imPAct Heart Failure Awareness

imPAct Heart Failure Awareness

In order to diagnose, treat and manage heart failure, it is first important to understand the clinical manifestations that allows us to recognize the disease. The signs and symptoms may initially vary from dyspnea, fatigue and exercise intolerance. As heart failure progresses, patients may develop dyspnea at rest, particularly at night or with lying down. The cause of symptoms is commonly due to refractory fluid overload that leads to pulmonary congestion, peripheral edema, and elevated jugular venous pressure. When we see patients suspected of heart failure, blood testing and imaging can help us clarify if heart failure, or something else may be leading to our patients’ symptoms.

Initial labs and imaging should include a Complete Blood Count, kidney function/electrolytes, liver functions, B-type natriuretic peptide and/or N-terminal pro-BNP, chest radiograph and an electrocardiogram (EKG). Labs may show impaired renal function with a low GFR and/or an elevated creatinine, due to decreased renal perfusion, increased renal venous pressure and/or right ventricular dysfunction. As heart failure becomes advanced, hyponatremia and hypoalbuminemia may develop. Chest radiographs may show pulmonary edema, pleural effusions, and/or pulmonary vascular congestion. EKGs may show Q waves, ST and T wave abnormalities, or other arrhythmias. There is no EKG finding consistent with heart failure. However, certain arrhythmias like atrial fibrillation for example can lead to or contribute to the development of heart failure.

In the 1970s, a majority of heart failure causes could be attributed to hypertension and coronary artery disease including myocardial infarctions. Although they remain responsible for a significant portion of heart failure, other causes have been linked to cigarette smoking, obesity, thyroid dysfunction, and valvular disease. Other less common causes may include myocarditis, peripartum cardiomyopathy, HIV infection, connective tissue disease, substance abuse, among others.

Heart Failure has been classified into two categories based on the left ventricular ejection fraction (LVEF): Heart Failure with preserved Ejection Fraction (HFpEF—formerly diastolic or right sided heart failure) and Heart Failure with reduced Ejection Fraction (HFrEF—formerly systolic or left sided heart failure). A preserved LVEF is estimated at roughly >55-60%, while reduced is considered roughly <40%. An echocardiogram is a key test in identifying which type of heart failure may be present in your patient when it is suspected. HFrEF, particularly when LVEF is <25-30% is associated with a worse prognosis and the goal of treatment is to reduce progression and if possible, reversal of the decreased LVEF.

Treating heart failure coincides with treating its underlying causes, such as those mentioned above. In patient with HFrEF, randomized control trials support the use of a diuretic, an angiotensin system blocker (angiotensin receptor-neprilysin inhibitor [ARNI], angiotensin converting enzyme [ACE] inhibitor, or angiotensin II receptor blocker [ARB]), a beta blocker and hydralazine plus nitrate to improve symptoms and prolong survival.

Additionally, patients should be educated to take their medications regularly, take their daily weights to assess for fluid accumulation, improve diet and limit sodium to <2000 mg per day, smoking cessation, alcohol restrictions, avoiding illicit drugs and any other offending agents.

Managing heart failure involves a team-based approach that includes the patient, their primary care provider and/or their cardiologist. A prompt referral is typically indicated when patients have persistent or worsening symptoms of heart failure including excessive fluid overload including pulmonary edema, severe dyspnea at rest, and/or hypoxia, which patients will typically need to be admitted to the hospital for IV diuresis. A mentor once told me, the most common reason for hospitalization due to decompensated heart failure, is having had a prior hospitalization for decompensated heart failure. With prevention, recognition, treatment, and management of heart failure we can help our patients live longer and healthier lives with our awareness of heart failure.

About the Author - Josh Loew

• Went to PA school at St. Catherine’s University (St. Kate’s)
• Primary practice is Family Medicine in New Hope, and moonlights in Urgent Care in Maple Grove, Blaine, Minnetonka and Elk River for North Memorial Health
• Former Director of Outreach for AAPA’s Student Association
• Currently a Minnesota Delegate to AAPA’s House of Delegates representing MAPA
• Current Co-chair of the Leadership and Development Committee and member of the Legislative Committee within MAPA