Dx¹

• HFrEF: HF w/ LVEF ≤ 40%
• HFpEF: HF w/ LVEF ≥ 50%
  • > 40% is borderline HFpEF
• Measure NT-proBNP or BNP if suspicious
• CXR and Doppler Echo on initial workup

Staging / Classification

AHA Stages

Stage	Description
A	High risk w/o structural heart disease and w/o HF SSx
B	SHD w/o SSx of HF
C	SHD w/ current or prior HF SSx
D	Refractory HF SSx

NYHA Classifications

Classification	Description
I	No limitations of physical activity d/t SSx
II	Normal physical activity results in SSx
III	Mild physical activity results in SSx
IV	SSx at rest

DDx of Dilated Cardiomyopathies

• Genetic / Familial
• Obesity
• DM
• Hyperthyroidism
• Acromegaly
• EtOH
• Cocaine
• HER-2 and/or anthracyclines
• Various other toxins
• Chronic Tachycardia
• Myocarditis
  • SLE
  • HIV
  • Other infections
  • Chagas disease
  • Hypersensitivity myocarditis
  • Scleroderma and other rheumatologist conditions
• Peripartum cardiomyopathy
• Hemochromatosis and iron overload
• Amyloidosis

Tx (HFrEF)^{1, 2}

Stage A

• Modify risk factors as appropriate, with emphasis on wt loss, smoking cessation, BP control, HLD control, and DM control

Stage B

All pts should receive…

• ACEI (ARB if CI)
• β-blocker
  • Metoprolol tartrate
  • Bisoprolol
  • Carvedilol
• Statins (if Hx of ACS or CAD)
• Other means of BP control PRN
  • Consider spironolactone if HTN is refractory to above agents
• Consider prophylactic ICD

Stage C

All pts should receive…

• ACEI or ARB or ARNI
  • Tolerating ACEI or ARB and able to afford => transition to ARNI
  • Do not give ARNI w/i 36hr of ACEI or ARB
  • Do not give ARNIs to pts w/ Hx of angioedema
  • Monitor and titrate slowly Q1-2wks
• β-blocker
  • Metoprolol tartrate
  • Bisoprolol
  • Carvedilol
  • Consider ivabridine if on maximum BB dose, LVEF ≤ 35%, and RHR ≥ 70
  • Start low and titrate up when SSx of current dose abide
• Spironolactone
  • CrCl > 30 and K < 5
  • If LVEF ≤ 35% OR LVEF ≤ 40% w/ HF or DM after MI
• Consider Hydralazine-Nitrate combos in black pts
• PRN Diurectics for fluid status control
  • Preferably Loops, with thiazides added for diuretic resistance PRN
• Additional BP Meds PRN for goal of < 130/80
• Consider Digoxin to decrease hospitalizations
  • 0.125-0.25mg QD NTE 0.5-0.75mg QD
  • Goal Plasma Range of 0.5-0.9 ng/mL
• Avoid CCBs except amlodipine

Dosing

HF Drug Dosing

Drug	Initial Dose	Max Dose
ACEIs
Captopril	6.25mg TID	50mg TID
Enalapril	2.5mg BID	10-20mg BID
Lisinopril	2.5-5mg QD	20-40mg QD
ARBs
Candesartan	4-8mg QD	32mg QD
Losartan	25-50mg QD	50-150mg QD
Valsartan	20-40mg BID	160mg BID
ARNI
Sacubitril/Valsartan	49mg/51mg BID (or 24mg/26mg BID)	97mg/103mg BID
If Channel Inhibitor
Ivabradine	5mg BID	7.5mg BID
Aldosterone Antagonists
Spironolactone	12.5-25mg QD	25mg QD or BID
Eplerenone	25mg QD	50mg QD
β-Blockers
Bisoprolol	1.25mg QD	10mg QD
Carvedilol	3.125mg BID	50mg BID
Carvedilol CR	10mg QD	80mg QD
Metoprolol Succinate	12.5-25mg QD	200mg QD
ISDN-Hydralazine
Combo Pill	20mg/37.5mg TID	40mg/75mg TID
Individual Pills	20-30mg/25-50mg TID or QD	40mg TID / 100mg TID

HF Diuretic Dosing

Drug	Initial Dose	Max TDD
Loops
Bumetanide	0.5-1mg QD-BID	10mg
Furosemide	20-40mg QD-BID	600mg
Torsemide	10-20mg QD	200mg
Thiazides
Chlorthiazide	250-500mg QD-BID	1000mg
Chlorthalidone	12.5-25mg QD	100mg
HCTZ	25mg QD or BID	200mg
Indapamide	2.5mg QD	5mg
Metolazone	2.5mg QD	20mg
K-Sparing
Amiloride	5mg QD	20mg
Spironolactone	12.5-25 QD	50mg
Triamterene	50-75mg BID	200mg

Stage D

• Fluid restrict to 1.5-2 L QD
• Consider milrinone or dobutamine for inotropy
• Consider LVAD
• Consider transplant

Acute Decompensated HF^{1, 3}

• Continue home HF meds unless CI or hemodynamically unstable / failing renal Fx
• IV diuretics for fluid-overloaded pts
  • Furosemide 40mg, Bumetanide 1-3mg, or Torsemide 10-20mg for naive pts
  • Should give higher doses than home
• Give vasodilators if pt has adequate hemodynamics and significant dyspnea
  • NTG 0.5-0.7 mcg/kg/min IV titrated NTE 200 mcg/min
  • Nitroprusside 0.3 mcg/kg/min titrated q5-10min
  • Nesiritide 2mcg/kg then 0.01 mcg/kg/min⁴
• Pressors / Inotropes if not perfusing
  • Milrinone 50 mcg/kg over 10min then 0.5 mcg/kg/min
  • Dobutamine 2-20 mcg/kg/min
• Consider LVAD or ECMO if absolutely necessary

References