What are the typical presentation patterns of heart failure (HF)?

From the Guidelines

Heart failure presents in several distinct patterns, including acute decompensated heart failure, right-sided heart failure, left-sided heart failure, high-output heart failure, and diastolic heart failure, each requiring targeted therapy to improve morbidity, mortality, and quality of life. The most common presentations include:

• Acute decompensated heart failure, characterized by sudden onset of severe dyspnea, fluid retention, and pulmonary edema requiring urgent intervention with diuretics like furosemide 40-80mg IV, oxygen therapy, and possibly nitrates 1.
• Right-sided heart failure, typically presenting with peripheral edema, jugular venous distension, hepatomegaly, and ascites, often requiring spironolactone 25mg daily and careful fluid management.
• Left-sided heart failure, manifesting primarily with pulmonary symptoms including dyspnea, orthopnea, and paroxysmal nocturnal dyspnea, commonly treated with ACE inhibitors like lisinopril 5-40mg daily or ARBs.
• High-output heart failure, presenting with warm extremities, bounding pulses, and wide pulse pressure, often secondary to conditions like anemia or thyrotoxicosis requiring treatment of the underlying cause.
• Diastolic heart failure (heart failure with preserved ejection fraction), typically affecting older patients and women with hypertension, presenting with exercise intolerance and dyspnea while maintaining normal ejection fraction, treated with blood pressure control and cautious diuresis, as well as the use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) which have been shown to reduce composite of cardiovascular death or HF hospitalizations 1.

These patterns reflect the underlying pathophysiology of cardiac dysfunction, whether it involves impaired contractility, relaxation problems, or volume/pressure overload, and recognizing them enables appropriate targeted therapy to improve patient outcomes. The management of heart failure has evolved over the years, with a growing appreciation for the importance of guideline-directed oral medical therapies (GDMT) and the role of novel therapies such as SGLT2i in improving outcomes 1.

Key considerations in the management of heart failure include:

• Controlling systolic and diastolic hypertension, in accordance with published guidelines 1.
• Using diuretics to control pulmonary congestion and peripheral edema 1.
• Implementing GDMT, including beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists, to reduce morbidity and mortality 1.
• Considering the use of SGLT2i in patients with heart failure with preserved ejection fraction to reduce composite of cardiovascular death or HF hospitalizations 1.

By recognizing the distinct patterns of heart failure and implementing targeted therapies, clinicians can improve patient outcomes and reduce the significant morbidity and mortality associated with this condition.

From the FDA Drug Label

The primary objective of PARADIGM-HF was to determine whether sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to an RAS inhibitor (enalapril) alone in reducing the risk of the combined endpoint of cardiovascular (CV) death or hospitalization for heart failure (HF)

Patients had to have been on an ACE inhibitor or ARB for at least four weeks and on maximally tolerated doses of beta-blockers.

At randomization, 70% of patients were NYHA Class II, 24% were NYHA Class III, and 0.7% were NYHA Class IV.

The presentation patterns of heart failure in the study population were:

• NYHA Class II: 70% of patients
• NYHA Class III: 24% of patients
• NYHA Class IV: 0.7% of patients
• Left ventricular ejection fraction: mean of 29%
• Underlying cause of heart failure: coronary artery disease in 60% of patients
• Comorbidities: 71% had a history of hypertension, 43% had a history of myocardial infarction, 37% had an eGFR less than 60 mL/min/1.73m2, and 35% had diabetes mellitus 2

From the Research

Heart Failure Presentation Patterns

• Acute heart failure (AHF) patients often present with a variety of chief complaints, symptoms, and physical exam findings, making diagnosis challenging 3
• The initial diagnostic workup for AHF typically includes a thorough history and exam, EKG, chest X-ray, laboratory testing, and point-of-care ultrasonography 3
• Treatment for AHF is often guided by the patient's presenting phenotype, with hypertensive patients treated with vasodilators and normotensive patients requiring diuresis with intravenous loop diuretics 3

Angiotensin Receptor-Neprilysin Inhibition (ARNI) in Heart Failure

• ARNI has been shown to be effective in reducing mortality and hospitalization in patients with heart failure with reduced ejection fraction (HFrEF) 4, 5, 6
• The use of sacubitril/valsartan, an ARNI, has been recommended as a frontline therapy for HFrEF in major guidelines 4, 5, 6
• Real-world experience with ARNI has demonstrated its safety and effectiveness in patients with HFrEF, including those with higher baseline serum creatinine and B-type natriuretic peptide levels 6

Pharmacological Treatment Options for Heart Failure

• The basic pharmacological treatment for patients with HFrEF typically consists of a combination of ACE inhibitors/ARNI, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors 7
• Treatment initiation of all four drug classes should be fast and simultaneous, with individualized treatment based on patient needs 7
• The use of ARNI, SGLT2 inhibitors, and other therapies can be effective in patients with severely reduced kidney function, and treatment of comorbidities such as iron deficiency is also important 7