: BP, diabetes, tobacco,

alcohol, exercise regularly, lose weight
Watch for: worsening shortness of breath or
edema, PND, abdominal pain/swelling, weight
gain, frequent cough, feeling more tired than
usual

Vaccines: Flu, pneumonia and COVID

Follow up within 1 week: Office, telehealth,

phone
 Seed Global Health
Etiology
•HTN, ischemic heart disease, valvular disease, a-fib, LVH, post-partum, cardiotoxic drugs/substances, viral, idiopathic

Classification
•A-B/I: no limitations

CCF
•C/II-III: mild-marked symptoms
•D/IV: refractory, symptoms at rest
Guideline directed therapy
•Start specified medications/interventions for each class to decrease morbidity and mortality

Medications
•Mortality: ACEI (ARB or ARNI), BB, spironolactone, SGLT-2 inhibitor
•Symptoms: furosemide
Interventions
HFrEF
•ICD, CRT, revascularization, valvular surgery, LVAD, transplant

Lifestyle
•Control: BP, diabetes, tobacco, alcohol, exercise regularly, lose weight
•Worsening shortness of breath or edema, orthopnea PND, abdominal pain/swelling, weight gain, frequent cough, feeling more
tired than usual
Vaccines
•Flu, pneumonia, COVID