HFpEF - Diastolic CHF
Heart Failure with PRESERVED Ejection Fraction
The heart walls are stiff causing impaired dilation/relaxation (the pump has trouble filling with blood, leading to back up in lungs and legs).
Diagnosis
EF ≥ 50% on ECHO
+
Signs/Symptoms of CHF
+
Exclusion of other causes
FOR DOCUMENTATION, NEED TO BE SPECIFIC and INCLUDE:
Decompensated = exacerbation needing increased/IV diuretics
Compensated = no exacerbation and continuing home therapy
Laterality: Left or Right sided HF
Example: Decompensated, left-sided HFpEF
(Also okay: Left-sided HFpEF Exacerbation)
Impaired Relaxation/Diastolic Dysfunction
NOT all patients who have “Impaired Relaxation/LV diastolic dysfunction” on Echo have HFpEF.
*They must also have SIGNS/SYMPTOMS*
Most ELDERLY patients will have diastolic dysfunction, BUT can only be diagnosed with HFpEF if they have signs/symptoms or a highly predictive HF2PF score of ≥ 6.
How is HFpEF Diagnosed?
GOLD STANDARD for diagnosis is right heart cath with elevated pulmonary capillary wedge pressure BUT this is rarely done due to easier indirect ways of diagnosing HFpEF:
-Clinical Diagnosis + Echo
or
-HF2PF Calculator + Echo
How can you clinically diagnose HFpEF?
At least one symptom of HF (dyspnea, orthopnea, fatigue, etc) AND other supporting signs (edema, lung crackles, JVD, elevated BNP, vascular congestion on CXR, etc)
+
ECHO with EF ≥ 50%
+
NO other cause for the symptoms
(Pulm embolism, fluid retention from liver/renal disease, severe valve disease, COPD with right-sided HF, Pulm HTN, etc)
IF UNCLEAR then utilize the calculators…
HF2PEF score can help dx HFpEF if clinically unclear
SCORE OF ≥ 6 is diagnostic of HFpEF
If still unclear then can also try the HFA-PEFF score but it’s more complicated.
What factors can lead to CHF exacerbation?
Factors | Questions to ask in HPI |
Noncompliance | Forgot to take meds? How often they forget? Diet changes with more salt (esp. during holiday season)? |
Anemia | Hematochezia, Melena? |
Arrhythmia (A.Fib with RVR) | Palpitations, Lightheadedness? |
Infections | Viral URI, Flu, PNA: cough, runny nose/congestion, sore throat, myalgias, N/V/D? |
COPD exacerbations | Wheezing? Increased cough? Increased sputum production/change in sputum purulence? |
Acute MI | Chest pain/pressure? Radiation to jaw or left arm? Past stress tests or heart caths? |
Renal failure | Missed HD sessions? Urinating less? New meds? CHF can cause cardiorenal syndrome |
Pulmonary Embolism | Pleuritic chest pain, syncope? Prolonged immobility with travel (plane/car) or surgeries/injuries? Unilateral leg swelling? |
Hyper/Hypothyroidism | Weight loss/gain?, Hot/cold intolerance, diarrhea/constipation? |
NSAID use | Ask about all OTC meds cause many have NSAIDs within them |
Iatrogenic w/ excessive IVFs | Always reassess need/put limit for IVFs to avoid causing fluid overload |
What questions/symptoms do you ask about in HPI for CHF?
As always, ask the OPQRST questions!! | |
Ask if they know what may have caused their HF to worsen. When did symptoms start to worsen? | Drug dependence (current/past)? History of MI, stents, CABG? Fam hx of CHF/heart problems? |
💗Dyspnea at rest or exertion? | 💗Swelling/Edema? |
💗Chest Pain? (especially exertional) | 💗Fatigue/Weakness? |
💗Orthopnea (dyspnea when lying flat that improves quickly after sitting up). How many pillows do you sleep with and have you needed more recently or now needing to sleep in recliner? | 💗Paroxysmal Nocturnal Dyspnea? (awaken from sleep with severe anxiety due to dyspnea that slowly gets better after about 30 minutes of sitting upright) |
💗Presyncope or syncope? | 💗Abdominal bloating from hepatic congestion or ascites.? |
What findings do you look for on exam?
💗EDEMA (check HIPS and sacral/truncal area for edema as it is gravity dependent) | 💗Extra heart sounds (S3/gallop) |
💗Tachycardia &/or Irregularly Irregular rhythm (Sinus or A.fib with RVR) | 💗Heart murmurs (aortic and mitral for stenosis/regurg that can cause HF) |
💗Lung crackles (pulm edema) | 💗Decreased breath sounds (effusions?) |
💗JVD &/or 💗Hepatojugular reflux | 💗Ascites with fluid wave |
What labs and diagnostic tests can you order?
💘 EKG, serial TROPONIN x3 (often mild rise or fall due to Type 2 MI), and Echocardiogram (ECHO)
💘 2-view Chest X-ray (1-view if patient not mobile enough): cardiomegaly, pulm edema, pleural effusions
💘 BNP (elevation suggests heart failure is present but look back in chart to see what their prior BNPs have been, if available, and if current BNP is higher or lower than prior)
💘 Lactate, Magnesium level, Phosphorus level, consider D-Dimer (if no active cancer or recent surgery/bleed, and be sure to adjust for age: a D-dimer level that is less than Age x 10 = NORMAL).
💘Consider Procalcitonin if history/exam unclear about CHF vs. PNA as a normal procalcitonin makes the chest x-ray “edema vs. infiltrate” less likely PNA. Consider ABG if pt is in respiratory distress, in respiratory failure (needing 4L of oxygen or more), or if concern for more severe hypoxia or hypercapnia (elevated lactate).
💘 CBC, CMP (often hyponatremia due to volume overload/dilutional effect), HA1c, Lipid Panel, TSH, HIV?, pregnancy test, Digoxin level?
DOES IT MAKE SENSE? Analyzing the collected data and CRITICAL THINKING`
🤔 If the history is dyspnea and there is swelling in the legs with elevated BNP, BUT the lungs are CLEAR and the CXR is fairly normal without much pulmonary edema, then that is NOT fully consistent with left-sided HFpEF and you need to consider other differentials, such as P.E., ACS, etc.
Example H&P Assessment/Plan:
What are the NON-Diuretic treatments for
decompensated CHF?
❥Low-Flow nasal cannula (NC) oxygen, Hi-Flow nasal cannula, BiPap, and Intubation as last resort
❥If hypotensive (<90 systolic or MAP <65), then consult cardio/ICU for possible inotropes (dobutamine) or vasopressors
❥If hypertensive emergency (>180/110), then consult cardio/ICU for possible IV nitroprusside or IV nitroglycerin
Loop Diuretic +/- SGLT2 = main meds for decompensated CHF
❥Start furosemide (most common) - give at least DOUBLE their home dose converted to IV
❥If not on loop or unknown home dose, then start with furosemide 20-40 mg IV BID (elderly, patient can start with 20 mg IV BID)
❥No consistent evidence that continuous infusion/drip is better than IV bolus therapy (more lines for the patient to pull on with the drip).
❥Start SGLT2 if no contraindication (Dapagliflozin 10 mg QD or Empagliflozin 10 mg QD)
Furosemide PO to IV conversion = 2:1 Ex: 40 mg PO = 20 mg IV |
Consults?
Consult | When to consider |
❥Cardiology | If new-onset HF, rising troponins, unknown cause, more severe HF decompensation, or minimal improvement with diuresis after the first 1-2 days. Also needed for HF with hypertensive emergency or hypotension. |
❥Nephrology | If having difficulty with CKD and the diuretics not working effectively. If ESRD, then notify nephrologist immediately as dialysis will be the only way to remove fluid (diuretics will not work). |
| |
Next day progress assessment of CHF
❥Your Attending will want to know if: improvement in symptoms (dyspnea, etc), lung exam/crackles, edema, oxygenation (needing less oxygen), and if good net negative fluid output from diuretics.
❥Check the recorded 24hr fluid INs & OUTs.
Total IN − Total OUT = NET total fluid for 24 hrs.
-Goal removal of fluid = NET NEGATIVE 1-3 Liters per day
-The first 24hr fluid recording might not be accurate as the fluid record from the ER is often not accurate. If urine output is low then get bedside bladder scan to see if urine retention.
How to decide on adjusting loop diuretic dosage
❥A small rise in BUN or Cr is okay but if Cr starts to rise ≥ 0.3-0.5 mg/dl then need to discuss reducing the diuretic dose and possible cardio/nephro consults. Need to consider the clinical context of this AKI as there could be other factors unrelated to CHF causing the AKI that need to be addressed.
❥As long as the kidneys are tolerating the diuretic dosage with good NET NEGATIVE fluid output of 1-3 Liters/day, then it’s okay to continue the same dose.
Progress Note: Assessment/Plan
Decide each day if you are continuing the same diuretic dose or giving more/less and your reasoning
A/P: 1) Acute HFpEF exacerbation
Examples:
💓Continue same dose furosemide as there was adequate net negative output of 1-2L in past 24hrs and kidneys are tolerating it.
💓Increase furosemide dose from 20mg IV BID to 40mg IV BID as there was only net negative 500ml in 24hrs and kidneys are tolerating it. (If on 40mg IV BID, then could increase to 40 TID or 60-80 BID).
💓Decrease furosemide from 40mg IV BID to 20 BID as this patient is elderly and put out net negative 2.1 L in 24 hours which is overly aggressive given their age, rise in BUN, and IV contrast they had from CT angio of chest in ER.
💓The patient has CKD with more diuretic resistance and only 400ml net negative output, so I will increase furosemide 40mg BID to TID and will add on metolazone 2.5-5mg PO x1 (to see if we can get better diuresis). I would also like to consult cardiology or nephrology to see if they agree. (Adding Acetazolamide 500mg IV x3 days to furosemide is a different option).
What are the criteria for hospital discharge?
😍Must see improvement in signs and symptoms (improved dyspnea and edema with less crackles in lungs).
😍Ideally, if they came in with no oxygen then it’s best to avoid sending them home on oxygen as they likely need more diuresis (unless end stage HF).
😍Must be able to ambulate safely without too much dyspnea. Order Physical Therapy evaluation and if needing lots of help then need Skilled Nursing Facility for acute rehab (order Case Manager for SNF placement).
At time of discharge for HFpEF exacerbation
+ Discharge with diuretic: Furosemide dose will depend on baseline dose.
-Furosemide 20-40 mg PO QD-BID
+ The most robust evidence for HFpEF is with SGLT2’s which help to reduce hospitalizations, so start this during hospitalization or upon discharge.
+ Can also add MRA (spironolactone, eplerenone) as there is some evidence it prevents hospitalizations.
+ Give Flu, Pneumococcal 20, and Covid vaccines. Order Home Health Nurse visit.
+ There is some evidence for reduced hospitalization with ARNI. Candesartan is an alternative if ARNI is not affordable. Add one of these agents if already on SGLT2 and MRA and still having exacerbations.
-Beta Blockers and ACE’s have NOT shown consistent benefit for HFpEF. So do NOT tell your attending that you will be continuing these meds for HFpEF cause they will not help.
Speak Medicare: DOCUMENTATION
ADD other related diagnoses:
-Acute Hypoxic Respiratory Failure DUE TO HFpEF exacerbation
-Acute Resp Failure criteria: At anytime, Pulse ox <92%, or pO2 <60, or pCO2 >45 (hypercapnic) AND requiring ≥4L oxygen via NC, or >24% FiO2 (masks or HFNC), or BiPAP, or Intubation.
-Acute on Chronic Respiratory Failure DUE TO HFpEF exacerbation (if on chronic home oxygen therapy)
-Respiratory Acidosis DUE TO HFpEF exacerbation (if seen on ABG)
-Hypoxic Encephalopathy DUE TO HFpEF (if confused on admission OR if you note their mentation has improved with treatment of CHF).
-Acute Myocardial Injury OR Type 2 MI DUE TO HFpEF (if elevated trops)
For reference only: ADMIT ORDERS for decompensated HFpEF
❥Admit: Telemetry. Consider ICU/pulm consultation if requiring lots of oxygen (>5L NC), acidotic, hypotensive or hypertensive emergency.
❥Diet: cardiac diet, 1.5 Liter fluid intake restriction per day. Or keep NPO if in resp distress.
❥Labs: BNP, serial Troponins x3, Lactate, HA1c, Lipid panel, Mag level daily, daily CBC, CMP x1 then daily BMP. TSH, consider D-Dimer, Digoxin level? Consider procalcitonin if history/exam unclear about CHF vs. PNA. Consider ABG if pt is in respiratory distress, hypoxic, or elevated lactate.
❥Diagnostics: EKG and Chest X-ray if not done in ER (or repeat if poor quality), order Echocardiogram
❥Nursing instructions: Strict IN’s and OUT’s (to measure net fluid balance). Avoid foley: use external female cath, condom cath, bedside commode, or urinal. Daily weights.
❥❥Meds: Furosemide 20-40 mg IV BID (or double their home dose). So, if at home they take 20 mg PO BID then give 20mg IV BID. SGLT2: Empagliflozin 25mg QD or Dapagliflozin 10mg QD.
❥IV Fluids: Saline Lock (No fluids!!! Not even KCL as it has fluid in it, give it PO)
❥Consults: Consider cardiology, especially with rising troponins. Sometimes need nephrology or pulmonology.
References