Heart Failure

Disease State Overview

​​Heart failure is a condition where the heart is unable to supply enough blood to meet metabolic demands either due to a filling issue (diastolic dysfunction) and/or a contracting issue (systolic dysfunction). The most common cause of heart failure is coronary artery disease (CAD). Other risk factors include hypertension, diabetes mellitus, metabolic syndrome, heart arrhythmias, and myocarditis (commonly caused by a viral infection). Heart failure may also result from various toxicities including chronic alcohol consumption, cocaine abuse, and cardiotoxic medications such as those used in cancer therapies.  

​Diastolic Heart Failure 

• ​Heart is unable to fill with enough blood and therefore cannot pump adequate blood volume 
• Heart Failure with Preserved Ejection Fraction (HFpEF); Left Ventricular Ejection fraction >50%

Systolic Heart Failure 

• ​ Heart is unable to contract hard enough and therefore cannot pump adequate blood volume

• Heart Failure with Reduced Ejection Fraction (HFrEF); ​Left Ventricular Ejection fraction < 40%

​Heart failure is staged and classified as outlined below. The ACC/AHA stages of heart failure emphasize the development and progression of disease whereas the NYHA classes focus on exercise capacity and the symptomatic status of the disease. These classifications also guide medication treatment.  

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​Heart Failure Stages and Classifications 

ACC/AHA Stage of HF 

A - at risk for HF but without structural heart disease or symptoms of HF 

• • NYHA Functional Classification: None

B - structural heart disease, evidence of increased filling pressures, or risk factors but without signs or symptoms of HF 

• • NYHA Functional Classification: No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. 

C - structural heart disease with prior or current symptoms of HF 

• • No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. 
  • Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. 
  • Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. 
  • Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. 
  • Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. 

D – Marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize GDMT  

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Risk of Condition 

​​Heart failure is a chronic, progressive condition making early diagnosis and proper treatment imperative to slow progression of the disease. Complications of heart failure may include respiratory failure, heart valve dysfunction, arrhythmia's, renal failure, poor quality of life, and even death.  

Medication 

Role of Medication 

The goals of treatment are to relieve symptoms, improve quality of life, slow progression, prevent hospitalizations, and reduce mortality. Pharmacologic management of HFpEF is vastly different than HFrEF in that HFpEF management focuses more on controlling concomitant conditions and managing heart failure symptoms while HFrEF treatment has robust, guideline directed medical therapy (GDMT) recommendations as outlined below. Choice of therapy should be based on multiple factors including heart failure stage and classification, medication side effect profile, insurance coverage, patient preference, patient’s age, comorbid conditions, and concurrent medications.  

Medication Recommendations for Treatment of HFrEF 

• Stage A
  • • ARNI (preferred over ACEi or ARB)  
      • sacubitril/valsartan (Entresto)
      OR

• • • ACEi (preferred over ARB) or ARB  
      
      • ACEi (captopril, enalapril, lisinopril ramipril)  
      • ARB (candesartan, losartan, valsartan) 
• Stage B

• • ARNI (preferred over ACEi or ARB)  
    • sacubitril/valsartan (Entresto) 
    OR

• • ACEi (preferred over ARB) or ARB  
    • ACEi (captopril, enalapril, lisinopril, or ramipril)  
    • ARB (candesartan, losartan, or valsartan) 
    AND
  • Evidence-based Beta Blocker 
    • bisoprolol, carvedilol or metoprolol succinate 
• Stage C
  
  • ARNI (preferred over ACEi or ARB)  
    • sacubitril/valsartan (Entresto)
    OR

• • ACEi (preferred over ARB) or ARB 
    • ACEi (captopril, enalapril, lisinopril, or ramipril)  
    • ARB (candesartan, losartan, or valsartan) 
      • For patients with persistent volume overload, NYHA Class II-IV, titrate:
        • Loop diuretics such as bumetanide, furosemide, and torsemide

• • Evidenced-based Beta Blocker 
    • bisoprolol, carvedilol or metoprolol succinate 
      • For persistently symptomatic African-American patients despite ARNI/beta-blocker/mineralocorticoid antagonists/SGLT-2 inhibitor, NYHA class III-IV, add: 
        • Hydralazine + Isosorbide dinitrate 
  • Mineralocorticoid Antagonist 
    • Eplerenone or spironolactone 
      
      • For patients with resting heart rate ≥ 70, on maximally tolerated beta-blocker dose in sinus rhythm, NYGA class II-III, add:  
        • Ivabradine
  • SGLT-2 Inhibitor 
    • Dapagliflozin (Farxiga), empagliflozin (Jardiance), or sotagliflozin (Inpefa)
      • For high-risk patients already on optimal GDMT with worsening HF as evidenced by a HF hospitalization or requirement for intravenous diuretics, add:
        • Vericiguat
• Stage D
  • Advanced Measures  
    • Palliative care, transplant, LVAD, investigational studies
      • *Digoxin is not commonly used in modern HFrEF management; it is most seen used as a rate control agent in heart failure patients with concomitant atrial fibrillation (Afib) 

ACEi= angiotensin converting enzyme inhibitor; ARB = angiotensin II receptor antagonist; ARNI = angiotensin receptor neprilysin inhibitor; SGLT-2 = sodium-glucose cotransporter-2 

Adherence 

​​To optimize adherence to heart failure treatments, patient and caregivers should both be educated on the disease state itself and how their medications play a role in managing it. Patients may also benefit from understanding the specific benefits their medications offer. All guideline directed medical therapies (GDMT) listed above have been shown to reduce hospitalizations and provide symptom relief. All therapies (excluding diuretics, digoxin, and ivabradine) have proven mortality benefit. It is important to also discuss any barriers to adherence and provide appropriate solutions. You may use the DRAW tool within the Worksheets & Forms category in this Knowledge Base.

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Monitoring 

Ongoing monitoring and frequent follow-up is crucial for patients with heart failure. Follow-up should involve medication titration to the target or maximumly tolerated dose. Patient’s renal function and potassium should be monitored regular, with closer follow-ups after medication initiation and titration. Patient’s volume status, blood pressure, and heart rate should also be monitored closely to assess medication benefit, side effects, and disease progression.  

Pharmacists should provide the following education to patients regarding self-monitoring: 

• Daily weighing: Encourage the patient to weigh themselves in the morning after they urinate, but before breakfast, to check for weight gain caused by fluid overload. Encourage them to call their healthcare provider if their weight goes up by 2 or more pounds in a day or 5 pounds in a week. 

• Symptom tracking: Encourage the patient to track symptoms such as fatigue, shortness of breath, and pitting edema and to keep a daily log. 

• Blood pressure tracking: Encourage the patient to monitor blood pressure daily and to keep a daily log. Patients should be instructed how to monitor for signs and symptoms of hypotension, including: fatigue, dizziness, clammy skin, blurry vision, and lightheadedness. 

• Quality of sleep: Encourage the patient to track nighttime awakenings and elevate position during sleep. 

Lifestyle Education 

Lifestyle modifications for patients with heart failure can help alleviate heart failure symptoms, slow disease progression, and improve quality of life. Discussion points may include: 

• Encourage regular physical activity for patients who are able as exercise may improve functional status; cardiac rehabilitation may be appropriate for some patients  

• Patients should be counseled on the importance of a low sodium diet (< 3 grams/day) due to the association of dietary sodium and increased risk of fluid retention  

• In patients who smoke recommend smoking cessation and provide counseling on appropriate options and resources  
• Patient’s should be counseled about alcohol intake; excessive alcohol consumption should be recommended against as it can worsen heart failure 
  
  

Additional Points 

It is important to educate the patient on medications to avoid that may worsen their heart failure (e.g. NSAIDs, non-dihydropyridine calcium channel blockers (verapamil, diltiazem), DPP4-inhibitors, and thiazolidinediones). Patients should be advised to consult with a health care provider prior to starting any new medication 

Resources 

1. Maddox, T, Januzzi, J, Allen, L. et al. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. JACC. 2024 Apr, 83 (15) 1444–1488.  
   https://www.jacc.org/doi/10.1016/j.jacc.2023.12.024 
2. Writing Committee Members; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Card Fail. 2022;28(5):e1-e167. doi:10.1016/j.cardfail.2022.02.010 
   https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001063