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Evaluating the likelihood of emerging acute or decompensated heart failure – Part 2

Heart failure is frequently underdiagnosed, particularly in frail individuals with atypical presentations. 

Case

Kanwar, a 72-year-old male with acute decompensated heart failure, was initiated on Lasix. Though his symptoms improved, his energy levels remained suboptimal. An echocardiogram was requested and the workup for contributing factors was unremarkable.

Part 2: Objectives

  1. Investigate guideline-directed medical therapy (GDMT).
  2. Personalize GDMT based on comorbidity profile.
  3. Tailor treatment considering "intrinsic capacity" or "biologic age."
    • a. Employ non-pharmacological management strategies.
    • b. Utilize pharmacological strategies.

Background

Heart failure is frequently underdiagnosed, particularly in frail individuals with atypical presentations. Only 13.2% of heart failure patients aged ≥65 years receive optimal Guideline-Directed Medical Therapy (GDMT).1-8

Chronological age presents a heterogeneous and limited parameter for individual diagnosis, prognosis and treatment recommendations, extending beyond heart failure to various clinical scenarios. Multiple tools are accessible for evaluating "biological age," "intrinsic capacity" or "physiological reserves," such as the clinical frailty scale.9-15 

Evidence

Precipitating factors

Exploring potential precipitating factors for heart failure is essential, including non-adherence to diet or medication, anemia, arrhythmia, infection, inflammation and more.16

Pharmacological therapy

Pharmacological therapy involves standard GDMT: ACE inhibitors (ACEi) or angiotensin receptor blockers (ARB), beta-blockers (BB), mineralocorticoid receptor antagonists (MRAs) and SGLT2 inhibitors. Loop diuretics are indicated in patients with functionally limiting edema. Other pharmacological treatments for heart failure include Digoxin, Isosorbide dinitrate/hydralazine, Ivabradine and Vericiguat. Their evidence for benefit is not as strong as GDMT.17-21 GLP-1 agonists have shown mixed results in heart failure patients.22,23

Definitions

GDMT is based on LVEF and NYHA classification.17-19, 21

Two strategies for sequencing GDMT exist: conventional and proposed new.

The conventional sequence: ACEi or ARB → beta-blocker → MRA → ACEi or ARB switch to ARNI (ideal but not common) → SGLT2i over 24 weeks. Up titration to target doses at each step.

The proposed new sequence: beta-blocker + SGLT2i → ARNI → MRA over four weeks. Up titration to target doses thereafter.18

Table 1: Heart failure types based on LVEF

Heart failure (HF) with a reduced ejection fraction (HFrEF)

LVEF ≤ 40%

HF with a mid-range ejection fraction (HFmEF)

LVEF 41-49%

HF with preserved ejection fraction (HFpEF)

LVEF ≥ 50%

Table 2: New York Heart Association (NYHA) functional classification

Class I

No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.

Class II

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.

Class III

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.

Class IV

Unable to perform any physical activity without symptoms of HF, or symptoms of HF at rest.

Table 3: Treatment based on LVEF and NYHA

Table 4: Tailoring GDMT based on heart failure and comorbidity profile

Non-pharmacological therapy for patients with heart failure

This includes exercise, sodium intake limitation, CPAP for sleep apnea, vaccines, smoking cessation, weight management, alcohol reduction and primary disease prevention.19,21 Some HFrEF patients benefit from device therapies like ICDs and CRTs, typically once on optimal GDMT.19,21,25,26

Tailoring non-pharmacological and pharmacological therapy based on intrinsic capacity

Though not common, emerging evidence supports stratifying patients based on their physiological reserves. Here are some recommendations based on evidence and expert advice:18,19,21,27-31,33,34,35

Table 5: Management Strategies based on extent of intrinsic capacity or physiological reserves

Back to the case

Echocardiogram: LVEF 35% with no significant valvulopathy.

Creatinine and electrolytes within normal limits on Lasix and ACEi.

Heart rate: 60-70 bpm on the beta-blocker.

Euvolemic status: Resolved symptoms at rest, NT-ProBNP = 300 pg/mL and improved chest X-ray.

Patient is mildly frail (CFS 5/9) reflected by a three-year decline and four-month deconditioning.

Pharmacological and non-pharmacological management strategies

GDMT: Started on low-dose Spironolactone 12.5mg. Send referral to the heart function clinic.

Exercise: Recommended at least three times a week, including balance, resistance and aerobic exercises. Suggesting a personal trainer due to the patient's unfamiliarity with exercises.

Diet: Suggested Mediterranean or DASH diet, supported by the patient's wife.

Cognition: No need for medication blister packing; the patient can manage his own medications and booking appointments.

Goals of care: Discussed and patient chose M1 goals of care based on baseline reserves.

Summary

Acute decompensated heart failure with volume overload: Optimize diuretic strategy.

Symptomatic heart failure: Echocardiogram. Optimize GDMT based on EF, NYHA, comorbidity profile and intrinsic capacity.

Non-pharmacological strategies, goals of care discussions and addressing adherence risk should align with the patient's intrinsic capacity or reserves.

Please see the CCS HF guidelines to help guide therapy in patients with heart failure.

References 

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Published: Jan 11, 2024

About the Author

Dr. Naheed Rajabali is an assistant clinical professor with the Faculty of Medicine and Dentistry at the University of Alberta. He received his training in internal medicine and geriatric medicine at the University of Alberta. He primarily works at the Royal Alexandra Hospital, on the acute inpatient ward and consult service as well as on the geriatric medicine emergency department consult service. He delivered care at the Parkinson's Disease and Movement Disorders Program at the Kaye Edmonton Clinic in collaboration with the Department of Neurology from 2017 to 2022. He is particularly interested in devising approaches to tailoring care across various disease settings, particularly in the perioperative setting. He also enjoys teaching.