What are the diagnosis and management approaches for Congestive Heart Failure (CHF)?

Diagnosis and Management of Congestive Heart Failure (CHF)

The diagnosis of CHF requires a systematic approach including clinical evaluation, laboratory tests, and imaging studies, while management should include ACE inhibitors, beta-blockers, SGLT2 inhibitors, and diuretics as cornerstone therapies to reduce mortality and improve quality of life. 1

Diagnosis of CHF

Clinical Presentation

• Key symptoms:
  • Exertional breathlessness
  • Fatigue
  • Pulmonary edema
  • Peripheral edema 2

Diagnostic Tests

1. Laboratory Tests:

   • Natriuretic peptides (BNP/NT-proBNP): Highly valuable as a "rule out" test due to high negative predictive value 2
   • Complete blood count, electrolytes, renal function, liver function

2. Imaging:

   • Echocardiography: Essential for diagnosis, assesses ventricular function, determines ejection fraction, evaluates valve function, and helps identify etiology 2
   • Chest X-ray: Evaluates pulmonary congestion and cardiomegaly

3. Additional Testing:

   • ECG: Identifies rhythm disturbances, ischemia, or prior infarction
   • Exercise testing: Normal maximal exercise test excludes heart failure; useful for prognostic stratification 2
   • Coronary angiography: Consider in acute or decompensated heart failure not responding to initial treatment 2

4. Classification:

   • Heart failure with reduced ejection fraction (HFrEF): LVEF ≤40%
   • Heart failure with preserved ejection fraction (HFpEF)
   • Heart failure with mildly reduced ejection fraction (HFmrEF) 1

Management of CHF

Pharmacological Therapy

1. First-Line Medications for HFrEF:

   • ACE Inhibitors: First-line therapy for reduced LVEF 2

     • Start at low dose and gradually titrate to target doses
     • Monitor renal function and electrolytes 1-2 weeks after each dose increase 1

   • Beta-Blockers: Indicated for all stable patients with current or prior HF symptoms and reduced LVEF 1

     • Only three have proven mortality benefit: bisoprolol, carvedilol, and sustained-release metoprolol succinate

   • SGLT2 Inhibitors (dapagliflozin or empagliflozin): Reduce mortality and hospitalization 1

   • Diuretics: Essential for symptomatic treatment of fluid overload 2

     • Initial doses: furosemide 20-40mg, bumetanide 0.5-1.0mg, torsemide 10-20mg
     • Should be administered with ACE inhibitors when possible 2

2. Additional Medications:

   • Mineralocorticoid Receptor Antagonists (MRAs): Recommended for NYHA class III-IV symptoms and LVEF ≤35% 1

   • Angiotensin Receptor-Neprilysin Inhibitors (ARNIs): Sacubitril/valsartan superior to ACE inhibitors in reducing cardiovascular death and heart failure hospitalization 3

     • In the PARADIGM-HF trial, sacubitril/valsartan reduced the risk of the combined endpoint of CV death or HF hospitalization (HR 0.80; 95% CI, 0.73,0.87, p<0.0001) 3

   • Ivabradine: Consider for patients with heart rate ≥70 bpm despite maximally tolerated beta-blocker doses 4

     • Reduces risk of hospitalization for worsening heart failure (HR: 0.82,95% CI: 0.75,0.90) 4

Device Therapy

• Implantable Cardioverter-Defibrillators (ICDs): Recommended for patients with LVEF ≤35% and NYHA Class II-III symptoms 1

• Cardiac Resynchronization Therapy (CRT): Recommended for patients with LVEF ≤35%, QRS ≥150ms, and left bundle branch block morphology 1

Lifestyle Modifications

• Exercise: Regular aerobic exercise to improve functional capacity and reduce hospitalization risk 1

• Diet:

  • Moderate sodium restriction for severe heart failure
  • Avoid excessive fluid intake in severe heart failure
  • Limit alcohol consumption 1

• Self-Monitoring:

  • Daily weight monitoring with instructions to increase diuretic dose if weight increases by 1.5-2.0 kg over 2 days 1
  • Self-recognition of worsening symptoms 2

Monitoring and Follow-up

• Regular assessment of symptoms, vital signs, weight, and volume status
• Monitor serum electrolytes, renal function during treatment
• Check electrolytes and renal function 1-2 weeks after each dose increment of ACE inhibitors/ARBs 1

Management Algorithm

1. Establish diagnosis through clinical evaluation, natriuretic peptides, and echocardiography
2. Determine HF type based on ejection fraction (HFrEF, HFmrEF, HFpEF)
3. For HFrEF:
   • Start ACE inhibitor (or ARNI if appropriate)
   • Add beta-blocker once patient is stable
   • Add SGLT2 inhibitor
   • Add MRA for persistent symptoms
   • Manage fluid status with diuretics as needed
4. For HFpEF/HFmrEF:
   • SGLT2 inhibitors
   • Diuretics for symptom management
5. Consider device therapy when appropriate
6. Implement lifestyle modifications
7. Regular monitoring of symptoms and medication effects

Common Pitfalls and Caveats

• Avoid rapid correction of hyponatremia which can worsen outcomes
• Avoid NSAIDs which can worsen renal function and fluid retention
• Monitor for hypotension when initiating vasodilator therapy
• Don't discontinue HF medications in patients with improved LVEF (>40%) who previously had HFrEF 1
• Don't rely solely on Holter monitoring for diagnosis of heart failure; it's only useful for detecting arrhythmias that could be causing or exacerbating symptoms 2