From the Guidelines
Hypertension is one of the most common causes of new onset heart failure (HF), and its management is crucial in reducing the incidence of HF. The etiology of new onset HF can be multifactorial, including coronary artery disease, valvular heart disease, cardiomyopathies, and others 1. According to the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment, new-onset HF, regardless of ejection fraction, requires referral to a specialist or program for evaluation of etiology, guideline-directed evaluation and management of recommended therapies, and assistance in disease management 1.
Key Causes of New Onset Heart Failure
- Hypertension: a major risk factor for HF, with anti-hypertensive therapy reducing the incidence of HF 1
- Coronary artery disease: a significant source of heart failure with reduced ejection fraction (HFrEF), with potential for improvement with revascularization 1
- Cardiomyopathies: such as dilated cardiomyopathy, hypertrophic cardiomyopathy, and arrhythmogenic right ventricular dysplasia
- Valvular heart disease: such as aortic stenosis, mitral regurgitation, and tricuspid regurgitation
Importance of Early Referral and Management
Early referral to a specialist or program is essential for new-onset HF patients to guide further evaluation and treatment, and to improve outcomes 1. The management of new-onset HF should include a comprehensive approach, with lifestyle modifications, such as sodium restriction, fluid restriction, daily weight monitoring, and moderate exercise, as well as pharmacological therapy, including ACE inhibitors, beta-blockers, diuretics, and SGLT2 inhibitors, as tolerated 1.
Recent Guidelines and Recommendations
The 2021 ACC expert consensus decision pathway update recommends that patients with new-onset HF be referred to a specialist or program for evaluation and management, and that guideline-directed medical therapy (GDMT) be continued in patients with recovered dilated cardiomyopathy, unless there is a defined, reversible cause for HFrEF 1. The ACR Appropriateness Criteria also emphasize the importance of distinguishing between ischemic and nonischemic etiologies in new-onset HFrEF to guide further evaluation and treatment 1.
Prioritizing Morbidity, Mortality, and Quality of Life
In the management of new-onset HF, it is essential to prioritize morbidity, mortality, and quality of life outcomes, and to consider the latest evidence and guidelines in making treatment decisions 1. By doing so, healthcare providers can provide optimal care for patients with new-onset HF and improve their outcomes.
From the Research
Causes of New Onset Heart Failure
- Cardiac ischemia is a common cause of heart failure with reduced ejection fraction (HFrEF) and should be considered in any patient with new-onset HFrEF 2
- Hypertension is also a common cause of new-onset heart failure, with patients often presenting with higher blood pressure and heart rate values upon admission 3
- Other factors that may contribute to new-onset heart failure include older age, higher global comorbidity, and lack of prescription of beta-blockers at discharge 3
Clinical Characteristics of New Onset Heart Failure
- New-onset heart failure patients are often older and have less global and disease-specific comorbidity and better baseline overall functional status compared to chronic-decompensated patients 3
- New-onset heart failure is more often characterized by preserved left ventricular ejection fraction (LVEF), milder baseline NYHA class, and lower plasma natriuretic peptide values 3
- The clinical presentation of HFrEF is remarkably similar to that of heart failure with preserved ejection fraction (HFpEF), but the primary etiology may be different 2
Risk Factors for Mortality in New Onset Heart Failure
- Older age, higher comorbidity, and lack of prescription of beta-blockers at discharge are associated with a higher risk of mid-term post-discharge mortality in new-onset heart failure patients 3
- LVEF is unrelated to mortality in new-onset heart failure patients 3
- Risk-adjusted mortality decreased over time from 19.9% to 18.4% between 2013 and 2019 in patients with recent-onset HFrEF 4