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Chronic Heart Failure – Symptoms, Causes & Treatment

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CHRONIC HEART FAILURE – INDIA

CLINICAL MANAGEMENT GUIDELINE

📋 For Healthcare Professionals Only | Not for Public Use

Scope: Diagnosis | Classification | Pharmacotherapy | Device Therapy | Monitoring | Comorbidities

Format: Stepwise, action-oriented

Note: This guideline covers chronic/stable heart failure. Acute decompensated HF is covered separately.

🔰 SYMBOL LEGEND

Symbol	Meaning
✅	Recommended / First-line
⚠️	Caution / Monitor
❌	Contraindicated / Avoid
💊	Drug name
🇮🇳	India-specific
📌	Key point
➡️	Next step
🔬	Evidence-based (major trial)

SECTION 1: DEFINITION AND CLASSIFICATION

1.1 WHAT IS HEART FAILURE?

Definition

Heart failure is a clinical syndrome caused by structural or functional cardiac abnormality, resulting in reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.

The Two Components

Component	Manifestation
Reduced cardiac output	Fatigue, exercise intolerance, poor perfusion
Elevated filling pressures	Congestion (dyspnea, edema, orthopnea)

1.2 CLASSIFICATION BY EJECTION FRACTION

Category	Abbreviation	LVEF	Key Features
HF with Reduced EF	HFrEF	≤ 40%	Systolic dysfunction; Best evidence for therapy
HF with Mildly Reduced EF	HFmrEF	41-49%	Intermediate; Likely benefits from HFrEF therapies
HF with Preserved EF	HFpEF	≥ 50%	Diastolic dysfunction; Comorbidity-driven
HF with Improved EF	HFimpEF	Previously ≤ 40%, now > 40%	Continue therapy; Do not stop

📌 LVEF category determines treatment strategy – Always document baseline EF and reassess after therapy

HFimpEF – Important Concept

Definition	LVEF was ≤ 40%, now improved to > 40% with treatment
Action	Continue all HFrEF therapies – Stopping leads to relapse
Prognosis	Better than persistent HFrEF, but still at risk

1.3 NYHA FUNCTIONAL CLASSIFICATION

Class	Symptoms	Activity Level
I	No symptoms	Ordinary physical activity does not cause symptoms
II	Mild symptoms	Comfortable at rest; Ordinary activity causes symptoms
III	Moderate symptoms	Comfortable at rest; Less than ordinary activity causes symptoms
IV	Severe symptoms	Symptoms at rest; Unable to carry out any activity without symptoms

📌 NYHA class guides symptom severity and prognosis – Reassess at each visit

1.4 STAGES OF HEART FAILURE (ACC/AHA)

Stage	Description	Examples	Action
A	At risk for HF	HTN, DM, CAD, Obesity, Cardiotoxin exposure, Family history of cardiomyopathy	Risk factor modification
B	Pre-HF (Structural disease, no symptoms)	Previous MI, LVH, Asymptomatic valve disease, Low EF without symptoms	Treat underlying cause; Start GDMT if reduced EF
C	Symptomatic HF	Current or prior symptoms with structural heart disease	Full GDMT; Consider devices
D	Advanced HF	Refractory symptoms despite maximal therapy	Advanced therapies (transplant, LVAD, palliative care)

1.5 ETIOLOGY – IDENTIFY THE CAUSE

Common Causes

Category	Causes
Ischemic	CAD (most common cause of HFrEF); Prior MI
Hypertensive	Longstanding HTN → LVH → HFpEF or HFrEF
Valvular	Aortic stenosis/regurgitation; Mitral regurgitation/stenosis
Cardiomyopathies	Dilated (idiopathic, familial, toxic); Hypertrophic; Restrictive; ARVC
Toxic	Alcohol; Chemotherapy (Anthracyclines, Trastuzumab); Cocaine
Inflammatory	Myocarditis (viral, autoimmune)
Metabolic	Thyroid disease; Diabetes; Obesity
Infiltrative	Amyloidosis; Sarcoidosis; Hemochromatosis
Tachycardia-induced	Prolonged AF with rapid rate
Peripartum	Peripartum cardiomyopathy
Congenital	Congenital heart disease
Right Heart	Pulmonary hypertension; RV infarct; Cor pulmonale

India-Specific Considerations

Cause	Notes
Rheumatic heart disease	Still common; Mitral stenosis, MR
Ischemic heart disease	Rising rapidly; Younger age of onset
Hypertensive heart disease	Very common; Often uncontrolled HTN
Dilated cardiomyopathy	Idiopathic, familial, alcoholic
Peripartum cardiomyopathy	Higher incidence in some regions
Endomyocardial fibrosis	Rare; Restrictive pattern; South India
Tuberculous pericarditis	Consider in restrictive picture

📌 Always try to identify etiology – Some causes are reversible (thyroid, tachycardia-induced, alcohol)

SECTION 2: DIAGNOSIS

2.1 CLINICAL PRESENTATION

Symptoms

Symptom	Mechanism	Notes
Dyspnea (exertional → rest)	Pulmonary congestion	Cardinal symptom
Orthopnea	↑ Venous return when supine	Ask: ”How many pillows?“
Paroxysmal Nocturnal Dyspnea (PND)	Fluid redistribution at night	Wakes patient from sleep
Fatigue	Low cardiac output	Often underestimated
Exercise intolerance	↓ Cardiac reserve	Early symptom
Ankle swelling	Elevated venous pressure	Often bilateral; Pitting
Abdominal bloating	Hepatic congestion, ascites	RHF predominant
Reduced appetite / Early satiety	Gut congestion	May cause cardiac cachexia
Nocturia	Fluid redistribution at night	Often misattributed to prostate
Cognitive impairment	Low output	Especially in elderly

Symptoms by Predominant Failure

Left Heart Failure	Right Heart Failure
Dyspnea, Orthopnea, PND	Peripheral edema
Fatigue	Ascites
Cough (especially nocturnal)	Hepatomegaly, RUQ discomfort
Pulmonary crackles	Elevated JVP
	Anorexia, nausea

📌 Most patients have biventricular failure – Features of both LHF and RHF

2.2 PHYSICAL EXAMINATION

Vital Signs

Parameter	Finding	Significance
BP	Low (hypotension)	Low output; Poor prognosis
	Normal or high	HFpEF; Hypertensive etiology
Heart rate	Tachycardia	Compensation; Decompensation
Respiratory rate	Tachypnea	Congestion
SpO₂	Low	Pulmonary edema
Weight	↑ from baseline	Fluid retention (1 kg ≈ 1 L fluid)

Systematic Examination

System	Finding	Significance
JVP	Elevated (> 4 cm above sternal angle)	↑ RA pressure; Volume overload
	Hepatojugular reflux positive	RV dysfunction
Apex	Displaced (lateral/inferior)	LV dilatation
	Heaving / Sustained	LVH
Heart sounds	S3 (ventricular gallop)	Volume overload; ↑ filling pressure
	S4 (atrial gallop)	Reduced compliance; Diastolic dysfunction
	Murmurs	Valvular disease (cause or consequence)
Lungs	Crackles (bibasal)	Pulmonary congestion
	Wheeze (”cardiac asthma“)	Bronchial edema
	Pleural effusion (dull bases)	Severe congestion
Abdomen	Hepatomegaly (tender)	Hepatic congestion
	Ascites	Severe RHF
	Pulsatile liver	Tricuspid regurgitation
Extremities	Pitting edema (bilateral)	Elevated venous pressure
	Cold peripheries	Low output
	Cyanosis	Low output; Hypoxia

Clinical Signs of Congestion vs Low Output

Congestion (”Wet“)	Low Output (”Cold“)
Elevated JVP	Cool extremities
Peripheral edema	Narrow pulse pressure
Pulmonary crackles	Hypotension
Hepatomegaly	Altered mental status
Orthopnea	Oliguria
Weight gain	Fatigue

Forrester Classification (Hemodynamic Profiles)

Profile	Congestion	Perfusion	Clinical	Management
Warm-Dry	No	Adequate	Compensated	Optimize oral therapy
Warm-Wet	Yes	Adequate	Most common decompensation	Diuretics
Cold-Dry	No	Low	Hypovolemic or over-diuresed	Careful fluids; Reduce diuretics
Cold-Wet	Yes	Low	Cardiogenic shock	Inotropes; Vasodilators; Urgent

2.3 DIAGNOSTIC WORKUP

Step 1: Suspect HF Based on Clinical Features

Suggestive Features

Symptoms: Dyspnea, fatigue, ankle swelling

Signs: Elevated JVP, displaced apex, S3, crackles, edema

History: HTN, CAD, DM, Cardiotoxic drugs, Family history

ECG: Abnormal (any abnormality increases likelihood)

Step 2: Order Natriuretic Peptides

Test	Rule-Out Threshold	HF Likely
BNP	< 35 pg/mL	> 100 pg/mL (> 400 if acute)
NT-proBNP	< 125 pg/mL	> 300 pg/mL (> 450/900/1800 if acute by age)

Interpretation:

Result	Likelihood of HF
Below rule-out threshold	HF very unlikely; Seek alternative diagnosis
Intermediate (”grey zone“)	HF possible; Echo indicated
Elevated	HF likely; Echo to confirm and classify

Causes of Elevated Natriuretic Peptides Without HF:

Cause

Renal impairment

Pulmonary embolism

Severe sepsis

Age (higher levels in elderly)

Causes of Lower-Than-Expected Levels:

Cause

Obesity (BNP/NT-proBNP inversely related to BMI)

Flash pulmonary edema (not yet released)

Right-sided HF (isolated)

Constrictive pericarditis

Step 3: Echocardiography (Essential for All Suspected HF)

Parameter	What to Assess	Classification
LVEF	Global systolic function	HFrEF ≤ 40%; HFmrEF 41-49%; HFpEF ≥ 50%
LV dimensions	LVEDD, LVESD	Dilatation = remodeling
Wall motion	Regional abnormalities	Suggests ischemic etiology
LV wall thickness	Hypertrophy	LVH; Consider infiltrative
Diastolic function	E/A ratio, E/e’, LA size	Grade diastolic dysfunction
RV function	TAPSE, RV S’	RV involvement
Valve function	AS, AR, MR, MS, TR	Cause or consequence
LA size	Volume index	Chronicity; AF risk
IVC	Diameter, collapsibility	RA pressure; Volume status
Pericardium	Effusion, thickening	Pericardial disease
Estimated PASP	From TR jet	Pulmonary hypertension

Step 4: Additional Investigations

Test	Purpose	When to Order
12-lead ECG	Rhythm, ischemia, LVH, conduction disease	All patients
Chest X-ray	Cardiomegaly, pulmonary congestion, effusions	All patients
CBC	Anemia (exacerbating factor)	All patients
U&E (Creatinine, eGFR, K⁺, Na⁺)	Renal function; Baseline before therapy	All patients
LFTs	Hepatic congestion; Baseline	All patients
Glucose, HbA1c	Diabetes (comorbidity, SGLT2i indication)	All patients
Lipid profile	CV risk; Ischemic etiology	All patients
TSH	Thyroid disease (treatable cause)	All patients
Iron studies (Ferritin, TSAT)	Iron deficiency (treatable comorbidity)	All patients
Urinalysis	Renal disease; Proteinuria	All patients
Troponin	Acute ischemia; Chronic elevation (prognosis)	If ischemia suspected
Cardiac MRI	Etiology (ischemic vs non-ischemic); Viability; Infiltrative	Selected patients
Coronary angiography	Confirm CAD; Revascularization potential	If ischemic etiology suspected
Stress testing	Ischemia; Exercise capacity	If CAD suspected; Prognosis
Holter monitor	Arrhythmias; ICD consideration	If arrhythmia suspected
Genetic testing	Familial cardiomyopathy	If clinical suspicion; Family history
Endomyocardial biopsy	Specific diagnosis (infiltrative, myocarditis)	Rarely; Specialist decision

2.4 ECG FINDINGS IN HEART FAILURE

Finding	Suggests
Q waves	Prior MI; Ischemic etiology
LBBB	Conduction disease; CRT candidate if QRS > 130
LVH (voltage criteria)	Hypertensive etiology; HCM
AF	Common comorbidity; May be cause
Low voltage	Pericardial effusion; Infiltrative disease
AV block	Conduction disease; Infiltrative (Lyme, sarcoid)

📌 A completely normal ECG makes HFrEF unlikely (NPV ~90%)

2.5 CHEST X-RAY FINDINGS

Finding	Indicates
Cardiomegaly (CTR > 0.5)	Cardiac enlargement
Pulmonary venous congestion	Upper lobe diversion
Interstitial edema	Kerley B lines
Alveolar edema	”Bat wing“ / Perihilar haziness
Pleural effusion	Usually bilateral; May be unilateral (often R > L)

2.6 DIAGNOSTIC CRITERIA FOR HFpEF

HFpEF is Diagnosed When:

Criteria

Symptoms and/or signs of HF

LVEF ≥ 50%

Evidence of elevated LV filling pressures (structural or functional)

No other obvious cause for symptoms

Evidence of Elevated Filling Pressures

Parameter	Threshold
Elevated natriuretic peptides	BNP > 35 pg/mL; NT-proBNP > 125 pg/mL
E/e’ ratio	> 9 (average)
LA volume index	> 34 mL/m²
TR velocity	> 2.8 m/s
LV mass index	Increased
Diastolic stress test	Rise in E/e’ or PASP with exercise

📌 HFpEF diagnosis can be challenging – Use H2FPEF or HFA-PEFF scores if uncertain

SECTION 3: TREATMENT OF HFrEF – GUIDELINE-DIRECTED MEDICAL THERAPY (GDMT)

3.1 THE FOUR PILLARS OF HFrEF THERAPY

📌 All four drug classes are MANDATORY in HFrEF unless contraindicated

Pillar	Drug Class	Mortality Benefit	Key Effect
1	ACE-I / ARB / ARNI	✅ Yes	Neurohormonal blockade; Reverse remodeling
2	Beta-Blocker	✅ Yes	↓ HR; Reverse remodeling; ↓ SCD
3	MRA	✅ Yes	↓ Fibrosis; ↓ Remodeling
4	SGLT2i	✅ Yes	↓ Hospitalizations; ↓ CV death

Additional Therapies

Therapy	Indication	Benefit
Diuretics	Congestion	Symptom relief (no mortality benefit)
Ivabradine	HR ≥ 70 despite max BB	↓ Hospitalizations
Hydralazine + Nitrate	ACE-I/ARB intolerant (especially Black patients)	Mortality benefit
Digoxin	Refractory symptoms; AF rate control	↓ Hospitalizations (no mortality benefit)
Vericiguat	Recent hospitalization; Worsening HF	↓ Hospitalizations

3.2 TREATMENT INITIATION – TWO APPROACHES

Traditional Approach (Sequential)

START WITH ONE DRUG

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UPTITRATE TO TARGET

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ADD NEXT DRUG

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UPTITRATE TO TARGET

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REPEAT

Advantage: Easier to identify cause of side effects
Disadvantage: Takes months to achieve full GDMT

Modern Approach (Rapid Sequencing / Simultaneous)

START ALL FOUR PILLARS

AT LOW DOSES TOGETHER

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UPTITRATE IN PARALLEL

(Every 1-2 weeks if tolerated)

Advantage: Faster time to full GDMT; Greater early benefit
Disadvantage: Harder to identify problematic drug

🔬 STRONG-HF Trial: Rapid uptitration (within 2 weeks) reduced HF events vs usual care

Practical Approach

Setting	Strategy
New diagnosis (stable)	Start 2-3 drugs simultaneously at low doses; Add 4th within 1-2 weeks
Post-hospitalization	Initiate all 4 before discharge if possible; Uptitrate as outpatient
Frail / Elderly / Low BP	Sequential approach; Slower titration
High-risk (low EF, high NP)	Prioritize rapid initiation of all 4 pillars

3.3 PILLAR 1: RAAS INHIBITION (ACE-I / ARB / ARNI)

Drug Options (Choose ONE)

Agent	Preference
ARNI (Sacubitril/Valsartan)	✅ Preferred over ACE-I/ARB if tolerated
ACE-I	✅ First-line if ARNI not available/affordable
ARB	Alternative if ACE-I cough

ARNI – Sacubitril/Valsartan

💊 Drug	Starting Dose	Target Dose	Notes
Sacubitril/Valsartan	24/26 mg (50 mg) BD	97/103 mg (200 mg) BD	Superior to ACE-I (PARADIGM-HF)

Key Points:

Neprilysin inhibitor + ARB
🔬 PARADIGM-HF: 20% ↓ CV death/HF hospitalization vs Enalapril
Requires 36-hour washout after stopping ACE-I (risk of angioedema)
Can cause hypotension (start low if SBP < 100)
Cost higher than ACE-I 🇮🇳

Contraindications:

History of angioedema
Concurrent ACE-I use
Pregnancy

ACE Inhibitors

💊 Drug	Starting Dose	Target Dose	Frequency
Ramipril	1.25-2.5 mg	10 mg	OD
Enalapril	2.5 mg	10-20 mg	BD
Lisinopril	2.5-5 mg	20-40 mg	OD
Perindopril	2 mg	8-16 mg	OD

Key Points:

🔬 CONSENSUS, SOLVD: Mortality and morbidity benefit
Monitor K⁺ and Creatinine
Cough in 5-20% → Switch to ARB

ARBs

💊 Drug	Starting Dose	Target Dose	Frequency
Candesartan	4-8 mg	32 mg	OD
Valsartan	40 mg	160 mg	BD
Losartan	25-50 mg	150 mg	OD

Key Points:

🔬 CHARM, Val-HeFT: Alternative to ACE-I
Use if ACE-I intolerant (cough)
Similar monitoring as ACE-I

Monitoring ACE-I/ARB/ARNI

When	What to Check
Baseline	Creatinine, K⁺, BP
1-2 weeks after starting/uptitration	Creatinine, K⁺
Stable	Every 3-6 months

Action Based on Results

Cr ↑ ≤ 30% from baseline → Continue; Recheck in 1-2 weeks

Cr ↑ > 50% or K⁺ > 5.5 → Hold; Investigate; Consider dose reduction

SBP < 90 (asymptomatic) → Can often continue; Consider dose reduction if symptomatic

3.4 PILLAR 2: BETA-BLOCKERS

Evidence-Based Beta-Blockers for HFrEF

💊 Drug	Starting Dose	Target Dose	Frequency	Trial
Bisoprolol	1.25 mg	10 mg	OD	CIBIS-II
Carvedilol	3.125 mg	25-50 mg	BD	COPERNICUS
Metoprolol Succinate XL	12.5-25 mg	200 mg	OD	MERIT-HF
Nebivolol	1.25 mg	10 mg	OD	SENIORS (elderly)

⚠️ Only these four beta-blockers have evidence in HFrEF – Do not use Atenolol or Propranolol

Key Points

🔬 CIBIS-II, COPERNICUS, MERIT-HF: ~35% ↓ mortality
Must be stable before starting (no recent decompensation; minimal diuretic changes)
Start low, go slow – Double dose every 2-4 weeks
Expect initial worsening (↓ CO) before benefit (6-12 weeks)
Do NOT stop abruptly (rebound tachycardia, ischemia)

Titration Protocol

Week	Bisoprolol	Carvedilol	Metoprolol XL
1-2	1.25 mg OD	3.125 mg BD	12.5-25 mg OD
3-4	2.5 mg OD	6.25 mg BD	50 mg OD
5-6	3.75 mg OD	12.5 mg BD	100 mg OD
7-8	5 mg OD	25 mg BD	150 mg OD
9-10	7.5 mg OD	37.5 mg BD	175 mg OD
11-12	10 mg OD	50 mg BD	200 mg OD

When to Hold/Reduce Beta-Blocker

Situation	Action
HR < 50 bpm (symptomatic)	Reduce dose
SBP < 90 mmHg (symptomatic)	Reduce dose
Worsening HF symptoms	Usually continue (may briefly reduce); Increase diuretics
Acute decompensation requiring inotropes	Hold temporarily
2nd/3rd degree AV block	Hold; Evaluate need for pacemaker
Severe bronchospasm	Reduce or switch to more cardioselective

📌 Target: Lowest sustainable HR (50-70 bpm) with highest tolerated dose

3.5 PILLAR 3: MINERALOCORTICOID RECEPTOR ANTAGONISTS (MRA)

💊 Drug	Starting Dose	Target Dose	Frequency	Notes
Spironolactone	12.5-25 mg	25-50 mg	OD	Gynecomastia in males
Eplerenone	25 mg	50 mg	OD	More selective; Less gynecomastia; Costlier

Key Points

🔬 RALES (Spironolactone): 30% ↓ mortality in severe HFrEF
🔬 EMPHASIS-HF (Eplerenone): 37% ↓ CV death/HF hospitalization in mild-moderate HFrEF
Indicated for NYHA II-IV with EF ≤ 40% (essentially all HFrEF)
Monitor K⁺ closely – Risk of hyperkalemia, especially with ACE-I/ARB

Contraindications

❌ Contraindication

K⁺ > 5.0 mEq/L

eGFR < 30 mL/min (relative; use with caution)

Concomitant K⁺-sparing diuretics (other than MRA)

Monitoring

When	What to Check
Baseline	K⁺, Creatinine
1 week after starting	K⁺, Creatinine
4 weeks after starting	K⁺, Creatinine
After dose change	K⁺ in 1 week
Stable	Every 3-6 months

K⁺ Level	Action
≤ 5.0	Continue
5.1-5.5	Reduce dose by 50%; Recheck in 1 week
> 5.5	Stop; Investigate cause; Restart at lower dose when K⁺ < 5.0

3.6 PILLAR 4: SGLT2 INHIBITORS

💊 Drug	Dose	Evidence
Dapagliflozin	10 mg OD	DAPA-HF
Empagliflozin	10 mg OD	EMPEROR-Reduced

Key Points

🔬 DAPA-HF, EMPEROR-Reduced: ~25% ↓ CV death/HF hospitalization
Benefit independent of diabetes status – Use in all HFrEF
Also reduces renal decline
Well tolerated; Can be started before discharge
Additive benefit on top of other GDMT

Benefits

Benefit	Evidence
↓ HF hospitalization	~30% reduction
↓ CV death	~20% reduction
↓ Renal decline	Preserved eGFR
Symptom improvement	Kansas City Cardiomyopathy Questionnaire
Safe even without diabetes	DAPA-HF, EMPEROR-Reduced

Side Effects and Monitoring

Side Effect	Management
Genital mycotic infections	Hygiene education; Antifungals if needed
Volume depletion	May need to reduce diuretic dose
UTI	Treat if symptomatic
Euglycemic DKA	Rare; Sick day rules; Hold before surgery
Hypotension	Reduce diuretics if over-diuresed

Prescribing

Do NOT withhold SGLT2i for:

Absence of diabetes

eGFR 20-30 (can initiate; continue even if drops below 20)

Mild hypotension (adjust other drugs)

Elderly age

❌ Contraindications

Type 1 diabetes

eGFR < 20 at initiation

Recurrent genital infections

Pregnancy/breastfeeding

3.7 COMPLETE GDMT SUMMARY TABLE

Drug Class	Drug	Starting Dose	Target Dose	Mortality Benefit
ARNI	Sacubitril/Valsartan	24/26 mg (50 mg) BD	97/103 mg (200 mg) BD	✅
ACE-I	Ramipril	1.25-2.5 mg OD	10 mg OD	✅
	Enalapril	2.5 mg BD	10-20 mg BD	✅
ARB	Candesartan	4-8 mg OD	32 mg OD	✅
	Valsartan	40 mg BD	160 mg BD	✅
BB	Bisoprolol	1.25 mg OD	10 mg OD	✅
	Carvedilol	3.125 mg BD	25-50 mg BD	✅
	Metoprolol XL	12.5-25 mg OD	200 mg OD	✅
MRA	Spironolactone	12.5-25 mg OD	25-50 mg OD	✅
	Eplerenone	25 mg OD	50 mg OD	✅
SGLT2i	Dapagliflozin	10 mg OD	10 mg OD	✅
	Empagliflozin	10 mg OD	10 mg OD	✅

3.8 PUTTING IT TOGETHER – PRACTICAL ALGORITHM

Step 1: Initiate Therapy

CONFIRMED HFrEF (LVEF ≤ 40%)

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┌────────────────────────────────┐

│ START 3-4 DRUGS TOGETHER: │

│ │

│ • ACE-I/ARB/ARNI (low dose) │

│ • Beta-blocker (low dose) │

│ • MRA (low dose) │

│ • SGLT2i (full dose) │

│ │

│ + Diuretic if congested │

└────────────────────────────────┘

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REASSESS EVERY 1-2 WEEKS

Step 2: Uptitrate to Target

Visit	Action
Week 1-2	Check BP, HR, symptoms, K⁺, Cr; Uptitrate if tolerated
Week 3-4	Continue uptitration; Monitor for side effects
Week 5-8	Aim for 50% of target doses
Week 9-12	Aim for target doses
Week 12+	On target doses; Reassess EF at 3-6 months

Step 3: Troubleshoot Barriers

Barrier	Solution
Hypotension (SBP < 90, symptomatic)	Reduce/stop non-essential antihypertensives; Reduce diuretic if euvolemic; Prioritize GDMT over BP numbers
Hypotension (SBP < 90, asymptomatic)	Often tolerated; Continue cautiously
Bradycardia (HR < 50)	Reduce/stop other rate-limiting drugs (Digoxin, Amiodarone); Reduce BB dose; Consider pacemaker if needed
Hyperkalemia (K⁺ > 5.5)	Review diet; Reduce MRA; Consider K⁺ binders (Patiromer, SZC); Do NOT stop RAAS inhibitors if possible
Renal dysfunction	Accept ↑ Cr up to 30%; Reduce diuretic if over-diuresed; Continue GDMT if stable
Cough (ACE-I)	Switch to ARB or ARNI
Gynecomastia (Spironolactone)	Switch to Eplerenone

Prioritization When Cannot Tolerate All Four

If Limited by…	Prioritize
Hypotension	BB and SGLT2i may be better tolerated than ACE-I/ARB; Can use Hydralazine/Nitrate instead
Renal dysfunction	Continue ACE-I/ARB/ARNI if Cr stable; SGLT2i renoprotective
Hyperkalemia	SGLT2i may help lower K⁺; Consider K⁺ binders to enable MRA
Bradycardia	May need pacemaker to enable BB
Cost	ACE-I + BB + Spironolactone + generic SGLT2i are affordable 🇮🇳

3.9 ADDITIONAL PHARMACOTHERAPY

Diuretics – For Congestion

Type	Drug	Dose	Notes
Loop	💊 Furosemide	20-240 mg/day	Most common; Adjust to maintain euvolemia
	💊 Torsemide	10-200 mg/day	Better bioavailability; May have outcomes benefit (TRANSFORM-HF neutral)
	💊 Bumetanide	0.5-5 mg/day	Alternative
Thiazide	💊 Metolazone	2.5-10 mg PRN	Add to loop for diuretic resistance
	💊 HCTZ	25-50 mg	Sequential nephron blockade

Key Points:

No mortality benefit – Used for symptom relief
Titrate to euvolemia – ”Dry weight“
Monitor K⁺, Na⁺, Creatinine – Electrolyte disturbances common
Patient self-adjustment – Teach flexible dosing based on weight/symptoms

Ivabradine – For Elevated Heart Rate

💊 Drug	Starting Dose	Target Dose
Ivabradine	5 mg BD	7.5 mg BD

Indication:

Sinus rhythm
HR ≥ 70 bpm despite maximally tolerated beta-blocker (or if BB contraindicated)
LVEF ≤ 35%
Symptomatic HF

Key Points:

🔬 SHIFT: 18% ↓ HF hospitalization (no mortality benefit)
Works by blocking If current in SA node
Only works in sinus rhythm – Not effective in AF
Side effect: Visual disturbances (phosphenes)

Hydralazine + Isosorbide Dinitrate

💊 Drugs	Target Dose
Hydralazine	75 mg TID
Isosorbide dinitrate	40 mg TID

Indication:

ACE-I/ARB/ARNI intolerant
Add-on in Black patients with persistent symptoms despite GDMT

Key Points:

🔬 A-HeFT: Mortality benefit in Black patients
Alternative when RAAS inhibitors contraindicated (angioedema, severe renal dysfunction)
Multiple daily doses; Compliance challenging

Digoxin

💊 Drug	Dose	Target Level
Digoxin	0.125-0.25 mg OD	0.5-0.9 ng/mL

Indication:

Persistent symptoms despite GDMT
AF with need for rate control (adjunct to BB)
Avoid in sinus rhythm if possible (DIG trial: no mortality benefit)

Key Points:

No mortality benefit – May reduce hospitalizations
Narrow therapeutic index – Toxicity risk
Reduce dose in renal impairment, elderly
Monitor levels; Watch for toxicity (nausea, visual changes, arrhythmias)

Vericiguat

💊 Drug	Starting Dose	Target Dose
Vericiguat	2.5 mg OD	10 mg OD

Indication:

Worsening HF despite GDMT
Recent HF hospitalization or need for IV diuretics

Key Points:

🔬 VICTORIA: 10% ↓ CV death/HF hospitalization
Soluble guanylate cyclase stimulator
Newer agent; Limited availability 🇮🇳
Additive to standard GDMT

3.10 DRUGS TO AVOID IN HFrEF

❌ Drug Class	Reason
NSAIDs	Fluid retention; ↓ Renal function; ↓ Diuretic efficacy; ↑ Mortality
Non-DHP CCBs (Verapamil, Diltiazem)	Negative inotropy; Can worsen HF
DHP CCBs (high dose)	Fluid retention; Reflex tachycardia (Amlodipine/Felodipine acceptable if needed for HTN/angina)
Thiazolidinediones (Pioglitazone)	Fluid retention; ↑ HF hospitalization
Saxagliptin, Alogliptin	↑ HF hospitalization (SAVOR-TIMI, EXAMINE)
Class I antiarrhythmics (Flecainide, Propafenone)	Negative inotropy; Pro-arrhythmic
Dronedarone	↑ Mortality in severe HF (ANDROMEDA)
Metformin	⚠️ Generally safe; Avoid in acute/decompensated HF or severe renal impairment
Moxonidine	↑ Mortality (MOXCON)
Alpha-blockers (Doxazosin, Prazosin)	Neurohormonal activation; ↑ HF events (ALLHAT)

SECTION 4: TREATMENT OF HFmrEF AND HFpEF

4.1 HFmrEF (EF 41-49%)

Evidence

Limited dedicated trials
Post-hoc analyses and meta-analyses suggest benefit from HFrEF therapies
Treat similarly to HFrEF

Recommendations

Treatment	Recommendation
SGLT2i	✅ Recommended (DELIVER, EMPEROR-Preserved included HFmrEF)
ACE-I/ARB/ARNI	✅ Consider (likely beneficial)
Beta-blocker	✅ Consider (especially if CAD, post-MI, AF)
MRA	✅ Consider
Diuretics	For congestion

📌 Treat HFmrEF like HFrEF – Most will benefit from quadruple therapy

4.2 HFpEF (EF ≥ 50%)

The Challenge

Heterogeneous syndrome
Multiple phenotypes
Limited disease-modifying therapies (until recently)
Focus on comorbidities

What Works in HFpEF

Treatment	Evidence	Recommendation
SGLT2i (Empagliflozin, Dapagliflozin)	🔬 EMPEROR-Preserved, DELIVER	✅ Recommended for all HFpEF
Diuretics	Symptom relief	✅ For congestion
Treat comorbidities	HTN, AF, CAD, Obesity, DM, Sleep apnea	✅ Essential

What May Help (Less Certain)

Treatment	Evidence	Recommendation
MRA (Spironolactone)	TOPCAT: Mixed results (benefit in Americas subgroup)	Consider
ARB	CHARM-Preserved: Borderline	May use for HTN
ARNI	PARAGON-HF: Borderline (benefit in women, lower EF)	Consider in women, EF closer to 50%
Beta-blocker	No clear benefit in HFpEF per se	Use for AF rate control, CAD

HFpEF Management Algorithm

CONFIRMED HFpEF (EF ≥ 50%)

│

▼

┌───────────────────────────────────────┐

│ 1. START SGLT2i (Empagliflozin or │

│ Dapagliflozin 10 mg OD) │

└───────────────────────────────────────┘

│

▼

┌───────────────────────────────────────┐

│ 2. DIURETICS for congestion │

│ (Titrate to euvolemia) │

└───────────────────────────────────────┘

│

▼

┌───────────────────────────────────────┐

│ 3. TREAT COMORBIDITIES AGGRESSIVELY │

│ • HTN → Target < 130/80 │

│ • AF → Rate/Rhythm control │

│ • CAD → Revascularize if needed │

│ • Obesity → Weight loss │

│ • Diabetes → SGLT2i covers this │

│ • Sleep apnea → CPAP │

│ • Iron deficiency → IV iron │

└───────────────────────────────────────┘

│

▼

┌───────────────────────────────────────┐

│ 4. CONSIDER MRA if symptomatic │

└───────────────────────────────────────┘

SECTION 5: DEVICE THERAPY

5.1 IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR (ICD)

Purpose

Primary prevention: Prevent sudden cardiac death in high-risk patients
Secondary prevention: After survived cardiac arrest or sustained VT

Indications for Primary Prevention ICD

Criteria	Details
LVEF ≤ 35%	Despite ≥ 3 months of optimal GDMT
NYHA II-III	Symptomatic HF
Ischemic etiology	≥ 40 days post-MI
Non-ischemic DCM	After excluding reversible causes
Life expectancy > 1 year	With good functional status

Indications for Secondary Prevention ICD

Criteria

Survived cardiac arrest due to VF or hemodynamically unstable VT

Sustained VT with structural heart disease

Syncope with inducible VT on EP study

Who Should NOT Get ICD

❌ Not Appropriate

NYHA IV (refractory) unless bridge to transplant/LVAD

Life expectancy < 1 year

Severe comorbidities

Within 40 days of MI (wait for recovery)

Within 90 days of revascularization (reassess EF)

Within 3 months of new GDMT (reassess EF)

Reversible cause of low EF (tachycardiomyopathy, myocarditis)

📌 Reassess EF after 3-6 months of GDMT – Many patients improve above 35% threshold

5.2 CARDIAC RESYNCHRONIZATION THERAPY (CRT)

Purpose

Restore synchronized ventricular contraction
Reverse remodeling
Improve symptoms and survival

Types

Type	Description
CRT-P	CRT with pacemaker only
CRT-D	CRT with defibrillator

Indications for CRT

Class I Indication (Strongest)

LVEF ≤ 35%

Sinus rhythm

LBBB with QRS ≥ 150 ms

NYHA II-IV (ambulatory) despite GDMT

Class IIa Indication

LVEF ≤ 35%; LBBB with QRS 130-149 ms

LVEF ≤ 35%; Non-LBBB with QRS ≥ 150 ms

AF with need for high % ventricular pacing and LVEF ≤ 35%

Class IIb Indication

Non-LBBB with QRS 130-149 ms

Upgrade from pacemaker if high RV pacing % and EF ≤ 35%

Who Benefits Most from CRT

Best Responders

True LBBB morphology

Wider QRS (≥ 150 ms)

Women

Non-ischemic etiology

Less scar on imaging

CRT vs ICD Decision

Scenario	Device
LVEF ≤ 35%, narrow QRS (< 130 ms), no pacing indication	ICD alone
LVEF ≤ 35%, LBBB, QRS ≥ 130 ms	CRT-D
High pacing requirement expected + LVEF ≤ 35%	CRT-P or CRT-D
LVEF ≤ 35% but life expectancy < 1 year	Consider CRT-P (not CRT-D)

5.3 CARDIAC CONTRACTILITY MODULATION (CCM)

Feature	Details
What it is	Device delivers non-excitatory electrical signals during refractory period
Effect	Improves contractility without increasing O₂ demand
Indication	NYHA III, EF 25-45%, QRS < 130 ms (not CRT candidates)
Evidence	FIX-HF-5C: Improved exercise capacity and QoL
Availability	Limited 🇮🇳

5.4 SUMMARY: DEVICE SELECTION

LVEF	QRS Duration	QRS Morphology	Device
≤ 35%	< 130 ms	Any	ICD (if meets criteria)
≤ 35%	130-149 ms	LBBB	CRT-D
≤ 35%	130-149 ms	Non-LBBB	Consider CRT-D (weaker evidence)
≤ 35%	≥ 150 ms	LBBB	CRT-D (strongest indication)
≤ 35%	≥ 150 ms	Non-LBBB	CRT-D

SECTION 6: MANAGEMENT OF COMORBIDITIES

6.1 ATRIAL FIBRILLATION

Prevalence

30-50% of HF patients have AF
AF worsens HF; HF promotes AF

Management Strategy

Component	Approach
Anticoagulation	All AF + HF patients (unless contraindicated)
Rate control	First-line for most
Rhythm control	Consider if symptomatic despite rate control; Early AF

Anticoagulation

Agent	Recommendation
DOAC	✅ Preferred over Warfarin
Warfarin	If mechanical valve, severe MS, or DOAC contraindicated

DOAC	Dose	Renal Adjustment
Apixaban	5 mg BD	2.5 mg BD if ≥ 2 of: Age ≥ 80, Weight ≤ 60 kg, Cr ≥ 1.5 mg/dL
Rivaroxaban	20 mg OD with food	15 mg OD if CrCl 15-50
Edoxaban	60 mg OD	30 mg OD if CrCl 15-50, Weight ≤ 60 kg, or P-gp inhibitor
Dabigatran	150 mg BD	110 mg BD if age ≥ 80 or high bleed risk; Avoid if CrCl < 30

Rate Control

Drug	Target HR
Beta-blocker (Bisoprolol, Carvedilol, Metoprolol)	< 110 bpm (lenient) or < 80 bpm (strict if symptomatic)
Digoxin (adjunct)	Add if BB insufficient
❌ Verapamil, Diltiazem	AVOID in HFrEF (negative inotropy)

Rhythm Control

Option	Notes
Amiodarone	Only antiarrhythmic safe in HFrEF; Toxicity with long-term use
Catheter ablation	Consider if symptomatic; May improve EF if tachycardia-mediated; CASTLE-AF showed mortality benefit
DC cardioversion	Acute conversion; May not maintain sinus long-term

📌 Catheter ablation for AF in HFrEF may improve outcomes – Consider early referral

6.2 CORONARY ARTERY DISEASE

Assessment

Question	Action
Is ischemic etiology?	Coronary angiography if not known
Is there viable myocardium?	Stress imaging, PET, MRI
Is revascularization appropriate?	MDT discussion

Revascularization

Indication	Recommendation
Significant CAD + Angina	Revascularization recommended
Significant CAD + Viable myocardium	Consider revascularization (STICH: modest late benefit with CABG)
Left main or multivessel disease	CABG generally preferred over PCI in HFrEF

Medical Therapy for CAD + HF

Agent	Notes
Beta-blocker	Anti-ischemic + HF benefit
ACE-I/ARB/ARNI	Cardioprotective
Statin	All CAD patients
Antiplatelet	Aspirin; DAPT post-PCI/ACS
Nitrates	For angina (not routine in HF)

6.3 DIABETES MELLITUS

Key Points

30-40% of HF patients have diabetes
Diabetes worsens HF prognosis
SGLT2 inhibitors benefit both conditions

Drug Selection

✅ Preferred	⚠️ Caution	❌ Avoid
SGLT2i (mandatory if HFrEF)	Insulin (fluid retention, weight gain)	Pioglitazone (fluid retention)
Metformin (safe in stable HF)		Saxagliptin, Alogliptin
GLP-1 RA (safe; CV benefit)

6.4 CHRONIC KIDNEY DISEASE

Key Points

~50% of HF patients have CKD (eGFR < 60)
Worsens prognosis
GDMT remains beneficial but requires dose adjustment

GDMT in CKD

Drug	Adjustment
ACE-I/ARB/ARNI	Can use down to eGFR ~20; Accept 30% Cr rise; Monitor K⁺
Beta-blocker	No major adjustment
MRA	Reduce dose; Caution if eGFR < 30; Monitor K⁺ closely
SGLT2i	Can initiate if eGFR ≥ 20; Continue even if drops below 20; Renoprotective
Diuretics	Higher doses of loop diuretics needed; Thiazides less effective < 30
Digoxin	Reduce dose; Monitor levels

Managing Cardiorenal Syndrome

Type	Description	Management
1	Acute HF → Acute kidney injury	Optimize hemodynamics; Careful diuresis
2	Chronic HF → Progressive CKD	Continue GDMT; Avoid nephrotoxins
3	Acute kidney injury → Acute HF	Treat underlying cause; Volume management
4	CKD → Chronic HF	Treat both; SGLT2i for both
5	Systemic disease → Both	Treat underlying cause

6.5 IRON DEFICIENCY

Definition in HF

Parameter	Diagnostic Threshold
Ferritin	< 100 ng/mL
OR Ferritin 100-299 + TSAT < 20%	Iron deficiency

📌 Screen ALL HF patients for iron deficiency – Check ferritin and TSAT at diagnosis and periodically

Why It Matters

Present in 30-50% of HF patients
Independent of anemia
Causes fatigue, reduced exercise capacity, worse outcomes
Treatable!

Treatment

Recommendation

IV Iron (Ferric carboxymaltose or Iron isomaltoside) is recommended

Oral iron is poorly absorbed and less effective

Trial	Finding
🔬 FAIR-HF	Improved symptoms, 6MWT, QoL
🔬 CONFIRM-HF	Sustained benefit
🔬 AFFIRM-AHF	↓ HF hospitalizations (trend)
🔬 IRONMAN	↓ Recurrent HF events

IV Iron Dosing

Drug	Dose	Administration
Ferric carboxymaltose (FCM)	500-1000 mg	IV infusion; Can repeat at week 4 if needed
Iron isomaltoside	1000-1500 mg	Single infusion

6.6 SLEEP-DISORDERED BREATHING

Types

Type	Prevalence in HF	Mechanism
Obstructive Sleep Apnea (OSA)	30-50%	Airway obstruction; Common in obese
Central Sleep Apnea (CSA)	25-40%	Cheyne-Stokes respiration; Worse prognosis

Screening

Suspect if:

Excessive daytime sleepiness

Snoring, witnessed apneas

Morning headaches

Refractory HF despite GDMT

Nocturnal arrhythmias

Diagnosis

Polysomnography (gold standard)
Home sleep testing (screening)

Treatment

Type	Treatment
OSA	CPAP (improves symptoms, BP, possibly outcomes); Weight loss
CSA	Optimize GDMT first (may resolve); CPAP less effective; Avoid ASV in HFrEF (SERVE-HF: ↑ mortality with ASV)

⚠️ Adaptive Servo-Ventilation (ASV) is contraindicated in HFrEF with CSA (SERVE-HF)

6.7 DEPRESSION

Prevalence

20-40% of HF patients
Bidirectional relationship
Worsens adherence, outcomes

Screening

Use PHQ-2 or PHQ-9 at visits
Ask about mood, anhedonia, energy

Treatment

Approach

Psychological support, CBT

Exercise (if able)

SSRIs (Sertraline safest studied in cardiac patients)

Avoid TCAs (pro-arrhythmic, anticholinergic)

6.8 HYPERTENSION

Target

Population	Target BP
HF patients	< 130/80 mmHg

Preferred Agents (Already in GDMT)

Agent	Notes
ACE-I/ARB/ARNI	First-line
Beta-blocker	Evidence-based for HFrEF
MRA	Part of GDMT
Diuretics	If volume overloaded

Additional Agents if Needed

Agent	Notes
Amlodipine	Safe in HFrEF; Fluid retention possible
Hydralazine	Vasodilator
❌ Verapamil, Diltiazem	AVOID in HFrEF

6.9 GOUT AND HYPERURICEMIA

Management

Acute Gout	Chronic Prevention
Colchicine (first-line in HF)	Allopurinol, Febuxostat
Low-dose corticosteroid (if colchicine fails)	Avoid Losartan (uricosuric but not preferred ARB in HF)
❌ Avoid NSAIDs
IL-1 inhibitors (if refractory)

SECTION 7: ADVANCED HEART FAILURE

7.1 DEFINITION OF ADVANCED HF

Criteria (All Must Be Present)

Persistent symptoms (NYHA III-IV) despite optimal GDMT

LVEF ≤ 35% (typically)

Recurrent HF hospitalizations (≥ 2 in past year) or ≥ 1 requiring inotropes

End-organ dysfunction due to HF (worsening renal/liver function)

Progressive exercise intolerance (↓ 6MWT, ↓ peak VO₂)

Escalating diuretic requirements

Episodes of congestion refractory to therapy

7.2 WHEN TO REFER TO ADVANCED HF CENTER

Trigger	Action
≥ 2 HF hospitalizations in 12 months	Refer
Persistent NYHA III-IV despite GDMT	Refer
Need for IV inotropes	Refer
Consideration for transplant or LVAD	Refer
eGFR declining progressively	Refer
Considering palliative care	Discuss

7.3 TREATMENT OPTIONS IN ADVANCED HF

Intravenous Inotropes (Short-term / Bridge)

Drug	Mechanism	Use
Dobutamine	β1-agonist	Acute support; Bridge
Milrinone	PDE-3 inhibitor	Acute support; Pulmonary vasodilation
Levosimendan	Ca²⁺ sensitizer + K⁺-channel opener	Intermittent use; May improve outcomes

⚠️ Chronic inotropes are associated with increased mortality – Use as bridge or palliation only

Mechanical Circulatory Support (MCS)

Device	Type	Indication
IABP (Intra-aortic Balloon Pump)	Temporary	Cardiogenic shock; Bridge
Impella	Temporary	Higher support than IABP
VA-ECMO	Temporary	Refractory shock; Bridge to decision
LVAD (Left Ventricular Assist Device)	Durable	Bridge to transplant; Destination therapy

LVAD (Left Ventricular Assist Device)

Indication

Bridge to transplant (BTT): While awaiting heart transplant

Destination therapy (DT): Not transplant candidate; Long-term support

Bridge to candidacy: Improve organ function to become transplant eligible

Contraindications

Severe RV failure

Severe aortic regurgitation

Irreversible end-organ damage

Inability to manage device

Active infection

Heart Transplantation

Indication

End-stage HF refractory to all medical/device therapy

No absolute contraindications

Motivated patient with good support

Contraindications

Age > 70 (relative)

Active malignancy

Irreversible pulmonary hypertension

Active infection

Severe peripheral or cerebrovascular disease

Substance abuse

Non-adherence

Multisystem disease

7.4 PALLIATIVE CARE IN HF

When to Introduce

Consider Palliative Care When:

Refractory symptoms despite optimal therapy

Frequent hospitalizations

Not candidate for advanced therapies

Worsening trajectory

Patient/family request

Goals

Goal

Symptom management (dyspnea, pain, depression)

Advance care planning

Quality of life over quantity

Support for family

Dignified end-of-life care

Symptom Management at End of Life

Symptom	Management
Dyspnea	Opioids (low-dose morphine); Oxygen if hypoxic; Diuretics if congested
Pain	Opioids; Non-pharmacological
Anxiety	Benzodiazepines; Counseling
Depression	SSRIs; Counseling
Nausea	Antiemetics
Edema	Continue diuretics for comfort

ICD Considerations at End of Life

Decision

Discuss ICD deactivation with patient/family

Shocks at end of life cause distress without benefit

Deactivation is ethically appropriate when goals change

SECTION 8: MONITORING AND FOLLOW-UP

8.1 FOLLOW-UP SCHEDULE

Phase	Frequency	Purpose
After initiation/titration	Every 1-2 weeks	Uptitrate GDMT; Monitor for side effects
After hospitalization	Within 7-14 days	Prevent readmission; Optimize therapy
Stable, optimized	Every 3-6 months	Reassess symptoms, function, adherence
Annual	Yearly	Comprehensive review; Echo; Labs

8.2 WHAT TO ASSESS AT EACH VISIT

Clinical Assessment

Parameter	Check
Symptoms	Dyspnea (NYHA class), fatigue, orthopnea, PND, edema
Weight	Compare to dry weight; Trend
Vital signs	BP, HR, SpO₂
Examination	JVP, lung crackles, edema, S3
Functional capacity	Can you climb stairs? Walk to market?
Adherence	Medications, salt restriction, fluid restriction
Side effects	Hypotension, cough, bradycardia, dizziness
Mental health	Depression, anxiety, coping

Laboratory Monitoring

Test	Frequency	Notes
U&E (Cr, eGFR, K⁺, Na⁺)	Every titration visit; Then 3-6 monthly	Essential for ACE-I/ARB/MRA
BNP/NT-proBNP	At baseline; If clinical change	Prognostic; Guide therapy
CBC	6-12 monthly	Anemia
Iron studies	6-12 monthly	Iron deficiency
HbA1c	6-12 monthly (if diabetic)	Glycemic control
Lipids	Annually	CV risk
LFTs	Annually; If symptoms	Hepatic congestion; Drug toxicity
TSH	Annually	Thyroid disease; Amiodarone
Digoxin level	If on digoxin; Renal change	Narrow therapeutic range

Echocardiography

When to Repeat Echo

3-6 months after initiating GDMT (assess response)

If clinical deterioration

After revascularization

Before device implantation

If considering advanced therapies

8.3 PATIENT SELF-MANAGEMENT

Daily Monitoring

Patient Should:

Weigh themselves daily (same time, after voiding, before breakfast)

Record weight

Report if weight ↑ > 2 kg in 3 days (fluid retention)

Monitor symptoms (dyspnea, swelling)

Flexible Diuretic Dosing

Teach Patients to Adjust Diuretics

If weight up 1-2 kg → Increase furosemide by 20-40 mg for 2-3 days

If weight down 1-2 kg below dry weight → Reduce furosemide

If significant weight gain or worsening symptoms → Contact clinic

📌 Educated patients have fewer hospitalizations – Invest time in teaching

8.4 REMOTE MONITORING

Options

Method	Description
Structured telephone support	Nurses call regularly; Review symptoms, weight
Telemonitoring	Devices transmit weight, BP, symptoms
Implant-based monitoring	CardioMEMS (pulmonary artery pressure); ICD/CRT alerts

Evidence

Trial	Finding
🔬 CHAMPION (CardioMEMS)	37% ↓ HF hospitalizations
Meta-analyses	Telemonitoring may reduce mortality/hospitalization

8.5 NATRIURETIC PEPTIDE-GUIDED THERAPY

Concept

Use NT-proBNP/BNP to guide uptitration of GDMT
Target: ↓ NP by > 30% or to below threshold

Evidence

Mixed results; Some trials show benefit
Not universally recommended
May be useful in younger patients

Practical Use

Use NP to:

Confirm diagnosis

Assess prognosis (higher = worse)

Detect worsening (rising trend)

Assess response to therapy (should fall)

SECTION 9: SPECIAL POPULATIONS

9.1 ELDERLY (≥ 75 YEARS)

Key Considerations

Issue	Approach
Polypharmacy	Simplify regimen; Deprescribe non-essential drugs
Frailty	Individualize targets; Quality of life focus
Falls risk	Avoid excessive hypotension; Cautious diuresis
Renal impairment	Dose adjust; Monitor closely
Cognitive impairment	Involve caregivers; Simplify dosing
Goals of care	Discuss early; Symptom control may be priority

GDMT in Elderly

Drug	Notes
ACE-I/ARB/ARNI	Start low; Uptitrate cautiously
Beta-blocker	Evidence supports use; Lower target HR acceptable
MRA	Use lower doses; Watch K⁺ closely
SGLT2i	Generally well tolerated; Watch volume
Diuretics	Avoid over-diuresis

📌 Elderly benefit from GDMT – Do not withhold due to age alone, but individualize

9.2 WOMEN

Key Points

Under-represented in trials
Present differently (more fatigue, less chest pain)
More likely to have HFpEF
May benefit more from CRT (LBBB more common)
May benefit more from ARNI (PARAGON-HF subgroup)

Pregnancy and HF

Scenario	Risk
Pre-existing HF	High-risk pregnancy; Multidisciplinary care
Peripartum cardiomyopathy	Develops late pregnancy or early postpartum; Recovery possible

Drugs in Pregnancy

❌ ACE-I, ARB, ARNI (teratogenic)

⚠️ Beta-blockers (generally safe; avoid Atenolol)

⚠️ Diuretics (only if essential)

✅ Hydralazine + Nitrates (if RAAS inhibitors needed)

⚠️ MRA (avoid – anti-androgen)

9.3 DIABETES

Covered in Section 6.3

Key Points:

SGLT2i mandatory (dual benefit)
Metformin safe in stable HF
Avoid TZDs
GLP-1 RA safe

9.4 CHRONIC KIDNEY DISEASE

Covered in Section 6.4

Key Points:

Continue GDMT with dose adjustments
SGLT2i renoprotective
Higher diuretic doses needed
Monitor K⁺ closely

9.5 CANCER (Cardio-Oncology)

Cardiotoxic Agents

Agent	Risk
Anthracyclines (Doxorubicin)	Dose-dependent; Irreversible
Trastuzumab	Reversible; Monitor EF
Tyrosine kinase inhibitors	Variable
Immune checkpoint inhibitors	Myocarditis
Radiation	Late effects (valvular, pericardial, CAD)

Management

Phase	Action
Before chemotherapy	Baseline Echo; Optimize CV risk factors
During chemotherapy	Monitor EF; Watch for symptoms
If EF drops	Cardiology consultation; Consider holding chemo; Start GDMT
After chemotherapy	Long-term surveillance

SECTION 10: PATIENT EDUCATION

10.1 KEY MESSAGES FOR PATIENTS

Understanding Heart Failure

Message	Explanation
”Your heart is weak and needs help pumping“	Simple explanation
”Treatment helps your heart work better and live longer“	Importance of GDMT
”You need to take medicines every day, even when feeling well“	Adherence
”Symptoms can be controlled“	Hope
”You play an important role“	Self-management

About Medications

Message

Take all medications as prescribed

Don’t stop without asking your doctor

Each medication has a specific job

Report side effects – there are often alternatives

Bring all medications to each visit

About Lifestyle

Topic	Advice
Salt	< 5 g/day (< 2 g sodium); Avoid adding salt; Limit pickles, papads, processed foods 🇮🇳
Fluid	Usually 1.5-2 L/day; Strict restriction (< 1.5 L) only if severe hyponatremia or refractory congestion
Weight	Weigh daily; Record; Report > 2 kg gain in 3 days
Exercise	Stay as active as possible; Walking is good; Cardiac rehab if available
Alcohol	Avoid or limit to ≤ 1 drink/day; Abstain if alcoholic cardiomyopathy
Smoking	Complete cessation
Vaccinations	Influenza (yearly); Pneumococcal; COVID-19

10.2 WARNING SIGNS – WHEN TO SEEK HELP

Teach Patients to Contact Clinic If:

Sign

Weight gain > 2 kg in 3 days

Increasing shortness of breath

Need more pillows to sleep

Waking up breathless at night

Increased ankle swelling

Persistent cough

Dizziness or near-fainting

Palpitations

Go to Emergency If:

Sign

Severe breathlessness at rest

Unable to lie flat

Chest pain

Fainting

ICD shock

10.3 SELF-MANAGEMENT ACTION PLAN

Weight Change	Action
At dry weight ± 1 kg	Continue usual medications
Up 1-2 kg	Increase furosemide; Reduce salt/fluid; Contact nurse in 2-3 days if not improving
Up > 2 kg or symptoms worsening	Contact clinic same day
Down > 1 kg below dry weight	May be over-diuresed; Reduce furosemide; Ensure hydration

SECTION 11: SUMMARY TABLES

11.1 GDMT SUMMARY – HFrEF

Drug Class	Drug	Starting Dose	Target Dose	Mortality Benefit
ARNI	Sacubitril/Valsartan	50 mg BD	200 mg BD	✅
ACE-I	Ramipril	1.25-2.5 mg OD	10 mg OD	✅
ARB	Candesartan	4-8 mg OD	32 mg OD	✅
BB	Bisoprolol	1.25 mg OD	10 mg OD	✅
	Carvedilol	3.125 mg BD	25-50 mg BD	✅
MRA	Spironolactone	12.5-25 mg OD	25-50 mg OD	✅
SGLT2i	Dapagliflozin	10 mg OD	10 mg OD	✅
	Empagliflozin	10 mg OD	10 mg OD	✅

11.2 TREATMENT BY EF CATEGORY

Therapy	HFrEF (≤ 40%)	HFmrEF (41-49%)	HFpEF (≥ 50%)
SGLT2i	✅ Mandatory	✅ Recommended	✅ Recommended
ACE-I/ARB/ARNI	✅ Mandatory	✅ Consider	May use
Beta-blocker	✅ Mandatory	✅ Consider	For AF/CAD
MRA	✅ Mandatory	✅ Consider	Consider
Diuretics	For congestion	For congestion	For congestion
ICD	If meets criteria	Individualize	No
CRT	If meets criteria	Individualize	No

11.3 DEVICE THERAPY INDICATIONS

LVEF	QRS	Device
≤ 35%	< 130 ms	ICD
≤ 35%	≥ 130 ms + LBBB	CRT-D
≤ 35%	≥ 150 ms (any morphology)	CRT-D

11.4 MONITORING SCHEDULE

Test	Frequency
Clinical assessment	Every 1-6 months based on stability
U&E (Cr, K⁺)	Each titration; Then 3-6 monthly
BNP/NT-proBNP	Baseline; If clinical change
Echo	3-6 months after GDMT initiation; If clinical change
Iron studies	6-12 monthly
CBC, HbA1c, Lipids, TSH, LFTs	Annually

11.5 DRUGS TO AVOID IN HFrEF

❌ Avoid

NSAIDs

Verapamil, Diltiazem

Pioglitazone

Saxagliptin, Alogliptin

Dronedarone

Class I antiarrhythmics

Moxonidine

11.6 COMORBIDITY MANAGEMENT SUMMARY

Comorbidity	Key Intervention
AF	Anticoagulate; Rate control with BB ± Digoxin; Consider ablation
CAD	Revascularize if appropriate; Statin
Diabetes	SGLT2i (mandatory); Metformin safe
CKD	Continue GDMT with monitoring; Higher diuretic doses
Iron deficiency	IV iron (FCM)
Sleep apnea	CPAP for OSA; Avoid ASV in HFrEF with CSA
Depression	SSRI (Sertraline); Support
Hypertension	Target < 130/80; GDMT achieves this

📚 ABBREVIATIONS

Abbreviation	Full Form
HF	Heart Failure
HFrEF	Heart Failure with Reduced Ejection Fraction
HFmrEF	Heart Failure with Mildly Reduced Ejection Fraction
HFpEF	Heart Failure with Preserved Ejection Fraction
HFimpEF	Heart Failure with Improved Ejection Fraction
LVEF	Left Ventricular Ejection Fraction
EF	Ejection Fraction
NYHA	New York Heart Association
GDMT	Guideline-Directed Medical Therapy
ACE-I	Angiotensin-Converting Enzyme Inhibitor
ARB	Angiotensin Receptor Blocker
ARNI	Angiotensin Receptor-Neprilysin Inhibitor
BB	Beta-Blocker
MRA	Mineralocorticoid Receptor Antagonist
SGLT2i	Sodium-Glucose Cotransporter-2 Inhibitor
ICD	Implantable Cardioverter-Defibrillator
CRT	Cardiac Resynchronization Therapy
CRT-P	CRT with Pacemaker
CRT-D	CRT with Defibrillator
LVAD	Left Ventricular Assist Device
MCS	Mechanical Circulatory Support
AF	Atrial Fibrillation
CAD	Coronary Artery Disease
MI	Myocardial Infarction
BNP	B-type Natriuretic Peptide
NT-proBNP	N-terminal pro-BNP
JVP	Jugular Venous Pressure
S3	Third Heart Sound
S4	Fourth Heart Sound
LBBB	Left Bundle Branch Block
QRS	QRS Complex Duration
6MWT	6-Minute Walk Test
VO₂	Oxygen Consumption
eGFR	Estimated Glomerular Filtration Rate
CKD	Chronic Kidney Disease
TSAT	Transferrin Saturation
IV	Intravenous
OD	Once Daily
BD	Twice Daily
TID	Three Times Daily
SBP	Systolic Blood Pressure
HR	Heart Rate
bpm	Beats Per Minute
Cr	Creatinine
K⁺	Potassium
Na⁺	Sodium
DOAC	Direct Oral Anticoagulant
OSA	Obstructive Sleep Apnea
CSA	Central Sleep Apnea
CPAP	Continuous Positive Airway Pressure
ASV	Adaptive Servo-Ventilation
BTT	Bridge to Transplant
DT	Destination Therapy
MDT	Multidisciplinary Team
QoL	Quality of Life
CV	Cardiovascular
SCD	Sudden Cardiac Death
VT	Ventricular Tachycardia
VF	Ventricular Fibrillation
DCM	Dilated Cardiomyopathy
HCM	Hypertrophic Cardiomyopathy
RHD	Rheumatic Heart Disease
MR	Mitral Regurgitation
MS	Mitral Stenosis
AS	Aortic Stenosis
AR	Aortic Regurgitation
TR	Tricuspid Regurgitation
PASP	Pulmonary Artery Systolic Pressure
RV	Right Ventricle/Ventricular
LV	Left Ventricle/Ventricular
LA	Left Atrium/Atrial
RA	Right Atrium/Atrial
IVC	Inferior Vena Cava
TAPSE	Tricuspid Annular Plane Systolic Excursion

📖 REFERENCES

Source	Year
ESC Guidelines for Diagnosis and Treatment of Acute and Chronic Heart Failure	2023
ACC/AHA/HFSA Guideline for Management of Heart Failure	2022
Cardiological Society of India (CSI) HF Guidelines	2022
PARADIGM-HF, DAPA-HF, EMPEROR-Reduced, DELIVER (Trials)	Various
Harrison’s Principles of Internal Medicine	21st Edition
Braunwald’s Heart Disease	12th Edition

Document Version: 1.0

Last Updated: December 2024

For: Healthcare Professionals Only

Disclaimer: Clinical judgment must be exercised for individual patients. Local protocols and resource availability should guide management. This guideline covers chronic/stable HF; acute HF is covered separately. Do not self-medicate.

End of Guideline

🛡️

Medical Advisory

Clinical guidelines are subject to change. Physicians should exercise their regular clinical judgment. This protocol does not replace individual institutional policies. Verified for Q1 2026.

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