Conges've)Heart)Failure)

Anju%Nohria,%M.D.%
Division%of%Advanced%Heart%Disease%
Brigham%and%Womens%Hospital,%Boston,%MA%
%

Disclosure)
I%have%no%rela@onships%to%disclose%

Objec'ves)
At%the%end%of%this%course,%you%will%be%able%to:%
Describe%the%epidemiology%and%pathophysiology%of%
HF%
Diagnose%acute%decompensated%HF%(ADHF):%%
Clinical%exam%
Natriure@c%pep@des%
Pulmonary%artery%catheteriza@on%

Manage%ADHF:%%
Pharmacologic%treatment%
Cardiorenal%syndrome%
NonLdurable%mechanical%support%

Deni'on)of)Heart)Failure)
"The"situa+on"when"the"heart"is"incapable"of"
maintaining"a"cardiac"output"adequate"to"
accommodate"metabolic"requirements"and"the"
venous"return."
"
"" " " " " " " " " "Eugene"Braunwald"

Heart)Failure:)The)Numbers)
Staggering%in%Scope%
Almost%6%million%Americans670,000%new%cases/yr%
50%%dead%within%5%yrs%of%diagnosis56,830%deaths/yr%

Healthcare%Burden%
1.1%million%hospitaliza@ons/yrmost%frequent%cause%of%
hospitaliza@on%in%pa@ents%>%65%yrs%
83%%hospitalized%at%least%once%aZer%diagnosis%
AZer%hospitaliza@on,%30%%1%year%mortality%
20%%reLadmission%rate%within%30%days,%50%%@%6%mths%
$39.2%billion%(1L2%%total%healthcare%cost)%
AHA%Sta@s@cs.%Circula@on%2012;125:e2L220.%

E'ology)of)Heart)Failure)
E@ology %
%
CAD %
%
Non%CAD %

%%%
%
%

%%%%
%50.3%
%49.7%

No%cause%given %13.3%
Cause%given
%36.4%
Idiopathic %18.2%
Valvular %%%4.0%
HTN %
%%%3.8%
Alcohol
%%%1.8%
Viral %
%%%0.4%
Postpartum%%%0.4%
Amyloid %%%0.1%
Other
%%%7.6%

Other%causes%to%consider%
Gene@c%
Congenital%heart%disease%
Cocaine%
Chemotherapy/XRT%
Chagas%
HIV%
Thyroid%
Pheochromocytoma%
Sarcoid%
Hemochromatosis%
Uncontrolled%tachycardia%(Ab)%
Adapted%from%Redeld,%Mayo%Clin%

Pathophysiology)of)Heart)Failure)
Coronary%Disease%

Cardiomyopathy%

Cardiac%Overload%

LeC)Ventricular)Dysfunc'on)
Neurohormonal)
Ac'va'on)

Vasoconstric'on)

%Peripheral%Organ%Bloodow%
Skeletal%%
bloodow%

RBF,%Na%%
reten@on%

Cardiac%Remodeling%
LV%%
Dilata@on%

LV%%
Hypertrophy%

Arrhythmias%
Symptoms,%Fluid%reten@on,%Death%%

EF 50 %

EF 40-50 %

EF 40 %

Distribu'on)of)EF)in)Pa'ents)Hospitalized)
with)HF)
HFIPEF)vs.)HFrEF)
%Older%
%Female%
%HTN%
%CKD%
%%CAD%

Fonarow%G,%et%al.%JACC%2007;%50:768L77%

Survival)ACer)Hospitaliza'on)for)HF)

2802)pts)with)CHF,)EF)assessment)Ontario)Province)1999I2001)
Mortality,)EF<40%)vs.)EF>50%)
30)days)7%)vs.)5%)(p=0.08))
1)year)26%)vs.)22%)(p=0.07)%%

Bha@a,%et%al.%NEJM%2006;%355:260L9%

Chronic)HF)Management)Based)on))ACC/
AHA)Classica'on))
STAGE)A)

At%high%risk%for%
HF%but%without%
structural%heart%
disease%or%
symptoms%of%HF%

L%Treat%%

%%underlying%%
%%risk%factors%

STAGE)B)

Structural%heart%
disease%without%
current%or%prior%
signs%or%
symptoms%of%HF%

L%ACELI%

L%LBlocker%
L%ARB%if%%
%%ACELI%%
%%intolerant%

STAGE)C)

Structural%heart%
disease%with%
prior%or%current%
symptoms%of%HF%
%
L%ACELI%
L%Lblocker%
L%Diure@cs%for%sxs%
In)selected)pts:)
L%Spironolactone%
L%Digoxin%
L%ARB%
L%Hydral/nitrates%
L%CRT%
L%ICD%

STAGE)D)

Refractory%HF%
requiring%
specialized%
interven@ons%
%
L%Pallia@ve%care%
L%Inotropes%
L%Transplant%
L%MCS%
L%Experimental%Rx%

Hunt%et%al.%Circula(on%2005;112:1825L52.%

Staging)Heart)Failure:)A)New)Paradigm)
ACC/AHA)Classica'on)
NYHA)Classica'on)

B.%%Structural%heart%disease%
without%symptoms%%

I.%%Cardiac%disease%without%
func@onal%limita@on%

C.%%Structural%heart%disease%with%
prior%or%current%symptoms%%

II.%Slight%limita@on%of%physical%
ac@vity%

D. Refractory%heart%failure%
%

III.%Marked%limita@on%of%physical%
ac@vity%
IV.%%Inability%to%carry%on%physical%
ac@vity%without%discomfort%

Worsening%QOL%

Progressive%Disease%

A.%%At%risk%pa@ents%without%
structural%heart%disease%%

ADHF)is)a)Clinical)Diagnosis)
CONGESTION?"
DRY%

ADEQUATE"
PERFUSION?"
Signs%of%Hypoperfusion%
%Hypotension%
%Narrow%pulse%pressure%
%Altered%menta@on%
%Cool%forearms/legs%
%Intolerance%of%vasodilators%
%,Cr,,,Na,

WARM%
COLD%

A,

(20%),

,
L

(rare)

WET%
,,,,,,,,,B,
, (50%),,,
,,,,,,,,,C,

(30%),

Signs%of%Conges@on%
%Orthopnea%
%Rales%
%Increasing%S3%
%Loud%P2%
%Elevated%JVP%
%HJR%
%Ascites%
%Edema%
%Valsalva%square%%%%
wave%

Nohria%et%al.%JAMA%2002;287(5):628L40.%

BNP)to)Assist)Diagnosis)of)HF)
Pts)presen'ng)to)EW)with)dyspnea)

BNP))100)pg/mL:))
Posi've)Predic've)Value)79%)
Nega've)Predic've)Value)89%)
)
NTIpro)BNP))900)pg/mL:)
Posi've)Predic've)Value)77%)
Nega've)Predic've)Value)92%)
Maisel%AS,%et%al.%NEJM%2002;347:161%
Januzzi%J%et%al.%Am%Heart%J%2005;149:744.%

Diagnos'c)Limita'ons)of)Natriure'c)
Pep'des))
Imperfect)surrogate)for)lling)pressures)

Levels)increase)with)age,)female)gender,)pressure)overload,)
renal)failure)
Levels)decrease)with)obesity,)medical)treatment)

Measurement)of)BNP)is)primarily)useful)
Levels)are)lower)in)HFIPEF)
when)there)is)diagnos'c)uncertainty)
Levels)may)be)elevated)even)in)compensated)chronic)
HF)
Limited)incremental)benet)over)clinical)assessment)
Redeld%et%al.,%JACC%2002;%Raymond%et%al.%Heart%2003;%McCullough%et%al.,%AJKD%2003;%Wang%et%
al.,%Circula@on%2004;%Januzzi%et%al.%Am%J%Cardiol%2005;%%Maisel%et%al.,%NEJM%2002;%Wu%et%al.%Eur%J%
Heart%Failure%2003;%Shah%et%al.%J%Card%Fail%2011.%%%

Other)Tests)to)Diagnose)ADHF)
CXR:%%
cardiomegaly,%increased%inters@@al%markings,%KerleyLB%
lines,%eusions%

Echo:%%
LVEF,%LVEDD,%MR,%TR%
IVC%diameter%>%2%cm,%collapse%with%sni%<%50%%%%CVP%
Lung%ultrasound:%Comets%

Pulmonary%artery%catheteriza@on%
Rou@ne%use%not%recommended%
Useful%in%certain%situa@ons%

Is)there)s'll)a)role)for)the)PA)
Catheter?)

ESCAPE Investigators, JAMA 2005; 294: 1625

When)to)consider)PA)Catheter?))
Severe%clinical%decompensa@on%with%uncertain%
hemodynamic%prole%by%bedside%evalua@on%
Hypotension%or%worsening%renal%func@on%with%
empiric%therapy%%
Presumed%cardiogenic%shock%
Apparent%inotrope%dependence%or%refractory%
symptoms%
Evalua@on%for%VAD%or%transplant%candidacy%
Evalua@on%of%pulmonary%arterial%hypertension%

Treatment)Goals)of)ADHF)
Address%precipita@ng%
factors%
Improve%sxs%and%endL
organ%perfusion%
Ini@ate%Rx%to%prevent%dz%
progression/mortality%
Reduce%LOS%and%reL
hospitaliza@on%

Iden(fy,inci(ng,factor,
and,treat,
Lower,PCWP,
Increase,CO,
Op(mize,oral,regimen,
Manage,related,risks,
(SCD,,VTE),
Pt,educa(on,
Longitudinal,dz,
management,programs,

Precipita'ng)Factors)

Acute%coronary%syndromes/coronary%ischemia%
Severe%hypertension%
Atrial%or%ventricular%arrhythmias%
Infec@on%
Pulmonary%emboli%
Renal%failure%
Medica@ons%(e.g.%NSAIDs,%steroids,%TZDs,%LLtype%CCBs)%
Nonadherence%(eg.%sodium%and%uid%restric@on,%medica@ons)%
Other%cardiac%dz%(acute%endocardi@s,%acute%dissec@on,%acute%
myopericardi@s)%

Ra'onaleI)CHF)Therapies)
LV)Dysfunc'on)
Salt/volume%
Diure@cs%
Venodilators%

Inotropes%
Vasodilators%
Cardiac%Output%

Preload%

AZerload%
RAAS/SNS%Ac@va@on%

Salt/H2O%Reten@on%
Vasoconstric@on%

ACE%Inhibitors%
ARB%
Aldosterone%Blockers
Beta%blockers%

Op'miza'on)of)Volume)and)Perfusion)
WARM%
COLD%

DRY%

WET%

A"

B"

Diuretics

Vasodilators)
Nitroprusside)
Nitroglycerin)
or)
Nesiri'de)
)

C"

L"

Low/Normal%SVR%

High%SVR%

Inotropic)Drugs)
Dopamine)
Dobutamine)
Milrinone%

Stevenson%LW.%Eur%J%Heart%Failure%1999%

Case)
53)y.o.)man)w/)nonIischemic)CMP)(EF)25%))admiged)w/)weight)gain)and)
dyspnea)despite)increasing)oral)loop)diure'cs.)
Exam:)HR)85)BP)100/50)RR)22)Weight)10)lbs)>)1)mth)ago.)
JVP)to)angle)of)jaw,)clear)lungs,)Loud)P2,)S3,)MR,)distended)abdomen,)
and)trace)peripheral)edema.)
Labs:)Hct)30%,)Na)135,)BUN)26,)Cr)1.6)(baseline)1.4))

) How%would%you%treat%this%pa@ent?%
A. IV%Loop%Diure@cs%
B. IV%Loop%Diure@c%+%IV%Vasodilator%
C. IV%Loop%Diure@c%+%IV%Inotrope%

Diuresis)in)ADHF)
Loop%diure@cs:%IV%bolus%or%con@nuous%infusion%

Furosemide,%torsemide,%bumetanide%
Ini@ate%rapidly%at%dose%%oral%regimen%
Give%at%frequent%intervals%
*Aldosterone,antagonists,are,weak,diure(cs,and,used,mostly,for,KP
sparing,and,neurohormonal,eects,

Lower%lling%pressures%lead%to%improved%outcomes%
JVP%<%10%usually%implies%PCW%<%22%mm%Hg%
Aim%for%JVP%<%8%mm%Hg%%
In%RV%failure,%may%have%to%se~le%for%a%slightly%higher%JVP%
Complica@ons:%K/Mg,%metabolic%alkalosis,%GFR,%
neurohormonal%ac@va@on,%ototoxicity%

DOSE)Trial)
N=308%pts%with%ADHF,%<%24%hrs%admission%
Q12
Bolus

HIGH%vs.%LOW%DOSE%Diure@cs%

%improvement%in%dyspnea%@%72%hrs%
Continuous
%net%diuresis%and%weight%loss%@%72%hrs%
%propor@on%w/%WRF%(Cr%>%0.3%mg/dL)%
No%di%in%death,%reLhospitaliza@on,%or%ED%visits%@%60d%

Low
Dose

High
Dose

1X oral

2.5X oral

1X oral

2.5X oral

BOLUS%vs.%CONTINUOUS%Diure@c%Infusion%
No%dierence%in%any%outcomes%%
Felker%et%al.%NEJM%2011;364:797L805.%

Case)Contd.)
Agempts)at)diuresis)with)escala'ng)doses)of)IV)furosemide)
(200)mg)IV)bid))lead)to)increased)BUN/Cr)40/2.3)with)net)
weight)loss)of)only)1)kg)since)admission.)

What%would%you%do%next?%%
A. Give%IV%hydra@on%
B. Change%to%a%lasix%drip%@%20%mg/hour%%
C. Start%empiric%inotropic%therapy%
D. Insert%a%PA%line%for%hemodynamic%evalua@on%

Diure'c)Resistance)
Reduced%natriure@c%response%to%a%given%dose%of%
diure@c,%necessita@ng%the%use%of%higher%doses%and%
combina@ons%of%loop%and%nonLloop%diure@cs%in%order%
to%achieve%net%sodium%and%uid%loss,%oZen%at%the%
expense%of%worsening%renal%func@on%(WRF).%%
WRF%is%associated%with%adverse%outcomes%and%longer%
length%of%stay%

Overcoming))Diure'c)Resistance))
High%dose%diure@cs%%
Thiazide%diure@cs%to%augment%loop%eect%
Metolazone,%Diuril%

Ultraltra@on%%
Novel%agents%that%promote%Na/H2O%excre@on%at%
dierent%parts%of%the%nephron:%%
No%benet%with%nesiri@de,%tolvaptan,%or%adenosine%
antagonists%(not%approved)%

IV%vasoac@ve%agents%
Renal%dose%dopamine%or%vasodilators%

CARESS:)UF)vs.)IV)Diure'cs)
N=188%
SHF%or%DHF%
%2%signs%of%ADHF%
%SCr%%0.3,%12%wk%prior%
to%or%10%d%aZer%admit%
No%IV%vasoac@ve%meds%
SCr%<%3.5%mg/dL%

Bart et al. NEJM 2012;367:2269-304

Vasopressin)Receptor)Antagonists)
N)=)4133,)HF)admit,)LVEF))40%,)<)48h)adm.,)SCr)<)3.5)mg/dL)
Compared%to%placebo,%
tolvaptan%30%mg/d:%

%body%weight%@%1%d%
%dyspnea%@%1%and%7%d%
%serum%sodium%
%thirst,%dry%mouth%

No%dierence%in%renal%
func@on%
Gheorghiade%et%al.,%JAMA%2007;297:1319%

Case)
35%y.o.%previously%well%female%w/%2%wks%of%progressive%dypnea%%now%@%
rest.%+%chest%@ghtness%
Exam:%HR%120,%BP%80/60,%RR%30,%Sats%94%%RA.%JVP%18%cm%H2O,%bilateral%
rales,%summa@on%gallup,%hepatomegaly,%and%cool%extremi@es%w/%1+%
edema.%%
Studies:%%Sinus%tach%w/%diuse%ST%eleva@on,%cTnI%0.7%
Echo:%LVEDD%15L20%,%global%HK,%LVEDD%5.5.%cm%

What%is%the%most%likely%diagnosis?%
A. Acute%myocardial%infarc@on%
B. Acute%myocardi@s%
C. Acute%pericardi@s%with%tamponade%

Determina'on)of)Bedside)
Hemodynamic)Prole)
CONGESTION?
DRY
ADEQUATE
PERFUSION?

WET

WARM

COLD

Causes)of)Cardiogenic)Shock)
Acute)MI

Pump%Failure%
Large%infarc@on%%
Smaller%infarc@ons%with%
preexis@ng%CHF%
%Infarc@on%extension%or%
expansion%
Mechanical%complica@ons%
VSD%
Acute%MR%
Free%Wall%rupture%
RV%infarc@on%

%%

%%

NonIcoronary)causes)
Fulminant%Myocardi@s%
Acute%valvular%insuciency%(e.g.%
endocardi@s,%chordal%rupture)%
LV%oulow%obstruc@on%(e.g.%AS,%HCM)%
LV%inow%obstruc@on%(e.g.%myxoma,%MS)%
Aor@c%Dissec@on%
Pericardial%Tamponade%
Massive%pulmonary%embolism%
EndLStage%Cardiomyopathy%
Prolonged%Cardiopulmonary%Bypass%
Cardiac%Contusion%

%
%

Op'miza'on)of)Volume)and)Perfusion)
WARM%
COLD%

DRY%

WET%

A"

B"

Diuretics

Vasodilators)
Nitroprusside)
Nitroglycerin)
or)
Nesiri'de)
)

C"

L"

Low/Normal%SVR%

High%SVR%

Inotropic)Drugs)
Dopamine)
Dobutamine)
Milrinone%

Stevenson%LW.%Eur%J%Heart%Failure%1999%

IV)Vasodilators)in)ADHF)
Nitroprusside:%%
Arterial%>%venous%vasodilator%
Titrate%to%SVR%800L1200%or%SBP%%80,%whichever%comes%rst%
Complica@ons:%hypotension,%thiocyanate%toxicity%

Nitroglycerin:%
Venous%>%arterial%vasodilator%
Drug%of%choice%for%ischemia%
Complica@ons:%hypotension,%headache,%tachyphylaxis%

Nesiri@de:%
Venous%>%arterial%vasodilator%
Promotes%natriuresis%and%diuresis%
Complica@ons:%hypotension%(greater%than%with%nitroglycerin)%

ASCEND)HF:)Nesiri'de)vs.)Std.)Care)
N=7141%
EF%<%40%%
ADHF%
<%24%hr%
SBP%%100%mm%Hg%
No%milrinone%or%
dobutamine%<%5g/kg/min%
Similar%outcomes%as%
nitroglycerin%%

* No difference in WRF
OConnor et al. NEJM 2011;365:32-43.

Acute)CHFI)IV)Inotropes)
Drug"

1"

1"

2"

HR"

CO"

SVR"

PVR"

Dobutamine)(2I10)g/kg/min))

+)

+++)

++)

))))1I2)g/kg/min)

))))2I10)g/kg/min)

+)

++)

)))10I20)g/kg/min)

+++)

++)

Dopamine)

Milrinone)(0.1I0.75)g/kg/min))

PDE)3)inhibitor)

Complica@ons:%%myocardial%oxygen%demand,%%arrhythmias,%
neurohormonal%ac@va@on%
No%mortality%benet%(increased,compared,to,vasodilators),
Use%only%as%bridge%to%deni@ve%therapy%or%for%pallia@on%in%
medically%refractory%pa@ents%

ShortIterm)IV)Milrinone)In)Hospitalized)
ADHF)Pa'ents:)OPTIMEICHF)
%)Pa'ents)During)Hospitaliza'on)

N=951)pts,)milrinone)@)0.5)g/kg/min)vs.)placebo,)60)d)F/U)

12

10
8
6

Placebo
Milrinone

2
0

MI)

A)Fib)

VT/VF)

)BP)

Death)

Cue%et%al.%JAMA%2002;287:1541L7.%

Ques'on)
Pts%hemodynamics%on%RHC%are:%
RA%15,%PCWP%30,%CI%1.8,%SVR%1000%
What%therapy%would%you%recommend?%
A. IV%diure@cs%
B. IV%vasodilators%
C. IV%inotropes%
D. A%+%B%
E. A%+%C%

Case)Contd.)
Treated%with%IV%dobutamine%and%furosemide%with%
improvement%in%hemodynamics%and%Cr%
A~empted%to%wean%milrinone%and%transi@on%to%oral%
ACELI%but%rising%crea@nine%and%decreasing%urine%
output%
Felt%to%be%milrinone%dependent%and%considered%for%
advanced%therapies%(VAD/transplant)%

Who)should)be)considered)for)advanced)
therapies?)

Escala@ng%diure@c%dose%requirements%%
Progressive%renal%dysfunc@on%
Increasing%frequency%of%HF%hospitaliza@on%
Increasing%burden%of%ventricular%arrhythmias%
Intolerance%of%standard%medical%therapy%
Refractory%HF%symptoms%%
Need%for%inotropic%support%
>%5%%nonLuid%related%weight%loss%(cachexia)%
Durable,VADs,are,not,salvage,therapy,for,acute,
cardiogenic,shock,

Use)of)IABP)
Consider%for%
pa@ents%with%STEMI%when%
cardiogenic%shock%is%not%
rapidly%reversed%with%
pharmacologic%therapy%%
inotropeLrefractory%heart%
failure%in%pa@ents%with%
cardiomyopathy%
Medically%refractory%
ventricular%tachycardia%
Mechanical%MI%complica@on%
(VSD,%Papillary%muscle%
rupture)%

Contraindica@ons%

Signicant%AI%
Severe%PAD%
Abdominal%aor@c%aneurysm%
Aor@c%Dissec@on%

Mechanical)Unloading)for)the)Failing)Heart:)
)Beyond)Balloon)Counterpulsa'on)
Impella)2.5,)5.0)Cardiac)
Assist)System)
))

Retrograde)cannula'on)of)LV)via)
femoral)artery)
)
Micro)Axial)Flow)Pump)
25000I30000)rpm)
Flow)2.5)or)5.0)L/m,)depending)
on)device)
)
LV)support)only)
Approved)for)facilita'on)of)highI
risk)PCI)

Mechanical)Unloading)for)the)Failing)Heart:)
)Percutaneous)Assist)Devices)
TandemHeart:)

)Inow:)21F)Transseptal)LeC)Atrial)
Cannula)via)femoral)vein))
)
Ouxlow):)15I17F)Femoral)Artery)
)
Centrifugal)pump)
Max)7000I8000)rpm)
Flow)4I5)L/m)
)
Can)be)congured)for)RV/BiIV)
support)with)direct)surgical)
cannula'on)
)
Intended)for)temporary)support)

Ins'tute)Therapies)for)Treatment)of))
Chronic)Stage)C)HF)
Diure@csL%%symptoms%
DigoxinL%%hospitaliza@ons%
VasodilatorsL%%survival%
ACE%Inhibitors%(ARBs)%
HydralazineLnitrate%in%African%Americans%

BetaLBlockersL%%survival%
Do%not%start%when%acutely%decompensated%

Aldosterone%antagonistsL%%survival%
EP%Device%TherapyL%%survival%
ICD,%CRT%

Treatment)I)Diastolic)CHF)
Treat%conges@on%
Control%HTN%
Treat%ischemia%
Maintain%sinus%rhythm%
Control%heart%rate%

Na/uid,restric(on,,
diure(cs,
An(Phypertensives,
Nitrates,,betaPblockers,,
CCB,,PCI/CABG,
Cardioversion,if,Ab,
BetaPblockers,,CCB,,
digoxin,,AV,nodal,
abla(on,

Summary)
HF%is%a%clinical%diagnosis,%but%BNP%may%be%useful%when%there%is%diagnos@c%
uncertainty%
Treatment%of%HF%should%be%targeted%at%op@miza@on%of%volume%status%with%
maintenance%of%adequate%endLorgan%perfusion%
Pa@ents%should%be%diuresed%to%JVP%<%10%cm%H2O%when%possible%and%
vasodilators%should%be%used%in%preference%to%inotropes%
Rou@ne%invasive%hemodynamic%monitoring%oers%no%advantage%over%
bedside%clinical%assessment%
Ini@ate%lifesaving%therapies%prior%to%hospital%discharge%and%coordinate%
longitudinal%followLup%
Pa@ents%with%refractory/recurrent%symptoms%that%are%resistant%to%
standard%therapy%should%be%referred%for%considera@on%of%advanced%
therapies%