Heart Failure- Complete Review & Management.pptx

Updated 2025 review

1. Heart Failure: Complete Review & Management Dr/Ahmed Khaled 2025

2. 01 Epidemiology & Definitions 02 Pathophysiology & Triggers 03 Diagnostic Work-up 04 Guideline-Directed Drugs 05 Device & Surgical Options 06 Special Scenarios & Wrap-up

3. Epidemiology & Definitions PART 01

4. Global Burden of Heart Failure A Growing Public Health Concern Over 64 Million Affected Worldwide The rising incidence is closely tied to aging populations , persistent hypertension, and the prevalence of ischemic heart disease. 20-30% Lifetime Risk in the U.S. This significant individual risk translates to a substantial increase in hospitalizations and a major economic burden on the healthcare system.

5. HF Classifications & Terminology HFrEF Heart Failure with reduced EF ≤ 40% HFmrEF Heart Failure with mid-range EF 41-49% HFpEF Heart Failure with preserved EF ≥ 50% ACC/AHA Stages A-D Stages classify HF development from At risk (A) to Advanced (D), guiding preventive and therapeutic intensity. NYHA Class I-IV Classifies functional limitation and symptom severity, from No limitation (I) to Symptoms at rest (IV).

6. Pathophysiology & Triggers PART 02

7. Neurohormonal Dysregulation The Vicious Cycle of HF Progression Initial Cardiac Injury e.g., MI, Hypertension → Sustained Activation Sympathetic Nervous System RAAS (Renin-Angiotensin-Aldosterone System) → Adverse Effects Vasoconstriction, Sodium/Water Retention, Myocyte Hypertrophy, Fibrosis This sustained activation creates a vicious cycle, accelerating adverse myocardial remodeling and progressive pump failure.

8. Myocardial Remodeling Process A cascade of structural and cellular changes driven by mechanical stress and neurohormonal activation. Structural Changes Eccentric or concentric hypertrophy, collagen deposition, and chamber dilation. Cellular Dysfunction Calcium mishandling, mitochondrial injury, and reduced contractile efficiency. Arrhythmogenic Substrate The remodeled myocardium promotes electrical instability and arrhythmias.

9. Diagnostic Work-up PART 03

10. Clinical Evaluation & Red Flags Core Symptom Triad Dyspnea Fatigue Fluid Overload Requires structured history, JVP assessment, and monitoring of weight trends. Red Flags (Advanced Decompensation) Hypotension Cool Peripheries Rising Creatinine These signs signal the need for urgent escalation of care.

11. Biomarkers & Imaging: The Diagnostic Cornerstones Biomarkers: NT-proBNP / BNP Levels correlate with filling pressures and provide strong prognostic value. Diagnostic Support: BNP ≥ 300 pg/mL Imaging: Echocardiography The gold standard for quantifying EF, diastolic function, and estimating filling pressures. Advanced Imaging: CMR or CT can clarify infiltrative or ischemic etiologies.

12. Guideline-Directed Drugs PART 04

13. Four Pillars for HFrEF 2022 ACC/AHA Guideline-Directed Medical Therapy (GDMT) ARNI / ACE-I Replaces ACE-I as first-choice RAAS blocker. Beta-Blocker Proven mortality benefit in HFrEF. MRA Reduces mortality and hospitalization. SGLT2 Inhibitor Significant benefit beyond diabetes. Rapid up-titration within weeks is recommended to reduce mortality and hospitalization.

14. Emerging Pharmacotherapy Vericiguat A soluble guanylate cyclase stimulator that reduces cyclic-GMP breakdown. In patients with worsening HF, it reduced the composite endpoint of cardiovascular death or HF hospitalization by 10% . Ferric Carboxymaltose Intravenous iron repletion therapy. Improves symptoms and quality of life in iron-deficient patients (with or without anemia), addressing a common comorbidity.

15. Device & Surgical Options PART 05

16. CRT & ICD: Device Decision Points Cardiac Resynchronization Therapy (CRT) Indicated for patients with: LVEF ≤ 35% LBBB with QRS ≥ 130ms OR QRS ≥ 150ms Implantable Cardioverter-Defibrillator (ICD) Indicated for primary prevention in: EF ≤ 35% NYHA Class II-III After ≥ 3 months of optimal GDMT Shared decision-making is crucial to balance sudden death prevention against device-related complications.

17. Mechanical Circulatory Support (MCS) Temporary MCS Devices like Impella or ECMO are used to stabilize patients in cardiogenic shock while determining the reversibility of the underlying condition. Durable LVAD A Left Ventricular Assist Device serves as destination therapy for inotrope-dependent, stage D patients ineligible for transplant, offering 5-year survival approaching 60% .

18. Special Scenarios & Wrap-up PART 06

19. HFpEF Management Nuances No single drug improves mortality; management is focused on a comprehensive approach. Comorbidity Control SGLT2 inhibitor: Shown to reduce HF hospitalizations. Blood Pressure: Tight control is paramount. Atrial Fibrillation: Rate and rhythm management. Obesity: Weight management strategies. Lifestyle Interventions Exercise Training: Improves functional capacity. Dietary Sodium Restriction: A cornerstone of self-care. Both improve functional capacity and quality of life scores.

20. Addressing Specific Etiologies Cardiac Amyloidosis (ATTR-CM) Diagnosed via PYP scan or mass spectrometry. Tafamidis stabilizes TTR tetramers, reducing all-cause mortality by 30% . Iron Deficiency Screen all HF patients (TSAT < 20%). Intravenous iron (e.g., ferric carboxymaltose) reduces hospitalizations and improves fatigue.

21. Pregnancy & Drug Safety Contraindicated Drugs ACE Inhibitors (ACE-I) Angiotensin Receptor Blockers (ARNI) Mineralocorticoid Receptor Antagonists (MRA) Preferred Therapies Hydralazine-nitrates combination Metoprolol (beta-blocker) Management requires a multidisciplinary team and delivery in a tertiary center with cardiac ICU availability.

22. Lifestyle & Self-Care Pillars Empowering patients is key to long-term success. Daily Weight Medication Adherence Sodium < 2g Fluid Restriction Cardiac Rehab Immunizations Teach-back education and remote monitoring can reduce 30-day readmission rates by up to 25% .

23. Palliative & Transitional Care Early Advance Care Planning Clarify goals of care while the patient can participate, especially as EF deteriorates despite maximal therapy. Seamless Hospice Referral Focus shifts to comfort, quality of life, and caregiver support, avoiding aggressive and often futile interventions at end-stage.

24. Quality Metrics & Continuous Audit 30-Day Readmission Rate A key indicator of care quality and transition success. GDMT Uptitration Rates Measures adherence to guideline-directed therapy. Patient-Reported Outcomes Captures quality of life and symptom burden. Institutional dashboards feed continuous quality improvement cycles, ensuring guideline adherence and equitable care.

25. Future Directions in HF Management (2025+) Gene Editing Targeting sarcomeric mutations that cause inherited cardiomyopathies. Cardioprotective mRNA Therapies Delivering instructions to produce protective proteins within cardiac cells. AI-Guided Monitoring Using artificial intelligence to analyze hemodynamic data for personalized therapy.

26. Take-Home Algorithm for HF Management 1. Confirm Phenotype (HFrEF, HFmrEF, HFpEF) ↓ 2. Initiate Four Pillars Rapidly (ARNI/ACE-I, BB, MRA, SGLT2i) ↓ 3. Screen for Iron Deficiency & Cardiac Amyloidosis ↓ 4. Escalate to Device (CRT/ICD) or MCS as Needed ↓ 5. Integrate Lifestyle & Palliative Care Throughout Regular audit and patient engagement close the loop for optimal long-term outcomes.

27. THANKS! Dr/Ahmed Khaled 2025