How to manage patients with heart failure according to heart failure phenotype

A new consensus-based clinical practice update from the Canadian Cardiovascular Society-Canadian Heart Failure Society (CCS-CHFS) is designed to provide healthcare providers with practical information on some fundamental issues in heart failure (HF) management. These include the appropriate timing for the introduction and optimization of different classes of medication according to specific patient phenotypes, when second-line therapies and valvular interventions should be considered, and how to manage difficult clinical scenarios such as cardiorenal syndrome and frailty.1 The update is designed to be used in conjunction with the existing CCS-CHFS heart failure guidelines, with the intent of assisting healthcare providers with the practical application of the guideline contents to specific situations encountered in practice.1 Patients living with heart failure (HF) can have different characteristics, traits and clinical presentations, defined as HF phenotypes. The CCS-CHFS update outlines how the healthcare team can recognize the following five specific HF phenotypes and apply the current HF guidelines to manage specific individuals. 1. Wet HF phenotype is the easiest to manage, due to an elevated systolic blood pressure (BP). A higher BP upon presentation is linked to better outcomes. Most patients with acute heart failure have volume overload or redistribution, with symptoms of pulmonary edema, ascites and/or lower extremity edema. Symptoms may have been present for hours (in rapid pulmonary edema) to days or weeks (in patients who slowly decompensate at home).1 The mainstay of initial treatment remains loop diuretics and/or a combination of loop and thiazide diuretics. Hospital admission provides an opportunity for early initiation of guideline directed medical therapy (GDMT, i.e., an angiotensin receptor-neprilysin inhibitor [ARNI], either as first-line therapy or switching from an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB); a β-blocker; a mineralocorticoid receptor antagonist [spironolactone or eplerenone]; and a sodium glucose co-transporter 2 inhibitor [SGLT2] inhibitor).1,2 2. De-novo HF phenotype presents with a new onset of symptoms and signs of HF without a previous diagnosis or documentation of HF or left ventricular dysfunction. Patients are generally younger and more likely to present with an acute coronary syndrome. They are also less likely to have significant co-morbid disease (e.g., diabetes, chronic obstructive pulmonary disease, atrial fibrillation or a history of vascular disease). Management requires the introduction of the four pillars of GDMT, while personalizing the order of drug introduction based on the individual’s biological and physiological characteristics (see guideline update for details).1 3. Worsening HF phenotype is generally defined as worsening HF symptoms and signs requiring an intensification of therapy. It accounts for 5% to 42% of HF hospital admissions. The most common causes are ischemia, arrhythmias, valvular dysfunction, systemic or pulmonary hypertension, volume overload or fluid retention, high output conditions (infection, anemia, thyrotoxicosis), drugs (NSAIDs, COX inhibitors, thiazolidinediones) and HF medication changes (e.g., decrease in diuretics, noncompliance with medications). It is a marker of poor prognosis; patients hospitalized with this phenotype are at high risk for adverse outcomes post-discharge, have high readmission rates and a rapid decline in survival, with almost 30% of patients dying within two years.1 The first step is optimization of GDMT, although many co-morbidities (e.g., chronic kidney disease, frailty, low BP) may limit the ability to implement GDMT. Second-line therapies are discussed in the guideline update.1 4. Cardiorenal Phenotype usually presents with signs and symptoms of volume overload; relief of clinical congestion is the primary goal. Most patients rapidly improve with intravenous diuretic therapy, but approximately 20% of inpatients fail to improve once initially stabilized. A management approach, including other therapies, is outlined in the guideline update.1 5. Frail HF Phenotype is characterized by progressive loss of physiological reserve, resulting in decreased energy, decreased physical activity and reduced cognitive ability. It is associated with increased morbidity and mortality. Patients are challenging to manage because of increased risk of falls from multimorbidity and polypharmacy, reduced healthcare access due to limited mobility, problems with self-care and frequent hospitalizations.1 GDMT has BP and/or heart rate lowering effects, which may be difficult to tolerate in patients who are unsteady in their movement or prone to falls. Doses of GDMT in these patients often need to be lower than the target doses used in clinical trials. Hypotension and risk of falls can be lessened by starting medications at small doses and titrating very slowly as tolerated (every 2–4 weeks). Medication administration times should be separated by at least several hours, so that the peak antihypertensive effects do not occur simultaneously. Changing the timing of medication administration might also be useful, such as giving meds with higher vasodilatory effects at bedtime. The guideline update suggests including a pharmacist on the multidisciplinary HF team to help with issues of polypharmacy, drug interactions and medication adherence, which are common in this population.1 Summary Identifying the various phenotypic presentations in patients with HF is critically important for the subsequent tailoring of therapies to improve symptoms and associated co-morbidities, increase patient lifespan and improve quality of life. References 1. Ducharme A, Zieroth S, Ahooja V, et al; Canadian Cardiovascular Society-Canadian Heart Failure Society focused clinical practice update of patients with differing heart failure phenotypes, Can J Cardiol 2023. (accessed May 16, 2023). 2. McDonald M, Virani S, Chan M, et al. CCS/CHFS heart failure guidelines update: defining a new pharmacologic standard of care for heart failure with reduced ejection fraction. Can J Cardiol 2021;37(4):531-46. (accessed May 16, 2023).

How to manage patients with heart failure according to heart failure phenotype

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