Heart Failure

History

• Common symptoms of heart failure include:
  • Dyspnea ^c1
    • Dyspnea on exertion; dyspnea at rest often occurs in advanced heart failure ^c2c3
    • Orthopnea ^c4
    • Paroxysmal nocturnal dyspnea ^c5
  • Fatigue ^c6
    • Exercise intolerance ^c7
    • Increased recovery time from activity ^c8
  • Peripheral edema ^c9
    • Ankle swelling ^c10
  • Ascites causing any of the following: ^c11
    • Anorexia ^c12
    • Early satiety ^c13
    • Gastrointestinal discomfort ^c14
    • Increased abdominal girth ^c15
    • Scrotal swelling ^c16
  • Change in weight ^c17
    • Rapid weight gain suggests volume overload ^c18
    • Weight loss may occur in advanced disease ^c19
• Other symptoms of heart failure may include:
  • Nonproductive cough during recumbency ^c20
  • Confusion, especially in older adults ^c21
  • Palpitations ^c22
  • Syncope ^c23
• Family history of cardiomyopathy may suggest underlying cause; ask patient about heart failure in family members going back 3 generations ^c24

Physical examination

• Specific signs include:
  • Prominent jugular venous distention ^c25
  • Positive hepatojugular reflux ^c26
  • Laterally displaced apical impulse ^c27
  • Presence of S₃ gallop with systolic heart failure; may have S₄ gallop with diastolic heart failure ^c28c29
• Less specific signs include the following (may be associated with many other conditions):
  • Tachypnea and tachycardia ^c30c31
  • Narrow pulse pressure ^c32
  • Cool extremities ^c33
  • Crackles/rales (may be absent in advanced chronic heart failure) ^c34c35
  • Wheezes ^c36
  • Peripheral edema, ascites, and hepatomegaly ^c37c38c39
  • Cachexia in advanced disease ^c40

Causes

• Most common causes of heart failure are hypertension and ischemic coronary artery disease ^r9r10c41c42
  • Risk of heart failure increases 8- to 10-fold after myocardial infarction ^r9c43
    • Patients with new onset (de novo) heart failure are more likely to present owing to acute coronary syndrome than patients with chronic heart failure ^r11
  • Patients with heart failure with preserved ejection fraction (usually older and female) more commonly have hypertension and less commonly have coronary artery disease ^c44c45
  • Patients who have heart failure with reduced ejection fraction are more likely to have coronary artery disease (approximately two-thirds of cases), with hypertension a contributing factor ^c46
• Other causes of heart failure with reduced ejection fraction include valvular disease and cardiomyopathies
  • Valvular disease ^c47c48
    • Predominantly mitral and aortic valve disease (eg, mitral regurgitation, aortic stenosis, aortic regurgitation) ^{r12c49c50c51c52c53}
  • Cardiomyopathies ^c54
    • Large group of dissimilar myocardial disorders with common characteristics including ventricular dilation and depressed myocardial contractility in absence of abnormal loading conditions (eg, hypertension, valvular disease) ^c55c56
    • Idiopathic dilated cardiomyopathy ^c57
    • Familial cardiomyopathy ^c58
      • 2 closely related family members must meet criteria for idiopathic cardiomyopathy ^r13
      • A substantial percentage of what were once presumed idiopathic cardiomyopathies or peripartum cardiomyopathies are now recognized as having a genetic basis ^r13
    • Toxic cardiomyopathy ^c59
      • Heart failure may result from toxic effect on cardiac preload, cardiac afterload, or myocardial contractility ^r14
      • Heart failure may be reversible (eg, secondary to propofol), irreversible (eg, secondary to doxorubicin), or either (eg, secondary to cyclophosphamide) ^r14c60c61c62
      • Cardiotoxic cancer chemotherapies, particularly anthracyclines, can cause structural changes ^c63
        • Other therapies that are cardiotoxic include trastuzumab (especially with concomitant anthracyclines), high-dose cyclophosphamide, taxoids, mitomycin C, fluorouracil, and the interferons ^{c64c65c66c67c68c69}
      • Long-term alcohol or cocaine use may cause dilated cardiomyopathy ^c70c71
      • Cardiomyopathy may be caused by other drugs, many with misuse potential (eg, ephedra, anabolic steroids, amphetamines, methylphenidate) ^c72c73c74c75
    • Inflammatory cardiomyopathy ^c76
      • Immune-mediated inflammatory myocarditis ^c77
        • Hypersensitivity to medication (eg, sulfonamides, penicillin, methyldopa, amphotericin B, streptomycin, phenytoin, isoniazid, tetanus toxoid, hydrochlorothiazide, dobutamine, chlorthalidone) ^{c78c79c80c81c82c83c84c85c86c87c88}
        • Autoimmune disorders (eg, systemic lupus erythematosus, scleroderma) ^c89c90c91
      • Infective inflammatory myocarditis ^c92
        • Most commonly of viral origin but also can be caused by other pathogens
        • Commonly occurs in patients with HIV infection
    • Metabolic/endocrine cardiomyopathy ^c93c94
      • Includes cardiomyopathy caused by obesity, diabetes, hyperthyroidism, acromegaly, growth hormone imbalances, hypophosphatemia, hypocalcemia, and pheochromocytoma ^{c95c96c97c98c99c100c101}
      • Also includes cardiomyopathy caused by nutritional deficiencies (eg, thiamine deficiency, selenium deficiency), which may be seen in patients with chronic alcohol use disorder and anorexia nervosa ^{c102c103c104c105c106}
    • Infiltration cardiomyopathy ^c107
      • Caused by malignancy, sarcoidosis, iron overload, or amyloidosis ^r5
    • Iron overload cardiomyopathy ^c108
      • Caused by increased iron deposition in heart. Associated with common genetic disorders (eg, primary hemochromatosis) and disorders that require lifetime transfusions (eg, thalassemia major) ^c109c110
    • Peripartum cardiomyopathy ^c111
      • Left ventricular dysfunction occurs typically in third trimester of pregnancy or in immediate postpartum period ^r15
      • Incidence varies from 0.2% to 3% of live births worldwide, depending on region ^r16
      • Prognosis is directly related to degree of recovery to near baseline left ventricular function; mortality rates are high ^r17
    • Arrhythmia-induced cardiomyopathy ^r2c112
      • Tachycardia, atrial fibrillation, and premature ventricular contractions may cause a dilated cardiomyopathy
        • Left ventricular myocardial dysfunction correlates with duration of tachycardia and magnitude of increased ventricular rate
        • Generally reversible with rate control
      • Right ventricular pacing, particularly substantial pacing greater than 20% to 40%, may induce cardiomyopathy ^r18
        • Cardiac physiologic pacing prevents or minimizes pacing-related heart failure
    • Stress cardiomyopathy (takotsubo cardiomyopathy) ^c113c114
      • Acute reversible left ventricular dysfunction in the absence of significant coronary artery disease; triggered by acute emotional or physical stress
      • Characteristic apical ballooning is present
      • Often affects postmenopausal patients

Risk factors and/or associations

Primary diagnostic tools

• Diagnosis is suspected on the basis of thorough history and physical examination ^r9c137
• Obtain chest radiograph in acutely dyspneic patients to identify pulmonary edema and assess heart size. In nonacute diagnostic settings, chest radiograph is also recommended to detect or exclude alternative causes of symptoms ^r2r9c138
• Obtain 12-lead ECG as part of initial evaluation in all patients ^r2r8c139
• For all patients presenting with heart failure, explore the specific cause using additional laboratory testing
  • All patients ^r2r9
    • Electrolyte levels, BUN and creatinine levels, and urinalysis (important for treatment decisions) ^c140c141c142
    • Liver function tests ^c143
    • Fasting lipid levels and fasting glucose level to assess cardiovascular risk factors ^c144c145
    • CBC, iron studies, and TSH level to exclude anemia and thyroid disease (as a cause or exacerbating factor of heart failure) ^c146c147c148
    • B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide ^c149c150
      • Obtain for all patients with symptoms suggesting acute heart failure
        • American College of Cardiology Foundation, American Heart Association, and Heart Failure Society of America guidelines recommend measuring B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide level to support clinical decision making, especially in the setting of clinical uncertainty (in both ambulatory and hospitalized patients) ^r2r9r24r25
      • When making initial diagnosis:
        • Negative predictive value exceeds positive predictive value. Negative predictive value is best used to rule out rather than rule in the diagnosis on initial evaluation
        • European Society of Cardiology guideline recommends obtaining these measurements to help establish initial working diagnosis and identify patients who require further cardiac investigation. If values are below cutoff point, echocardiography is not needed ^r5
      • On admission to hospital for heart failure and prior to discharge, measure B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide level to inform a trajectory and help establish a postdischarge prognosis ^r2r25
  • Patients with acute decompensated heart failure
    • On admission to hospital, measure baseline levels of natriuretic peptide biomarkers and/or cardiac troponin to help establish a prognosis ^r2
• Obtain transthoracic 2-dimensional echocardiogram with Doppler flow studies for all patients with suspected heart failure ^r2r5r8
• Consider cardiac MRI for better assessment of myocardial structure and function, particularly if echocardiographic images are inadequate ^r5
• Noninvasive (eg, myocardial perfusion/ischemia imaging) and/or invasive (eg, coronary angiography) cardiac evaluation is not routine, but it is recommended for new-onset heart failure in the setting of known or suspected coronary artery disease or ischemic symptoms ^r5r26r27
• Hemodynamic monitoring via pulmonary artery catheter (right-sided heart catheterization) is not routine, but it may be indicated in critically ill patients and in some noncritically ill patients to obtain additional information ^r2
• Consider genetic testing for first-degree relatives of patients with genetic or inherited cardiomyopathies. Referral for genetic counseling is reasonable for selected patients with nonischemic cardiomyopathy to identify conditions that could guide treatment for patient and family members ^r2
• Because echocardiogram and natriuretic peptide levels may be nondiagnostic in heart failure with preserved ejection fraction, consider a clinical scoring system (eg, H₂FPEF) ^r3r28

Laboratory

• Routine laboratory tests ^r2r9
  • Obtain on presentation to assist in determining causes of heart failure, identifying risk factors, and assessing baseline kidney function
    • Comprehensive metabolic panel ^c151
      • Electrolyte, magnesium, calcium, BUN, and creatinine levels ^{c152c153c154c155c156}
      • Elevated liver enzyme levels may be due to hepatic congestion or dysfunction ^c157
    • Fasting blood glucose level ^c158
      • Diabetes is a common comorbidity and risk factor for heart failure
    • Fasting lipid profile ^c159
      • To assess risk for coronary artery disease and metabolic syndrome
    • TSH level ^c160
      • Thyroid disease may mimic, aggravate, or cause heart failure
    • CBC ^c161
      • Anemia may cause or exacerbate heart failure
    • Urinalysis ^c162
• Cardiac biomarker tests ^r29
  • Natriuretic peptide levels ^c163c164
    • Hormones secreted by cardiomyocytes with myocardial stretch
    • Diagnosis during an acute episode ^r24r25
      • B-type natriuretic peptide level less than 100 pg/mL or N-terminal pro–B-type natriuretic peptide level less than 300 pg/mL have an excellent negative predictive value (94%-97%) to rule out heart failure
      • B-type natriuretic peptide level greater than 400 pg/mL or N-terminal pro–B-type natriuretic peptide levels above age-related cutoffs have excellent positive predictive value to diagnose heart failure
        • 450 pg/mL for patients aged younger than 50 years
        • 900 pg/mL for patients aged 50 years to 75 years
        • 1800 pg/mL for patients aged older than 75 years
      • B-type natriuretic peptide levels between 100 pg/mL and 400 pg/mL, or N-terminal pro–B-type natriuretic peptide levels between 300 pg/mL and the age-related cutoffs (450, 900, or 1800 pg/mL), are suggestive of heart failure but require additional testing
    • In nonacute situations, natriuretic peptides are primarily used for prognosis and risk stratification, but also aid in diagnosis ^r2r24r25
      • B-type natriuretic peptide level less than 35 pg/mL or N-terminal pro–B-type natriuretic peptide level less than 125 pg/mL indicate a diagnosis of heart failure is unlikely; levels above these thresholds are suggestive of heart failure ^r5r25r30
    • High degree of sensitivity but low degree of specificity for heart failure; natriuretic peptide levels may be elevated owing to other cardiac and noncardiac causes ^r31
    • Note that obese patients may have falsely low natriuretic peptide levels
    • Maintain awareness that many patients with heart failure with preserved ejection fraction have natriuretic peptide levels within reference range ^r3
  • Cardiac troponin T or I levels ^{c165c166c167c168}
    • Elevated levels:
      • May reflect acute coronary syndrome
      • Are often associated with severe heart failure without an obvious acute ischemic process
    • Decreasing cardiac troponin levels over time suggest improving heart failure and are associated with better prognosis

Imaging

• Chest radiography ^r9c169
  • Indicated for suspected new-onset heart failure and acute decompensated heart failure ^r2
  • Posteroanterior and lateral chest views are recommended; supine chest radiography has limited value
  • Has low sensitivity and specificity for heart failure; useful in identifying an alternative pulmonary process causing patient's symptoms and signs
  • Cardiomegaly and/or pulmonary venous congestion are suggestive of heart failure
    • Characteristic findings are cardiac chamber enlargement, increased pulmonary venous pressure, interstitial or alveolar edema, and valvular or pericardial calcification
    • Increased pulmonary venous pressure may be seen as:
      • Redistribution of blood flow from base of lung to apex
      • Linear densities reflecting interstitial edema
      • Bilateral perihilar haziness in a butterfly pattern

Functional testing

• ECG ^r10c170
  • Perform 12-lead ECG initially on all patients presenting with symptoms of heart failure ^r2
  • Very few patients who have heart failure with systolic dysfunction will have a completely normal ECG result. If results are normal, consider other causes of symptoms. Routine ECG is performed primarily to identify those patients and to detect other abnormalities that may need investigation or treatment
  • No particular ECG feature is specific to heart failure
    • Left ventricular hypertrophy may be evident on ECG
    • Q waves indicate myocardium loss due to previous infarction
    • Atrial and ventricular arrhythmias are common
• 2-dimensional echocardiography with Doppler flow imaging ^r32r33c171
  • 2-dimensional echocardiography displays cross-sectional view of beating heart, including chambers of heart, valves, and major blood vessels; Doppler flow imaging evaluates blood flow
    • Provides essential information on chamber volumes, wall thickness, wall motion abnormalities, and valve structure
    • Left ventricular ejection fraction and cardiac output can be estimated
    • Diastolic and systolic function of heart can be assessed
    • Pulmonary capillary wedge pressure can be estimated
    • Transthoracic echocardiography is preferred method
      • Transesophageal echocardiography is an alternative if transthoracic route is nondiagnostic owing to inadequate transthoracic window, which may occur in patients who are obese, have chronic lung disease, and require mechanical ventilation
  • Interpretation ^r10
    • Heart failure with reduced or mildly reduced ejection fraction (left ventricular systolic dysfunction) is suggested by:
      • Ejection fraction less than 50%
      • Hypokinesis, akinesis, or dyskinesis
      • Increased left ventricular diameter and volume
      • Decreased outflow velocity
    • Heart failure with preserved ejection fraction (left ventricular diastolic dysfunction) is suggested by: ^r34
      • Normal or near normal ejection fraction (50% or higher)
      • Abnormal mitral inflow
      • Increased atrial volume
      • Increased left ventricular mass
    • Recognize sex-specific differences in echocardiograph findings during interpretation ^r3
      • Females have more concentric remodeling and more impaired diastolic relaxation compared with males; left ventricular dysfunction may be underestimated
• Cardiac MRI ^r2r10c172
  • Alternative to echocardiography for assessing left ventricular volume and ejection fraction; may be used if echocardiography is not diagnostic
  • Provides high anatomic resolution of all aspects of the heart and surrounding structures and can yield additional information on myocardial perfusion, viability, and fibrosis
  • Can identify inflammatory and infiltrative causes and provide prognostic information
  • Less accurate than echocardiography with high heart rates
  • Contraindications include metal implants or severe kidney disease, which preclude use of contrast solution

Procedures

Other diagnostic tools

• Genetic testing ^c177
  • Contributes to risk stratification and has implications for treatment, currently most often for decisions regarding defibrillators for primary prevention of sudden death and regarding exercise limitation for hypertrophic cardiomyopathy ^r2
  • Offer genetic screening and counseling for first-degree relatives of patients with genetic or inherited cardiomyopathies and for select patients with nonischemic cardiomyopathies ^r2
  • Some genes implicated in inherited dilated, restrictive, and hypertrophic cardiomyopathies for which genetic testing is available include: ^r2
    • TTN, encoding the large structural protein titin; truncation variants are implicated in dilated cardiomyopathy
    • LMNA, encoding lamin A/C, associated with conduction block and atrial arrhythmias as well as ventricular arrhythmias
    • Mutations in various desmosomal protein variants (eg, DSP) implicated in arrhythmogenic right ventricular cardiomyopathy
    • Mutations in FLNC (encoding filamin-C) have been associated with skeletal myopathies and with isolated cardiomyopathy with ventricular arrhythmias

Most common

• Conditions that cause dyspnea ^r36
  • Chronic obstructive pulmonary disease ^r37c178d1
    • Group of chronic and progressive pulmonary diseases (emphysema and chronic bronchitis) that limit airflow; occur nearly exclusively in smokers
    • Similar feature: chronic dyspnea
    • Differing features: great variation of dyspnea from day to day, productive cough, rhonchi and/or expiratory wheezing on auscultation, hyperinflation (barrel chest), and hyperresonant chest sounds
    • Diagnosis: spirometry shows decreased pulmonary function; chest radiography may show diaphragm flattening, increased retrosternal air space, or bronchovascular markings
    • Chronic obstructive pulmonary disease may coexist with heart failure
  • Asthma ^c179d2
    • Chronic inflammatory condition of airways that produces edema and bronchoconstriction; episodes are often caused by triggers (eg, allergens, exercise, infection)
    • Similar features: wheezing and dyspnea
    • Differing features: typically earlier age of onset; episodic and reversible symptoms of airflow obstruction, often after triggers; and chest tightness
    • Diagnosis: spirometry with postbronchodilator response; chest radiograph may show hyperinflation
  • Pulmonary embolism ^r38c180d3
    • Pulmonary artery or branch artery is suddenly occluded, most often because of a dislodged thrombus
    • Similar features: dyspnea, tachypnea, and tachycardia
    • Differing features: abrupt onset of chest pain, which may be pleuritic; hypoxia; and sometimes hemoptysis
    • Diagnosis: CT angiography detects pulmonary emboli; D-dimer levels are elevated
  • Myocardial infarction ^r39c181d4
    • Myocardial necrosis resulting from occlusion of coronary artery
    • Similar features: dyspnea and fatigue
    • Differing features: retrosternal chest pain or pressure (radiating to neck, jaw, shoulder, or arm) is typical; atypical presentation without chest pain may occur in female patients, older patients, and those with diabetes
    • Diagnosis: ECG shows ST elevation, ST depression, or T-wave inversion; cardiac troponin levels are elevated
  • Pneumonia ^c182
    • Acute inflammation of lung tissue caused by infection
    • Similar features: tachypnea, tachycardia, rales, and wheezing
    • Differing features: productive cough, fever and rigors, rhonchi, and hypoxia
    • Diagnosis: chest radiograph shows lobar or lobular consolidation; viral or atypical bacterial pneumonias often appear as interstitial infiltrates
  • Acute respiratory distress syndrome ^c183d5
    • Severe and often fatal acute respiratory failure; characterized by diffuse inflammatory lung injury rapidly progressing to increased pulmonary vascular permeability, increased lung weight, and hypoxemia
    • Similar features: dyspnea, cough, tachypnea, tachycardia, and pulmonary edema
      • Cardiogenic and noncardiogenic pulmonary edema can coexist
    • Differing features: cardiac biomarker levels are less likely to be elevated; echocardiographic findings are more likely to be within reference range
    • Diagnosis: history, physical examination, arterial blood gas levels, and chest radiography or CT
      • Criteria include:
        • Timing of symptoms (within 1 week of a known clinical insult such as pneumonia, sepsis, or trauma)
        • Hypoxemia (as shown by blood gas levels)
        • Bilateral opacities not otherwise explained and not cardiogenic in nature
        • Respiratory failure or pulmonary edema not fully explained by heart failure or fluid overload
• Conditions that cause edema ^r36
  • Cirrhosis ^c184d6
    • Irreversible liver disease caused by long-term excessive alcohol intake, viral hepatitis, or other reason
    • Similar features: peripheral edema and ascites; dyspnea may be present because of ascites
    • Differing features: stigmata of liver disease are usually present; liver function test results are outside reference range
    • Diagnosis: abdominal sonography or other abdominal imaging shows liver nodularity and features of portal hypertension; definitive diagnosis is by liver biopsy
  • Nephrotic syndrome ^c185
    • Renal disease affecting kidney basement membrane, resulting in heavy proteinuria and hypoalbuminuria
    • Similar features: peripheral edema (including edema of face/eyes) and ascites
    • Differing features: dyspnea may occur but is usually exertional only and associated with pleural effusion and very low protein levels
    • Diagnosis: high random urine protein to creatinine ratio is suggestive; protein excretion of 3.5 g or more per 24 hours confirms. Renal biopsy confirms renal pathology

Admission criteria

Patients with de novo acute heart failure or acute decompensated heart failure: admit for appropriate laboratory tests, imaging, and start of treatment

Specific heart failure admission indications include: ^r9

• Evidence or suspicion of acute coronary syndromes
• Respiratory distress and/or pulmonary edema
• Hemodynamically significant arrhythmias
• Syncope or symptomatic hypotension
• Worsening renal function
• Altered mentation

Recommendations for specialist referral

• Cardiologist for diagnostic evaluation of heart failure causes and optimization of medical management
• Cardiothoracic surgeon for coronary revascularization surgery and/or ventricular assist device
• Electrophysiologist for implantation of cardiac defibrillator and/or cardiac resynchronization therapy
• Transplant specialist for heart transplant and management of immunosuppressant therapy
• Nephrologist for associated kidney disease and treatment with ultrafiltration
• Geriatrician for critical decisions on older patients with multiple comorbidities
• Palliative care specialist for end-of-life decisions
• Genetic counselor to identify inherited or genetically based cardiomyopathies

Drug therapy ^c186c187

• ACE inhibitors ^c188
  • Captopril ^c189
    • Captopril Oral tablet; Adults: 6.25 mg PO 3 times daily, initially. Titrate dose every 1 to 2 weeks (Usual Max: 150 mg/day [Max: 450 mg/day]).
  • Enalapril ^c190
    • Enalapril Maleate Oral tablet; Adults: 2.5 mg PO twice daily, initially. Increase the dose every 1 to 2 weeks to the highest dosage level tolerated. Max: 20 to 40 mg/day.
  • Lisinopril ^c191
    • Lisinopril Oral tablet; Adults: 2.5 to 5 mg PO once daily, initially. Increase the dose every 1 to 2 weeks to the highest dosage level tolerated. Max: 20 to 40 mg/day.
• Angiotensin receptor blockers ^c192
  • Candesartan ^c193
    • Candesartan Cilexetil Oral tablet; Adults: 4 to 8 mg PO once daily, initially. Double the dose every 1 to 2 weeks to the highest dosage level tolerated. Max: 32 mg/day.
  • Losartan ^c194
    • Losartan Potassium Oral tablet; Adults: 25 to 50 mg PO once daily, initially. Increase the dose every 1 to 2 weeks to the highest dosage level tolerated. Max: 50 to 150 mg/day.
  • Valsartan ^c195c196
    • Valsartan Oral tablet; Adults: 20 to 40 mg PO twice daily, initially. Increase the dose every 1 to 2 weeks to the highest dosage levelas tolerated. Max: 320 mg/day.
• Angiotensin receptor–neprilysin inhibitor ^c197
  • Sacubitril-valsartan ^c198
    • Sacubitril, Valsartan Oral tablet; Adults: 49 mg sacubitril/51 mg valsartan PO twice daily, initially. Double the dose after 2 to 4 weeks as tolerated. Max: 97 mg sacubitril/103 mg valsartan PO twice daily.
• β-Blockers ^c199c200
  • Bisoprolol ^c201c202
    • Bisoprolol Fumarate Oral tablet; Adults: 1.25 mg PO once daily, initially. Increase the dose every 2 weeks to the highest dosage level tolerated. Max: 10 mg/day.
  • Carvedilol ^c203c204
    • Carvedilol Oral tablet; Adults weighing 85 kg or less: 3.125 mg PO twice daily, initially. Double the dose every 2 weeks to the highest dosage level tolerated. Max: 50 mg/day.
    • Carvedilol Oral tablet; Adults weighing more than 85 kg: 3.125 mg PO twice daily, initially. Double the dose every 2 weeks to the highest dosage level tolerated. Max: 100 mg/day.
  • Metoprolol succinate ^c205c206
    • Metoprolol Succinate Oral tablet, extended-release; Adults: 12.5 or 25 mg PO once daily, initially. Double the dose every 2 weeks to the highest dosage level tolerated. Max: 200 mg/day.
• Sodium-glucose co-transporter 2 inhibitor
  • For the reduction of the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visits in persons with heart failure
    • Dapagliflozin
      • Dapagliflozin Oral tablet; Adults: 10 mg PO once daily.
    • Empagliflozin
      • Empagliflozin Oral tablet; Adults: 10 mg PO once daily.
  • For the reduction of the risk of hospitalization for heart failure in persons with type 2 diabetes mellitus and chronic kidney disease
    • Canagliflozin
      • Canagliflozin Oral tablet; Adults: 100 mg PO once daily, initially. May increase the dose to 300 mg PO once daily if additional glycemic control is needed. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
    • Dapagliflozin
      • Dapagliflozin Oral tablet; Adults: 10 mg PO once daily.
    • Empagliflozin
      • Empagliflozin Oral tablet; Adults: 10 mg PO once daily, initially. May increase dose to 25 mg PO once daily if additional glycemic control is needed.
    • Sotagliflozin
      • Sotagliflozin Oral tablet; Adults: 200 mg PO once daily, initially. Increase the dose to 400 mg PO once daily after at least 2 weeks as tolerated. Dose may be decreased to 200 mg PO once daily as needed.
• Aldosterone receptor antagonists ^c207
  • Eplerenone ^c208
    • Eplerenone Oral tablet; Adults: 25 mg PO once daily, initially. Increase the dose within 4 weeks as tolerated to 50 mg PO once daily. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
  • Spironolactone ^c209
    • Spironolactone Oral tablet; Adults: 25 mg PO once daily, initially. Increase the dose after 4 weeks as tolerated to 50 mg PO once daily.
  • Finerenone
    • Finerenone Oral tablet; Adults: 20 mg PO once daily. Adjust dose based on serum potassium concentrations every 4 weeks as needed. Dose range: 10 to 20 mg PO once daily.
• Loop diuretics ^c210
  • Bumetanide ^c211c212
    • Bumetanide Oral tablet; Adults: 0.5 to 1 mg PO once daily, initially. Repeat the dose every 4 to 5 hours as needed for up to 2 doses. Usual dose: 0.5 to 2 mg/day. Max: 10 mg/day.
    • Bumetanide Solution for injection; Adults: 0.5 to 1 mg IV/IM once, initially. Repeat the dose every 2 to 3 hours as needed for up to 2 doses. Max: 10 mg/day.
  • Furosemide ^c213
    • Furosemide Oral tablet; Adults: 20 to 80 mg PO once, initially. Repeat the dose or increase by 20 to 40 mg/dose every 6 to 8 hours as needed. Usual dose: 40 to 240 mg/day in 1 to 2 divided doses. Max: 600 mg/day.
    • Furosemide Solution for injection; Adults: 20 to 40 mg IV/IM once, initially. May repeat the dose or increase by 20 mg/dose every 2 hours as needed until the desired diuretic effect is attained. Usual dose: 40 to 240 mg/day in 1 to 2 divided doses.
  • Torsemide ^c214
    • Torsemide Oral tablet; Adults: 10 to 20 mg PO once daily, initially. Double the dose as needed. Max: 200 mg/day.
• Thiazide diuretics ^c215
  • Hydrochlorothiazide ^c216
    • Hydrochlorothiazide Oral tablet; Adults: 12.5 to 100 mg/day PO given in single or divided doses, initially. Max: 200 mg/day.
  • Indapamide ^c217c218
    • Indapamide Oral tablet; Adults: 2.5 mg PO once daily, initially. Increase the dose to 5 mg PO once daily after 1 week if needed.
  • Metolazone ^c219
    • Metolazone Oral tablet; Adults: 5 to 20 mg PO once daily.
• Vasodilators ^c220
  • Hydralazine ^c221
    • Hydralazine Hydrochloride Oral tablet; Adults: 25 to 50 mg PO 3 to 4 times daily, initially. Increase the dose every 1 to 2 weeks to the highest dosage level tolerated. Max: 300 mg/day.
  • Isosorbide dinitrate ^c222
    • Isosorbide Dinitrate Oral tablet; Adults: 20 to 30 mg PO 3 to 4 times daily, initially. Increase the dose every 1 to 2 weeks to the highest dosage level tolerated. Max: 120 mg/day.
  • Nitroglycerin ^c223
    • Nitroglycerin Solution for injection; Adults: 5 mcg/minute continuous IV infusion, initially. Titrate by 5 mcg/minute every 3 to 5 minutes to clinical response, or a dose of 20 mcg/minute. May further titrate by 10 mcg/minute, and if the desired effect is still not achieved, by 20 mcg/minute. Max titration: 20 mcg/minute every 3 to 5 minutes. Usual dose range: 5 to 100 mcg/minute. Max: 200 mcg/minute.
  • Nitroprusside ^c224
    • Sodium Nitroprusside Solution for injection; Adults: 0.3 to 0.5 mcg/kg/minute continuous IV infusion, initially. Titrate by 0.5 mcg/kg/minute every 5 minutes until desired effect or blood pressure cannot be further reduced without compromising organ perfusion. Max: 10 mcg/kg/minute for 10 minutes.
• Hyperpolarization-activated cyclic nucleotide–gated channel blocker ^c225c226
  • Ivabradine ^c227
    • Ivabradine Oral tablet; Adults: 2.5 to 5 mg PO twice daily, initially. Adjust dose by 2.5 mg/dose every 2 weeks as needed based on heart rate and tolerability to a target resting heart rate of 50 to 60 beats/minute. Max: 7.5 mg PO twice daily.
• Digitalis glycoside ^c228
  • Digoxin ^c229
    • Digoxin Oral tablet; Adults: 3.4 to 5.1 mcg/kg/dose PO once daily. May consider a loading dose of 5 to 7.5 mcg/kg/dose PO as a single dose, then 2.5 to 3.75 mcg/kg/dose PO every 6 to 8 hours for 2 doses for a total loading dose of 10 to 15 mcg/kg PO. Base dose on lean body weight. Adjust dose based on toxicity, efficacy, and serum digoxin concentrations. Round dose to the nearest whole/half tablet.
    • Digoxin Oral tablet; Older Adults: 3.4 to 5.1 mcg/kg/dose PO once daily. May consider a loading dose of 5 to 7.5 mcg/kg/dose PO as a single dose, then 2.5 to 3.75 mcg/kg/dose PO every 6 to 8 hours for 2 doses for a total loading dose of 10 to 15 mcg/kg PO. Base dose on lean body weight. Adjust dose based on toxicity, efficacy, and serum digoxin concentrations. Round dose to the nearest whole/half tablet. Usual Max: 0.125 mcg/day.
• Guanylate cyclase stimulator ^c230
  • Vericiguat ^c231
    • Vericiguat Oral tablet; Adults: 2.5 mg PO once daily, initially. Double the dose approximately every 2 weeks as tolerated to the target dose of 10 mg PO once daily.
• Inotropic agents ^c232
  • Dopamine ^c233
    • Dopamine Hydrochloride Solution for injection; Adults: 2 to 5 mcg/kg/minute continuous IV infusion, initially. Titrate by 5 to 10 mcg/kg/minute until goal hemodynamic and/or renal response is attained. Usual dose: 5 to 15 mcg/kg/minute. Max: 50 mcg/kg/minute
  • Dobutamine ^c234
    • Dobutamine Hydrochloride Solution for injection; Adults: 0.5 to 1 mcg/kg/minute continuous IV infusion. Titrate every few minutes to clinical response. Usual dose: 2 to 20 mcg/kg/minute. Max: 40 mcg/kg/minute.
  • Milrinone ^c235
    • Milrinone Lactate Solution for injection; Adults: 50 mcg/kg IV loading dose, then 0.125 to 0.75 mcg/kg/minute continuous IV infusion.

Nondrug and supportive care

Dietary recommendations ^c236

• Normal fluid intake guided by the sense of thirst is recommend; this generally falls within the range of 1.5 to 2.5L/day. Selected patients with acute heart failure may benefit from a restricted fluid intake of less than 1 to 1.5L/day to manage dilutional hyponatremia ^r50
• At least 1 session of nutritional evaluation and counseling is recommended for patients with heart failure ^r51
  • Ensure adequate intake of macro- and micronutrients
  • Recommend DASH (Dietary Approaches to Stop Hypertension) or Mediterranean style diet of patients of normal weight ^r52c237c238
  • Recommend weight loss of 5% to 10% for patients with BMI 35 kg/m² or higher
  • Aim for protein intake of at least 1.1 g/kg/day for patients with malnutrition or cachexia (develops in 10%-20% of patients with heart failure)
  • Consider some degree of sodium restriction (eg, less than 3 g/day) for patients with stage C and D heart failure while noting that evidence is lacking for this recommendation
    • American College of Cardiology Foundation/American Heart Association guideline recommends restricting sodium to 1500 mg/day or less for patients with stage A and B heart failure
    • European Society of Cardiology advise limiting salt intake to < 5 g/day ^r50
• American Heart Association recommends 1 to 2 meals of seafood per week be included to reduce risk of congestive heart failure, coronary heart disease, ischemic stroke, and sudden cardiac death ^r53
  • Marine omega-3 supplementation of 1 g/day is recommended for primary prevention for individuals who do not consume at least 1.5 fish or seafood meals per week ^r54
  • High-dose marine omega-3 supplements are recommended for patients with congestive heart disease who are taking statins and who have elevated triglycerides ^r54

Exercise ^c239

• Recommend exercise interventions (eg, cardiac rehabilitation), stressing full adherence to recommended regimens ^r2r52
  • Center-based supervised exercise training, home based with or without virtual support, and hybrid programs were all found effective in reducing hospitalizations and increasing quality of life in both short (follow-up up to 12 months) and long term (follow-up greater than 12 months) ^r55
• In adults with chronic heart failure with reduced ejection fraction, evidence suggests that exercise training (eg, cardiac rehabilitation): ^r56
  • Reduces all-cause hospitalizations
  • Reduces hospitalizations due to heart failure in the short term
  • Improves quality of life
  • Reduces long-term mortality
• For patients with preserved ejection fraction, exercise training has also been shown to be beneficial ^r57
  • Supervised exercise training is safe, improves exercise capacity (eg, peak oxygen consumption, total exercise time, 6-minute walk distance), and improves quality of life
  • Home-based training and hybrid programs have also been shown to be safe and effective in improving exercise capacity and quality of life
  • Studies have been underpowered to detect any effect on clinical outcomes such as cardiovascular events or survival
  • In the United States, insurance coverage for supervised exercise programs is less available for patients with preserved ejection than for reduced ejection fraction; clinicians may need to pursue referrals and coverage more aggressively
• Exercise is contraindicated in life-threatening or unstable conditions, including severe decompensated heart failure ^r26

General recommendations

• Order careful intake and output measurements in acute care setting ^c240
• Order daily weight monitoring on inpatient and outpatient basis; have patient or caregiver notify physician for overnight gain of 0.9 kg or more or 1-week gain of 2.3 kg or more ^c241
• Advise and assist with moderation or elimination of alcohol intake owing to its negative effect on ventricular systolic function ^c242
• Advise and assist with smoking cessation ^c243d8
  • Smoking increases myocardial oxygen consumption (via increased heart rate and blood pressure) and decreases myocardial oxygen supply
• Vaccinations
  • Patients with heart failure are recommended to receive all vaccinations for which they are eligible (eg, zoster vaccination for those aged 50 years and older), but with particular attention to respiratory diseases ^r58
    • Patients with heart failure are at increased risk of severe disease, hospitalization, and/or death from infections such as influenza, pneumococcal disease, respiratory syncytial virus, and COVID-19 ^r2
    • Vaccination against respiratory diseases has been shown to decrease morbidity and mortality, including all-cause hospitalizations and cardiovascular events ^r2r46
    • Vaccination is specifically recommended against SARS-CoV-2 (patients aged 6 months and older); influenza virus (patients aged 6 months and older); pneumococcus (patients aged 19 years and older with chronic heart diseases including heart failure); and respiratory syncytial virus (patients aged 60 years and older) ^r58

Provide patients and caregivers with comprehensive education about heart failure, medication regimens, and lifestyle modifications ^r2c244c245

• Educational initiatives including multimedia, phone, or text interventions, nurse-led education, and post-discharge follow-up may reduce rehospitalizations ^r59

Comorbidities

• Hypertension ^c251c252
  • In the Framingham study, 91% of patients with incident heart failure had underlying hypertension ^r65
  • Control of hypertension is important for all patients with heart failure and is the primary management strategy for those with preserved ejection fraction ^r2
  • Treatment goals ^r66
    • In patients at increased risk for heart failure (stage A heart failure), blood pressure of less than 130/80 mm Hg is optimal in those with hypertension as a novel strategy to prevent progression to symptomatic heart failure ^r66
    • For patients who have heart failure with reduced ejection fraction and hypertension, prescribe guideline-directed management and titrate therapy to attain systolic blood pressure less than 130 mm Hg ^r66
      • This is a threshold now associated with improved clinical outcomes but not yet proven by randomized clinical trials in a population with heart failure
    • For patients who have heart failure with preserved ejection fraction and persistent hypertension after management of volume overload, prescribe guideline-directed management and titrate therapy to attain systolic blood pressure less than 130 mm Hg ^r66
  • For patients in all stages of heart failure with reduced ejection fraction, antihypertensive therapy with a diuretic (if required for volume overload), an ACE inhibitor/angiotensin receptor blocker or angiotensin receptor–neprilysin inhibitor, and a β-blocker is recommended based on high-quality, randomized controlled data ^r2r67
    • Add second line agents (mineralocorticoid receptor antagonists or hydralazine) as required
    • Avoid nondihydropyridine calcium channel blockers and α-blockers ^r42
  • For patients who have heart failure with preserved ejection fraction, diuretics, angiotensin receptor–neprilysin inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists are reasonable choices to manage blood pressure ^r3
• Diabetes ^c253c254
  • Association between type 2 diabetes and heart failure is well established; an association is also recognized in type 1 diabetes ^r68
  • Risk factor for, and common comorbidity of, heart failure
    • Each condition independently increases risk for the other
    • Type 2 diabetes has additive effect on myocardial impairment in association with obesity, hypertension, chronic kidney disease and/or coronary artery disease ^r68
    • A subset of patients with type 2 diabetes and heart failure may have diabetic myocardial dysfunction (systolic and/or diastolic myocardial dysfunction in the presence of diabetes; formerly described as diabetic cardiomyopathy) which occurs independently of other cardiometabolic risk factors ^r68
    • Patients with type 2 diabetes without symptomatic heart failure often have subclinical abnormalities of cardiac structure and function
  • Having both conditions is associated with worse clinical outcomes
    • Health-related quality of life is worse than for patients with heart failure alone ^r69r70
    • Higher risk of hospitalization (up to 50% higher)^r71 and rehospitalization^r72 with diabetes
    • Diabetes increases mortality risk in both ambulatory and hospitalized patients with heart failure ^r73
      • Overall mortality risk is similar risk for both heart failure with reduced ejection fraction and heart failure with preserved ejection fraction
      • Cardiovascular mortality risk is higher for patients with diabetes and heart failure with preserved ejection fraction as compared to heart failure with reduced ejection fraction ^r74r75
  • Management of heart failure in diabetes
    • Based on benefit in patients who have heart failure with reduced ejection fraction (regardless of diabetes status), these therapies should routinely be implemented in patients with diabetes and heart failure with reduced ejection fraction who meet guideline indications: ^r73
      • Sodium-glucose cotransporter-2 inhibitor ^r44
      • Angiotensin receptor–neprilysin inhibitors
      • Renin-angiotensin-aldosterone system inhibitors
      • β-Blockers
      • Ivabradine
      • Implantable cardioverter-defibrillators and cardiac resynchronization therapy
    • Sodium-glucose cotransporter-2 inhibitor are also indicated for patients who have diabetes and heart failure with mildly reduced or preserved ejection fraction ^r3r44
    • Use the mineralocorticoid receptor antagonist finerenone in patients with type 2 diabetes and chronic kidney disease to prevent heart failure hospitalizations ^r44
  • Management of diabetes in heart failure
    • Consider glycemic goals and the impact of heart failure medications on glycemic control
      • Moderate, rather than intensive, glycemic control may be optimal for patients with diabetes and heart failure
        • U-shaped relationship between mortality and hemoglobin A1C in patients with heart failure (lowest risk of death with modest glucose control and hemoglobin A1C of 7.1%-7.8%) ^r76
        • Recommend target hemoglobin A1C of 7% to 8% for most patients with heart failure and diabetes ^r73
        • Less stringent goals may be appropriate for patients with advanced stage D heart failure not pursuing mechanical circulatory support or transplant ^r73
      • ACE inhibitors, angiotensin receptor blockers, and angiotensin receptor–neprilysin inhibitors have favorable effects on the development of diabetes mellitus and glycemic control in patients with heart failure with reduced ejection fraction ^r73
      • Spironolactone may modestly worsen glycemic control in patients with diabetes mellitus and heart failure with reduced ejection fraction ^r73
      • Carvedilol may be preferable to metoprolol succinate and bisoprolol for patients with heart failure with reduced ejection fraction and diabetes mellitus with poor glycemic control ^r73
    • Management of type 1 diabetes in patients with heart failure is same as for patients without heart failure
    • In patients with type 2 diabetes, consider the effect of specific glucose-lowering pharmacotherapies on cardiovascular outcomes ^r77r78
      • In patients at high risk for heart failure and those with established heart failure, metformin and sodium-glucose cotransporter-2 inhibitors are preferable to use over sulfonylurea drugs ^r73
        • Metformin
          • First line treatment for most patients with type 2 diabetes ^r79
          • Reduced mortality and a small reduction in all-cause hospitalization in patients with heart failure compared with control subjects
          • Lower risk of heart failure hospitalization than with sulfonylurea drugs
        • Sodium-glucose cotransporter-2 inhibitors
          • First class of glucose-lowering agents demonstrated to reduce heart failure symptoms, risk of heart failure hospitalization, and death in patients with diabetes, with and without established diagnosis of heart failure at baseline ^{r3r44r80r81r82}
          • Cardiovascular benefit must be balanced with potential risks, including genital candidiasis and other rare potential complications (ie, euglycemic diabetic ketoacidosis, lower-limb amputation, fractures associated with canagliflozin)
      • Glucagon-like peptide-1 receptor agonists have a beneficial effect on atherosclerotic cardiovascular disease outcomes, heart failure hospitalizations, and weight loss ^r3
        • Use glucagon-like peptide 1 receptor agonists with caution in patients who have heart failure with reduced ejection fraction and recent decompensation ^r73
      • Insulin may be considered; use with caution and close monitoring only if adequate glycemic control cannot be achieved with metformin and sodium-glucose cotransporter-2 inhibitors; associated with weight gain and increased risk of hypoglycemia ^r73r77
      • Do not use dipeptidyl peptidase-4 inhibitors saxagliptin or alogliptin in patients with established heart failure or those at high risk for heart failure; it is unknown whether potential increased risk of heart failure events is a class effect ^r3r73r77
      • Thiazolidinediones are not recommended for patients with established heart failure; both rosiglitazone and pioglitazone are associated with fluid retention and heart failure events ^r73r77
• Atrial fibrillation ^r2c255c256d7
  • Heart failure and atrial fibrillation have a bidirectional association, share many of the same risk factors, and frequently complicate each other
  • Heart failure with atrial fibrillation is associated with worse outcomes, including increase in stroke severity and all-cause mortality. Female patients have worse outcomes than male patients ^r83
  • Best treatment strategies for patients with heart failure and atrial fibrillation are uncertain ^r84
    • Approach (rate control versus restoration of sinus rhythm) may be individualized depending on whether atrial fibrillation is resulting from or contributing to progression of underlying cardiac failure ^r85
      • Recent data suggest that early rhythm control (atrial fibrillation present for less than 1 year) in high-risk patients, including those with heart failure, may be beneficial in reducing composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome ^r86
    • Rate control is typically accomplished with β-blockers in patients with heart failure
      • Nondihydropyridine calcium channel blockers are contraindicated in patients with left ventricle systolic dysfunction but are reasonable when systolic function is preserved ^r87
      • Digoxin has been associated with increased mortality risk in patients with atrial fibrillation and patients with heart failure when used in high doses ^r88r89r90
    • Atrial Fibrillation and Congestive Heart Failure Trial showed that pharmacologic rhythm control is not superior to rate control strategy for preventing cardiac death. Consider rhythm control strategy for patients who remain symptomatic despite rate control alone ^r91
      • Pharmacologic rhythm control options are limited to amiodarone and dofetilide in heart failure with reduced ejection fraction ^r87
    • Catheter ablation (pulmonary vein isolation) may be superior to both pharmacologic rate and rhythm control in patients with both heart failure and atrial fibrillation
      • CASTLE-AF trial (Catheter Ablation versus Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation) results showed that, for patients with heart failure with reduced ejection fraction, atrial fibrillation catheter ablation was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization for worsening heart failure ^r92
      • Catheter ablation appears to be similarly effective for atrial fibrillation (eg, freedom from recurrent atrial arrhythmia, improvements in New York Heart Association functional class, symptom severity) in both heart failure with reduced ejection fraction and heart failure with preserved ejection fraction ^r93
      • For the overall population, results from CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation)^r94r95 do not show improved survival with catheter ablation; detailed analysis of heart failure subgroup in the trial is ongoing and will add additional information ^r84
    • Atrioventricular nodal ablation and cardiac resynchronization device placement can be useful if other methods fail ^r2
  • Anticoagulation is typically indicated for the prevention of thromboembolic complications based on CHA₂DS₂-VASc scoring system ^r42
• Coronary artery disease ^c257
  • Present in approximately two-thirds of patients with heart failure
  • Evaluate patients with heart failure with reduced ejection fraction for coronary artery disease and treat accordingly
  • β-Blockers and ACE inhibitors are used to treat both heart failure and ischemic heart disease ^r96
  • Guidelines recommend against routine use of nitrates in heart failure with preserved ejection fraction; consider dihydropyridine calcium channel blockers or ranolazine ^r2r3
  • Revascularization may be considered ^r3r42
• Anemia ^c258d9
  • Often normocytic and accompanied by an abnormally low reticulocyte count ^r97
  • Associated with an increased risk of hospitalization and mortality and decreased exercise capacity and quality of life
  • Correct any specific underlying cause (eg, iron, vitamin B₁₂, folate deficiency)
  • Utilize IV iron replacement to improve functional status and quality of life in symptomatic patients with reduced or mildly reduced ejection fraction and iron deficiency (ferritin lower than 100 ng/mL or transferrin saturation less than 20%) ^r44r98r99
  • Consider IV iron replacement to reduce risk of heart failure hospitalization in symptomatic heart failure patients with reduced or mildly reduced ejection fraction and iron deficiency (ferritin lower than 100 ng/mL or transferrin saturation less than 20%) ^r44r99
  • Patients with heart failure and symptomatic anemia may require RBC transfusion; in patients without symptoms due to anemia, a restrictive transfusion strategy (at hemoglobin levels of 7-8 g/dL) is recommended ^r100
    • Care must be taken to monitor volume status and avoid overload when transfusion is administered
  • Do not use erythropoietin-stimulating agents to improve morbidity and mortality in patients with anemia and heart failure ^r100
• Chronic kidney disease ^{r101c259c260d10}
  • Complex interplay between heart and kidney whereby dysfunction in 1 organ can induce or worsen dysfunction in the other ^r101
    • Chronic heart failure resulting in chronic kidney disease is described as chronic cardiorenal syndrome
    • Chronic kidney disease resulting in chronic heart failure is described as chronic renocardiac syndrome
  • GFR is reduced in most patients with advanced heart failure
  • Reduced renal function is strongly prognostic of poor outcome
  • Avoid treatment with nephrotoxic agents ^r42
  • Decline of renal function may be slower with angiotensin receptor–neprilysin inhibitors compared to angiotensin receptor blockers in patients with preserved ejection fraction ^r3
  • Sodium-glucose cotransporter-2 inhibitors are also associated with slowing the decline in renal function ^r3r44
  • Use the mineralocorticoid receptor antagonist finerenone in patients with type 2 diabetes and chronic kidney disease to prevent heart failure hospitalizations ^r44
• Chronic obstructive pulmonary disease ^c261
  • Present in approximately one-third of patients with heart failure
  • Associated with poorer functional status and prognosis
  • β-Blockers may exacerbate bronchospasm; oral corticosteroids can lead to sodium and fluid retention and thus worsen congestive symptoms
• Depression ^c262c263
  • Major depression is common in patients with heart failure during hospitalization and is often not recognized
  • Associated with nonadherence to heart failure therapy and worse prognosis ^r102
  • Avoid tricyclic antidepressants in patients with heart failure owing to association with cardiovascular adverse effects; selective serotonin reuptake inhibitors are a safer alternative for these patients
• Hyperlipidemia ^c264
  • Most patients with heart failure also have hyperlipidemia
  • Statin therapy has not been shown to improve symptoms of heart failure ^r103
  • Statin therapy is recommended according to current guidelines^r104r105 for prevention of atherosclerotic cardiovascular disease; not recommended routinely for heart failure in the absence of other indications ^r52
• Sleep disturbances ^c265
  • Common owing to orthopnea, paroxysmal nocturnal dyspnea, and nocturnal diuresis associated with diuretic use
  • In addition, obstructive sleep apnea has been noted in approximately one-third of patients with chronic heart failure ^r106
  • In patients with New York Heart Association class II through IV heart failure who are suspected to have sleep disordered breathing or excessive daytime sleepiness, consider formal sleep assessment ^r2
  • In patients with cardiovascular disease and obstructive sleep apnea, consider CPAP to improve sleep quality and alleviate daytime sleepiness ^r2

Special populations

• Female patients
  • In general, female patients with heart failure have a survival advantage compared with male patients ^r85
    • Female patients are more likely to have nonischemic heart failure than male patients
    • Female patients are more likely to have heart failure with preserved ejection fraction compared to male patients ^r20
  • Digoxin is associated with increased risk for death in female patients compared with male patients, presumably owing to increased serum digoxin levels related to decreased lean body mass and renal function
  • Benefits of treatment with ACE inhibitors, angiotensin receptor blockers, and β-blockers are observed at lower dosages than required by male patients ^r107
• Pregnant patients ^r2
  • Pregnancy is generally well tolerated in patients with cardiomyopathy and New York Heart Association class 1 heart failure prepregnancy, but provide contraceptive counseling and preconception counseling regarding risks of decompensation
  • Avoid ACE inhibitors, angiotensin receptor blockers, angiotensin receptor–neprilysin inhibitors, mineralocorticoid receptor antagonists, sodium-glucose cotransporter-2 inhibitors, ivabradine, and vericiguat during pregnancy owing to risk of fetal harm
  • Owing to hypercoagulability of pregnancy and with stasis due to poor ejection fraction, consider anticoagulation during pregnancy through 6 to 8 weeks postpartum in patients who have peripartum cardiomyopathy and left ventricular ejection fraction less than 30%
  • Guidelines on management of heart failure and obstetric management of patients with heart failure during pregnancy have been published ^r108
• Black populations
  • Age of onset of heart failure is significantly younger in Black populations compared with White populations ^r9
  • Heart failure in Black populations is less likely due to ischemia and more likely due to hypertension compared with White populations ^r9
  • Morbidity and mortality are higher in Black populations than in White populations ^r2
  • ACE inhibitors are less effective and carry increased risk of angioedema in Black patients with heart failure compared with White patients with heart failure ^r2
  • Use hydralazine and isosorbide dinitrate in addition to, or in place of, ACE inhibitors for Black patients with disease of New York Heart Association class II or higher ^r2
• Older patients
  • Heart failure is associated with increased morbidity and mortality in older patients; median survival is 2.5 years after hospitalization for heart failure, with a 1-year mortality rate of 25% in patients aged 70 years and older ^r9
  • During treatment with ACE inhibitors, β-blockers, and diuretics, it is imperative to monitor volume status, postural hypotension, and cerebrovascular symptoms