What are the diagnostic steps and treatment options for heart failure?

Diagnostic Steps and Treatment Options for Heart Failure

The diagnosis of heart failure requires objective evidence of cardiac dysfunction at rest, with echocardiography being the preferred diagnostic method, followed by a comprehensive treatment approach including ACE inhibitors, beta-blockers, diuretics, and other medications based on heart failure severity. 1, 2

Diagnostic Steps for Heart Failure

Initial Evaluation

• Assess for typical symptoms (fatigue, dyspnea) and signs (peripheral edema) of heart failure, though these are not necessarily specific 1
• Perform chest X-ray to detect cardiomegaly and pulmonary congestion 1
• Obtain electrocardiogram (ECG) - a normal ECG has >90% negative predictive value to exclude LV systolic dysfunction 1
• Order complete blood count, electrolytes, creatinine, glucose, hepatic enzymes, and urinalysis 1
• Measure natriuretic peptide levels (BNP/NT-proBNP) which have high negative predictive value and can rule out heart failure when normal 1

Confirmatory Testing

• Perform echocardiography to confirm cardiac dysfunction and determine left ventricular ejection fraction (LVEF), which distinguishes between systolic dysfunction and preserved systolic function 1
• Echocardiography also provides assessment of valvular function, cardiac filling characteristics, and helps determine heart failure etiology 1
• Consider additional non-invasive imaging in patients with coronary artery disease:
  • Stress echocardiography
  • Nuclear cardiology
  • Cardiac magnetic resonance imaging (CMR) 1

Additional Testing in Selected Cases

• Exercise testing may be useful for prognostic stratification but has limited diagnostic value 1
• Consider invasive investigation (coronary angiography, hemodynamic monitoring) in acute or acutely decompensated heart failure not responding to initial treatment 1
• Pulmonary function tests to exclude respiratory causes of breathlessness 1

Treatment Options for Heart Failure

First-Line Pharmacological Therapy

• ACE inhibitors are first-line therapy for patients with reduced left ventricular systolic function to reduce mortality and hospitalizations 2, 3
  • Start with low dose and gradually titrate up
  • Monitor blood pressure, renal function, and electrolytes after dose increments 3
• Beta-blockers (e.g., metoprolol succinate) for all stable patients with mild to severe heart failure (NYHA class II-IV) with reduced ejection fraction 2, 3, 4
  • For heart failure, start metoprolol succinate at 25 mg daily for NYHA Class II or 12.5 mg daily for more severe heart failure
  • Double dose every two weeks to highest tolerated level or up to 200 mg 4
• Diuretics (loop diuretics or thiazides) for symptomatic treatment of fluid overload, always in combination with ACE inhibitors when possible 1

Second-Line and Add-On Therapy

• Mineralocorticoid receptor antagonists (spironolactone) for advanced heart failure (NYHA III-IV) to improve survival 1, 2
• Angiotensin receptor blockers (ARBs) for patients who cannot tolerate ACE inhibitors 2, 3
• Sacubitril/valsartan as replacement for ACE inhibitors in patients who remain symptomatic despite optimal treatment 2, 3
• Consider cardiac resynchronization therapy (CRT) for symptomatic patients with QRS duration ≥150 msec, LBBB morphology, and LVEF ≤35% 3
• Consider implantable cardioverter defibrillators (ICDs) for patients with symptomatic heart failure and LVEF ≤35% despite optimal medical therapy 3

Non-Pharmacological Measures

• Patient education about heart failure, symptom recognition, and self-management 1
• Daily physical activity in stable patients to prevent muscle deconditioning 1
• Control sodium intake when necessary, especially in severe heart failure 1
• Avoid excessive fluid intake in severe heart failure 1
• Avoid excessive alcohol consumption 1

Common Pitfalls and Caveats

• Avoid initiating potassium-sparing diuretics during ACE inhibitor initiation 1
• Avoid NSAIDs in patients on ACE inhibitors as they may worsen renal function 1
• Diltiazem and verapamil are not recommended in patients with reduced ejection fraction heart failure 2, 3
• If heart failure patients experience symptomatic bradycardia on beta-blockers, reduce the dose rather than discontinuing 4
• Avoid the combination of ACE inhibitor, ARB, and MRA due to increased risk of renal dysfunction and hyperkalemia 3