Welcome to Lesson 2 of ACC's Heart Failure Accreditation Overview Course. This learning activity was developed by myself. I am Liza St. Clair, and I will also be narrating this presentation. The purpose of this lesson is to provide an understanding of the pathophysiology and treatment of heart failure. Our objectives for this lesson will be to define the types of heart failure, identify what causes the disease as well as how to familiarize ourselves with the frequent symptoms these patients experience, and finally, to review the appropriate treatment options to manage the disease. For those that are not familiar with heart failure, it is important to understand the pathology and physiology of the disease. It is important to note that specific language was established to identify types of heart failure in the 2013 guidelines. The heart failure population is split into two types of heart failure. The first is reduced ejection fraction or HFREF, and the second is heart failure with preserved ejection fraction or HFPEF. We no longer use the terminology of congestive in terms of defining or describing heart failure. Education provided to both patients and providers should be utilized and use this language as these are how the guidelines are written and how clinical pathways are developed. More recently in the spring of 2022, new heart failure guidelines were updated and published. Two categories of heart failure were added and defined. These new categories identified those that recovered with an improved EF after an initial finding of an EF less than 40% and a population that is borderline for developing HFREF. The top 10 most important takeaways from the new 2022 heart failure guidelines include an improved definition of heart failure and LVEF, the addition of SGLT2 inhibitors as an additional pillar of heart failure guideline directed medical therapy that serves for both the HFREF and HFPEF population. Since the treatment of heart failure with GDMT involves polypharmacy and the expenses for these medications can get very high, value statements that analyze cost-benefit were added to provide additional guidance. It reinforced the need to refer patients to heart failure specialists for those with advanced diseases and how to prevent heart failure. The guidelines also address treatment for heart failure with specific core morbidities and causes of heart failure. There are many clinical conditions that can cause and put a patient more at risk for developing a heart failure. This includes hypertension or uncontrolled hypertension that can be systematic or pulmonary, myocardial infarction, valve disease, viral dilated or hypertrophic cardiomyopathy, diabetes, congenital heart disease, drug and alcohol use, and immune disorders such as amyloid or sarcoid. These patients can display a vast continuum of symptoms and will impact their daily life. Most commonly, we see these patients do suffer from dyspnea or orthopnea, loss of appetite, nausea and vomiting. Volume overloaded patients will present with edema. Patients in severe heart failure can also present with multi-system organ disease, the need for advanced therapies, have multiple hospital admissions, and an overall poor quality of life. This diagram may look very intimidating and complex. However, the pathophysiology of heart failure is simple. The main takeaway here is that when there is injury to the myocardium or the heart muscle, there will be an initial fall in left ventricular function and performance. This causes an activation of the renin-angiotensin system and sympathetic nervous systems, which initiates a cascade of toxins, chemicals, and hormones being released into the body system that cause myocardial toxicity, peripheral constriction, hemodynamic alterations, and lastly, resulting in remodeling and progressive worsening of LV function, exacerbating heart failure, and increase the patient's risk for morbidity and mortality. The heart failure population is split evenly with those with reduced ejection fraction and preserved ejection fraction. In normal left ventricular function, the squeeze of the left ventricle, which serves as the pumping or systolic function of the heart, has a normal ejection fraction of above 40%, and a normal relaxation or filling of the heart in the diastolic phase of the heart. In heart failure patients with reduced ejection fraction, as referred to as HFREF, the patient will have a dilated left ventricle where the pump is weakened in the systolic phase, thus also known as systolic heart failure. HFREF is indicated by an ejection fraction of 40% or less, and the relaxation of the myocardium is either normal or abnormal in the diastolic function. This results in the blood backing up and overloading the heart. On the flip side, heart failure patients can also present with a preserved ejection fraction referred to as HFPEF. The patient will have a normal ejection fraction and abnormal filling or relaxation. This could be due to stiff or scarred myocardium, which is sometimes referred to as a thickened myocardium. Therefore, this results in diastolic heart failure, as the abnormal relaxation of the heart will not allow it to fill the heart before it squeezes. The documentation of the Heart Failure Staging and New York Heart Association functional class is imperative to identify in all heart failure patients. This sets the platform and basis to define the appropriate clinical pathway for the heart failure patient. Heart failure staging and functional class should be an integral part of the facility heart failure program and used as common language among staff caring for the heart failure patient. Heart failure staging and functional class should be included in the education provided to the patient, any documentation, prescribing guideline-directed medical therapy, and order sets implemented. If this is not something providers are using in current documentation, this is a definite educational opportunity. The benefits of improved documentation can result in better reimbursement, but also for better communication and improved patient outcomes. On the left-hand side are stages of heart failure from A to D. It is important to remember that once the stage has been reached, the patient cannot regress to a previous stage. Stage A are those patients who are at high risk for heart failure, but without structural heart disease or symptoms of heart failure. These include patients with comorbid conditions such as hypertension, coronary artery disease, and diabetes. Stage B, structural heart disease, but without symptoms of heart failure. So these patients have never had symptoms. They've never been admitted for heart failure. However, they have had some structural damage or injury, or there has been changes to the heart. Stage C is the most common or found within the inpatient or observation setting. These are patients who have structural heart disease with prior or current symptoms of heart failure. Lastly, stage D are those patients with an end-stage heart failure or refractory heart failure, such as transplants or continuous IV ionotropic therapy. On the right-hand side are the NYHA functional classes. The functional classes are labeled 1 through 4. Class 1 are those patients who are asymptomatic. Class 2 are those patients that are symptomatic with moderate exertion. Class 3 are those patients that are symptomatic with minimal exertion. And lastly, class 4 are those patients that are symptomatic even at rest. Unlike heart failure staging, NYHA functional classification is different. Once a patient has reached an NYHA class, the patient cannot go back, and we hope that we can bring them back to a class 1. Many patients will present at an NYHA functional class of 3 or 4. During the course of treatment and hospitalization, the goal will be to return the patient to class 1 so that, once again, they are asymptomatic and can return home. If patients worsen or stalls in their progression of reaching class 1, providers should be notified and a review of the patient's treatment may need to be adjusted to ensure a positive clinical trajectory of the patient's care. To further support guideline-directed medical therapy, this illustration demonstrates how different heart failure therapeutic options play a role and affect the disease. As noted in orange, device therapy such as cardiac resynchronization therapy, implantable cardiac defibrillator, left ventricular assist device, and diuretics, and medications such as evabredine, digoxin, hydralazine isosorbide dinitrate impacts the hemodynamic and myocardial failure. And as noted in teal, beta blockers, ACE inhibitors, angiotensin blockers create a blockade of neurohormonal activation and prevent cardiovascular failure. This is the 2013 guideline-directed medical therapy diagram from the 2013 heart failure guidelines. The new 2022 guidelines modify the diagram to reflect the new recommendations and protocols to treat those diagnosed with heart failure throughout all stages. In many cases, those that are hospitalized due to heart failure will be in stages C and D, and clinicians should be familiar with these protocols. Most importantly, this new diagram stresses the importance of continuing GDMT and optimizing dosing, patient education, and address the patient's goals for treatment. This is a class one recommendation and should be performed unless contraindicated. To achieve optimal guideline-directed medical therapy, not only do you have to ensure that heart failure patients are prescribed oral medical therapies, but that they are effective and at an optimal level that the patient can tolerate. Patients in the inpatient and outpatient setting need to be aware that patients should be uptitrated on their heart failure medications along with more frequent visits and laboratory testing to ensure these medications are not causing any adverse effects. Frequent vital signs may be required and adjustments or different medication classes may be needed. Renal function and electrolytes need to be monitored closely. Notifying patients and family members regarding the importance of their medications is extremely important. Patients should be aware that these medications may make them feel tired or weak, which is normal, especially during the initial initiation of a beta blocker and ACE inhibitors. Sudden discontinuation of their heart failure medications without consulting their physician first is strongly discouraged. Laboratory adjustments can be made in small increments, so rather than stopping a medication completely because they are slightly hypotensive, down titrating the overall dose or alternating a dose may be a preferable option, then returning the patient back to the optimal dose that's already been achieved. The I-NEED-HELP acronym was developed in 2017 and specifically designed to give some objective guidance in identifying heart failure patients in need of advanced therapy options, such as LVAD, heart transplant, or palliative care. It is a screening process that can be implemented and used as a guide to make an objective decision of when to refer a patient to more specialized care. It aids in identifying patients who would begin advancing in their disease and should seek an evaluation by a heart failure specialist or cardiologist or refer to an advanced heart failure program that offers advanced therapies. A tough reality here is that not all patients are candidates for advanced therapies. Advanced therapy options is more available for the HFREF population. Unfortunately, a heart transplant and LVAD are not typically available to the heart failure population with preserved ejection fraction. Palliative care is an option of course for all patients with a pure focus on symptom management which may include the use of inotrope or hospice. This concludes lesson 2 of 4. Thank you for your participation.

ACC's Heart Failure Accreditation Overview Course

pathophysiology of heart failure

types of heart failure

2013 guidelines

2022 updated guidelines