Background

Contents Prevention, Diagnosis, Classification, & Staging of Heart Failure »

• 3 types of heart failure: Heart Failure with Reduced Ejection Fraction (HFrEF), Heart Failure with Preserved Ejection Fraction (HFpEF), and Right Sided Heart Failure (RHF)
• Effective management involves comprehensive, multidisciplinary care
• While this pathway’s major focus is on HFrEF, the content outlines, in appropriate sections, unique considerations for HFpEF and RHF
• Hypertension control, dietary compliance, reduced salt intake apply to all types of heart failure
• The optimal care of patients with HFrEF involves a commitment to guideline directed medical therapy (GDMT) and a multidisciplinary care team
• Primary care has a vital role in providing holistic, person-centered care from first symptoms to end of life
• This document is intended to provide guidance to support primary care providers and the collaborative team on heart failure diagnosis and management

Prevention, Diagnosis, Categorization, and Staging of Heart Failure

« Background Contents Medications »

Prevention

To prevent the initial development of heart failure^[1]:

• Effectively manage contributing comorbidities such as diabetes and hypertension
• Regular physical activity (exercising at least 5 d/wk)
• Maintaining a healthy body weight
• Not smoking
• Eating fruits and vegetables (4 servings/day) and moderate alcohol intake (1 drink/day)

Diagnosis

Initial evaluation of patients with symptoms or signs suggestive of HF includes clinical assessment (history and physical exam), electrocardiogram, echocardiogram, blood tests, and chest radiograph.

Early measurement of brain natriuretic peptide (BNP) or N-terminal proBNP levels is suggested in patients with suspected HF in whom the diagnosis is uncertain. BNP levels > 400 ng/L imply a cardiac cause with a sensitivity of 95-97% and a negative predictive value of 90-97%. While BNP levels < 100 ng/L imply a pulmonary cause, BNP levels 100-400 BNP are neither sensitive nor specific for excluding or confirming HF^[2,3].

Categorization of Heart Failure ^4,5

Heart Failure with Reduced Ejection Fraction (HFrEF)

EF less than or equal to 40%. Mortality benefit proven with Carvedilol, long acting metoprolol (succinate), and bisoprolol, ACE inhibitors/ARBs or Spironolactone

Heart Failure with Preserved Ejection Fraction (HFpEF)

A clinical syndrome in which patients have symptoms and signs of HF, a normal or near normal left ventricular ejection fraction (LVEF at least 50 percent), and evidence of cardiac dysfunction as a cause of symptoms (eg, abnormal left ventricular filling and elevated filling pressures).

• Approximately 50% of patients with heart failure have an EF> 50%, a proportion that is increasing over time. Dominant form of heart failure in the elderly.
• No therapies with proven mortality benefit, unlike HFrEF.

Right Sided Heart Failure (RHF)

RHF is a clinical syndrome in which symptoms and signs are caused by dysfunction of the right heart structures (predominantly the right ventricle [RV], but also the tricuspid valve apparatus and right atrium) or impaired vena cava flow, resulting in impaired ability of the right heart to perfuse the lungs at normal central venous pressures.

• Commonly seen with HFrEF (48%) and HFpEF (20-40%) and, when present, independently associated with increased morbidity and mortality, thus important to ensure actively managed in conjunction with treatment of left heart failure
• Cardiac MRI more accurate than echocardiogram in assessing RV structure and function
• Cardiac catheterization is definitive test, if non-invasive testing inconclusive

Common Classifications of Heart Failure

New York Heart Association (NYHA) Functional Classification

ACC/AHA Stages of Heart Failure

Medications

« Prevention, Diagnosis, Categorization, and Staging of Heart Failure Contents Care Delivery »

Guidelines for Initial Medication Selection in Heart Failure with Reduced Ejection Fraction (HFrEF) Based Primarily on Clinical Findings ^[4,6,7]

Guideline-Recommended Indications for ARNI and Ivabradine Use

Contraindications and Cautions for Ivabradine

Dose Adjustments of Sacubitril/Valsartan for Specific Patient Populations

Contraindications and Cautions for Sacubitril/Valsartan

Recommended Indications/Contraindications for Vasodilators ^[3,4]

Recommended Indications/Contraindications for Cardiac Glycoside ^[4]

New Therapies for HFrEF: SGLT-2i (Sodium Glucose Cotransporter-2 Inhibitors

SGLT-2 Inhibitors, which were originally used for diabetic control, now have an increasing role in HFrEF care.

Mechanism: The primary mechanism for glucose regulation of these medications is through inhibition of reabasorption of glucose in the kidney.

Impact: Of note, all 3 SGLT-2i show benefit in HF with DM^[8,9]. Please note table below.

Effect of SGLT-2i on Select CV Outcomes in Placebo Controlled Trials ^[8]

When to Consider and How to Prescribe

In patients with and without diabetes, with HFrEF or worsening CKD, (Step 4 if still symptomatic on ARNI, B-Blocker, Mineralocorticoid Receptor Antagonist) consider adding a SGLT2 Inhibitor if GFR >30.

If the patient’s HbA1C is < 8% and are taking agents which can cause hypoglycemia (e.g. insulin, sulfonylureas/metaglitinides), their regimen may need to be modified to avoid hypoglycemia. For those with HbA1C > 10%, attention should be paid towards excessive glucosuria induced diuresis and an increased incidence of GU/mycotic infections.

If not able to tolerate or GFR <30, add a Glucagon-like peptide 1 receptor agonists (GLP-1 RAs), which are more easily tolerated without the risk of DKA or amputations.

Of note, a SGLT-2i diabetic medication, Dapagliflozin (Trade: Farxiga), was FDA approved10 in May 2020 for adults with NYHA Class II-IV HFrEF with and without DM to reduce the risk of cardiovascular death and heart failure hospitalizations. In 2019, in the Dapagliflozin And Prevention of Adverse-Outcomes in Heart Failure (DAPA-HF) trial^[11], a randomized, double-blind, placebo-controlled study of nearly 5,000 HFrEF patients who received 10 mg daily of dapagliflozin in addition to standard care exhibited fewer cardiovascular deaths, hospitalizations for heart failure, and urgent heart failure visits compared to controls receiving the placebo after 18 months.

26% relative risk reduction and 5% absolute risk reduction for composite outcome of CV death or the worsening of HF (triggering hospitalization or urgent visit requiring IV diuretics).

NNT was 21 for death or hospitalization for HF or urgent visit.

Findings were similar in those with and without diabetes.

Dapagliflozin is covered through a majority of payers. Of note, costs $589 per month ($7,068 annually), without discount¹².

Contraindications and Cautions for Dapagliflozin ^[9,13]

Vaccinations for Heart Failure Patients

Care Delivery Steps & Clinical Integration Models

« Medications Contents Testing & Referrals »

A wide-variety of team members can be involved in the diagnosis, severity classification and care of heart failure. Please see the table below for care delivery steps.

Below are potential team members and options to integrate primary and advanced care for heart failure patients.

Team Member Acronym Legend

Testing & Referral

« Care Delivery Steps & Clinical Integration Models Contents Initial and Subsequent Office Visit Templates »

Use of BNP in Heart Failure ^[3]

B-type natriuretic peptide (BNP) and N-terminal pro–B type natriuretic peptide (NT-proBNP) are the most studied biomarkers in heart failure.

BNP is released in direct relationship to myocardial wall stress and plays a role in diagnosis and prognostication.

Higher concentrations of BNP or NT-proBNP in an ambulatory patient with HFrEF informs high risk, particularly when the concentrations are rising. Current clinical practice guidelines give a Class I recommendation to measure NT-proBNP or BNP to support a clinical diagnosis of HF, to assess disease severity, or to establish prognosis.

More recently, biomarkers have been examined for their role as a marker of clinical responsiveness to GDMT for HFrEF. Patients whose natriuretic peptide concentrations do not fall with GDMT (“nonresponders”) have a worse prognosis.

Measurement can support clinical judgment with respect to prescription of GDMT, and to provide helpful objective data regarding decision-making for referral to advanced HF therapies. In the setting of worsening symptoms, the reassessment of BNP or NT-proBNP may be informative.However, serial assessment of BNP or NT-proBNP to guide aggressive titration of GDMT is not indicated and not warranted.

Several factors may interfere with the interpretation of natriuretic peptide concentrations:

• Severe renal dysfunction
• Sacubitril/valsartan (Entresto) will increase BNP levels due to neprilysin inhibition, and concentrations tend not to return to baseline despite chronic therapy. BNP concentrations will increase (while NT-proBNP will most often fall) with ARNI therapy, and thus it may be more prudent to check only NT-proBNP in patients on ARNI.
• Also, transient increases in natriuretic peptide levels have been documented in the initial phases of beta-blocker initiation; such changes should not preclude up-titration of beta-blocker therapy, which should be guided by patient tolerance instead of asymptomatic change in natriuretic peptide levels.

Palliative Care ^[26]

Palliative care is beneficial at any stage of a serious illness²⁷. Palliative care, and the medical sub-specialty of palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and their family.

Referral Criteria

Consider a specialty-level palliative care referral for patients who meet any of these criteria:

• NYHA class III/IV symptoms with frequent heart failure readmissions
• Anxiety or depression adversely affecting patient's quality of life or their ability to manage their illness
• Assistance with decision-making regarding advanced therapies (VAD, transplant, home inotropic therapy)

Referral Options for Palliative Care within MSHS

Patients with Congestive Heart Failure may be referred to one of two practices. The services provided at each location are identical; please choose the location that is most convenient to your patient.

To make a referral to the Martha Stewart Center for Living at 1440 Madison Avenue, please call: 212-241-1446

To make a referral to the Martha Stewart Center for Living Downtown at Union Square, please call: 212-844-1712

Remote patient monitoring facilitates care. Strongly consider use of pulmonary artery pressure monitoring (CardioMEMS) to reduce heart failure hospitalization rates.

Remote Patient Monitoring

Remote patient monitoring is important in chronic disease management for select patients.

Connected Hearts Program

• Using Omron® devices for home blood pressure measurement and weight measurement via Bluetooth data hub transmission to Epic EMR flowsheet

• Clinical Pharmacist monitoring data and intervening directly with patients on medications, diet and care coordination

CardioMEMS

• Consider use of pulmonary artery pressure monitoring (CardioMEMS) to reduce heart failure hospitalization rates, for both HFrEF and HFpEF[19]

• Many current Mount Sinai patients (especially HFpEF and RHF) benefit from this monitoring

Pharmacy

Pharmacists are a key part of the care team for chronic disease management including heart failure, diabetes, and COPD. The team of pharmacists is rapidly expanding in primary and specialty care. They are credentialed providers that can prescribe and adjust medications through the Collaborative Drug Treatment Model^[20]

Referrals to pharmacists are appropriate for:

• Uncontrolled chronic diseases, such as hypertension, diabetes, heart failure, asthma, COPD
• Polypharmacy
• Medication Reconciliation
• Medication Adherence

Home Health

Referrals for Home Health should be handled through the designated Home Health nurse coordinator, a member of the care management team.The Home Health nurse coordinator will assess the patient’s needs and determine appropriateness of Home Health.Telephonic education and reinforcement can be also be delivered by the Nurse Clinical Coordinator. The Home Health RN will not provide patient interventions, they will refer to the nurse care coordinator, if needed.

Providing Home Health nursing and therapy can promote recovery in vulnerable HF patients with post-hospital syndrome and potentially reduce readmissions^[21]. Nursing interventions can include various educational components, including recognition of HF symptoms with an action plan, dietary guidelines, medication management, and weight monitoring.

Care Coordination in Heart Failure at MSHS^[22]

The medical complexity inherent in most patients with HF generally requires the involvement of multiple clinicians across many care settings. Interdisciplinary, team-based care may be the most effective approach to complex HF care. Mount Sinai Health Partners Care Management social workers and nurses partner with patients, family caregivers, and providers to identify and address known risk factors that can impact patients’ health. Care Management intervention includes:

• A comprehensive assessment of the patient’s understanding of and ability to manage their illness and the psychosocial issues that impact their care
• Development of a comprehensive care plan to set goals to optimize health and quality of life

Referral criteria may include those with:

• Multiple no-shows
• Unexplained non-adherence to medications, testing or treatment
• Demonstrated difficulty managing symptoms and/or disease processes (including those newly diagnosed)
• Frequent admissions or ED visits that may be preventable with additional support
• Complex family dynamics that deplete the provider
• Difficulty accessing needed community-based care
• A high “worry score” (patients you as the provider are most worried about from visit to visit)

How to Refer to Care Management

Use the MSHP Care Management Referral in Epic (order #391414)
or
Send an email
or
Call 212-241-7228

Providers who refer patients can expect prompt and efficient processing of their referral, communication about referral processing and assignment through the Epic Inbasket, and follow up from clinical staff within one week of assignment.

Behavioral Health ^[23]

Patients should be screened for depression using the PHQ-2/PHQ-9 and referred to psychiatric services, as indicated, through their current care pathway depending on their clinic.

Individuals with CHF are 2-5 times more likely to have anxiety and depressive disorders compared with the general population^[24]. Patients with chronic medical illness and a co-morbid psychiatric diagnosis have poorer quality of life, increased functional disability, and increased mortality, to name a few. Increased recognition of treatment of these comorbid conditions is essential.

Rapid Follow Up Clinics (RFU Clinics)

• RFUs can provide additional post-discharge support
• Treatment in specialized HF clinics using nurse intervention reduces readmission frequencies and improves quality of care for HF patients^[25]
• For referrals contact the individuals listed below

MSHS Heart Failure Rapid Follow Up Clinics Referral Contacts

Initial and Subsequent Office Visit Templates

« Testing & Referrals Contents References »

Initial Visit: Confirm Diagnosis and Etiology and Initiate Therapy

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