Managing Heart Failure

Documents to Request

• Most recent echocardiogram report (LVEF, diastolic function, valve disease)
• Current medication list with dosages and timing
• Comprehensive metabolic panel within 2 weeks
• BNP or NT-proBNP (baseline and trend)
• 12-lead ECG (for QRS duration — CRT candidacy)
• Recent discharge summary if hospitalized
• Iron studies (ferritin, TSAT) for IV iron candidacy
• Device interrogation if ICD/CRT present

Step 1: Heart Failure Classification and Staging

LVEF-Based Classification (2022 AHA/ACC/HFSA):

ACC/AHA Staging:

• Stage A: At risk (HTN, DM, CAD, cardiotoxin exposure) — no structural disease or symptoms
• Stage B: Pre-HF — structural disease (LVH, reduced LVEF, valve disease) but no symptoms
• Stage C: Symptomatic HF
• Stage D: Advanced HF — refractory symptoms despite optimal GDMT

Step 2: GDMT Initiation — The Four Pillars for HFrEF

Simultaneous Initiation Strategy (2022 Guideline Recommendation): Start all four drug classes at low doses simultaneously, then uptitrate each to target over 3–6 months.

Initiation Guardrails:

• SBP must be ≥ 100 mmHg for ARNi/ACEi initiation
• HR must be ≥ 60 bpm for beta-blocker initiation
• K+ must be ≤ 5.0 mEq/L and eGFR ≥ 30 for MRA initiation
• eGFR ≥ 20 for SGLT2i (per updated labeling)
• 36-hour washout required between ACEi and ARNi to prevent angioedema

Step 3: Uptitration Protocol and Monitoring

Uptitration Schedule:

• Double the dose of one pillar every 1–2 weeks as tolerated
• Recheck BMP (Cr, K+) within 1–2 weeks of any dose change for ARNi/ACEi/MRA
• Monitor symptoms, BP, and HR at each visit

When to Hold or Reduce:

• SBP < 90 mmHg with symptoms → reduce ARNi/ACEi first, then BB
• K+ > 5.5 mEq/L → hold MRA; recheck in 3 days
• Cr rise > 30% from baseline → hold ARNi/ACEi; evaluate volume status
• HR < 55 bpm with symptoms → reduce BB dose

Adjunctive Therapies:

• Hydralazine/Isosorbide dinitrate: add for African American patients with NYHA III–IV on optimal GDMT (A-HeFT trial)
• Ivabradine: consider when HR ≥ 70 bpm on maximally tolerated BB
• IV iron (ferric carboxymaltose): if ferritin < 100 or ferritin 100–300 with TSAT < 20%
• Loop diuretics: for volume management (not mortality benefit) — titrate to euvolemia

Step 4: Device Therapy Evaluation

ICD Eligibility (Primary Prevention):

• LVEF ≤ 35% despite ≥ 3 months of optimal GDMT
• NYHA II–III
• Life expectancy > 1 year
• Ischemic etiology: ≥ 40 days post-MI
• Non-ischemic etiology: ≥ 3 months on GDMT

CRT Eligibility:

• LVEF ≤ 35%, NYHA II–IV (ambulatory), LBBB with QRS ≥ 150 ms → Class I
• LBBB with QRS 120–149 ms → Class IIa
• Non-LBBB with QRS ≥ 150 ms → Class IIa
• Non-LBBB with QRS 120–149 ms → Class IIb

Step 5: Monitoring and Follow-Up Schedule

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the HF classification correct based on the documented LVEF?
2. Are all four pillars of GDMT addressed — initiated, dose documented, or contraindication noted?
3. Is the uptitration plan documented with specific next-dose targets and lab monitoring?
4. Has device therapy candidacy been evaluated or scheduled for reassessment?
5. Are volume status management and diuretic dosing addressed?

Quality Audit

• HF classified as HFrEF, HFmrEF, or HFpEF with LVEF documented
• ACC/AHA stage (A–D) assigned
• NYHA functional class documented
• All four GDMT pillars addressed with current doses
• Contraindications to each pillar explicitly documented
• Uptitration targets and timeline established
• Lab monitoring schedule defined (BMP, BNP trend)
• ICD/CRT eligibility assessed or assessment scheduled
• Volume status documented with diuretic plan
• Iron studies checked and IV iron considered
• Hydralazine/isosorbide dinitrate considered for eligible patients
• 30-day readmission risk factors addressed
• Follow-up visit scheduled with specific titration goals

Guidelines

1. Never delay GDMT initiation for sequential uptitration — start all four pillars simultaneously at low doses per 2022 guidelines.
2. ARNi is preferred over ACEi/ARB in all HFrEF patients who tolerate it — switching from ACEi to ARNi improves outcomes (PARADIGM-HF).
3. SGLT2 inhibitors benefit HFrEF, HFmrEF, and HFpEF — do not withhold based on diabetes status.
4. An initial eGFR dip of up to 30% with ARNi or SGLT2i may be acceptable and often stabilizes — do not reflexively discontinue.
5. Beta-blockers should not be initiated during acute decompensation — stabilize volume status first, then start in the euvolemic state.
6. MRA-related hyperkalemia risk increases with eGFR < 30 and concurrent ACEi/ARB — monitor K+ closely.
7. Document the reason for every GDMT pillar that is not at target dose — "patient intolerant" requires documentation of the specific adverse effect and dose attempted.
8. Refer to advanced HF specialist for Stage D: persistent NYHA IV, recurrent hospitalizations, need for inotropes, or consideration of LVAD/transplant.