Heart failure: Intervene as early as possible

Heart failure (HF) is a chronic disease that develops in flares and is still too often diagnosed late during acute decompensation. However, detecting them and treating them early would slow down the remodeling of the heart.

Four categories are now distinguished: patients at risk for heart failure, asymptomatic patients with structural changes in echocardiography or elevated natriuretic peptides, symptomatic patients with structural changes and advanced heart failure.

An asymptomatic CI must be sought in every patient with cardiovascular risk factors (hypertension, diabetes, coronary insufficiency, valvular heart disease, hypercholesterolemia, obesity, even very old chemotherapy with anthracycline) by questioning, clinical physical examination, dosage of the natriuretic peptides (NT-proBNP > 125 pg/ml) and when it rises and echocardiographically for left ventricular dysfunction: preserved left ventricular ejection fraction (LVEF) ≥ 50% (maintained LVEF CI, formerly diastolic). CI) or < 50% changed.

The new recommendations recommend treating heart failure with altered ejection fraction as quickly as possible and no longer sequentially with the four therapy classes that reduce mortality. Namely: angiotensin-2 converting enzyme (ACE) inhibitors or angiotensin-neprilysin RNAi receptor inhibitors (valsartan/sacubitril); beta blockers ; mineralocorticoid receptor antagonists (MRAs); and sodium/glucose cotransporter type 2 (iSGLT2) inhibitors or gliflozine, at low doses by dose escalation, combined with a diuretic.

In heart failure with preserved LVEF (≥50%), iSGLT2 (in combination with furosemide) should be used, which also has a beneficial effect on the risk of hospitalization for heart failure and cardiovascular death. ARMs may also have a place in preserved function ICs.

The questions to ask

– Does the patient at risk have symptoms that indicate cardiac insufficiency (dyspnea on exertion, orthopnea, weight gain, unexplained asthenia)?

– Does the examination find jugular swelling, sensitive hepatomegaly, edema? Does auscultation detect tachycardia, galloping sounds, crackles, signs of pleural effusion, heart murmurs?

– What is the type of CI? Questioning, clinical examination, dosage of natriuretic peptides and ultrasound enable staging.

– Is there coronary involvement associated with heart failure? Order a scintigraphy and a stress ultrasound or even a coronary angiography or a coronary computed tomography.

– Is there a pathological context likely to guide the biological assessment (autoimmune diseases, dysthyroidism, etc.)?

What to do

– Refer the patient with symptomatic heart failure to the cardiologist.

– Post-treatment monitoring every 15 days to adjust doses (IEC or RNAi, ARM, beta-blockers, iSGLT2), then every three months with annual echocardiography when patient is stable. Eliminate iatrogenic causes of decompensation, fix arrhythmias (atrial fibrillation), iron deficiency, treat diabetes.

– Inform the patient of their pathology, treatments and symptoms reflecting decompensation based on therapeutic education. If possible, offer cardiac rehabilitation.

– Reduce cardiovascular risk factors (smoking, excessive salt, alcohol abuse, sedentary lifestyle); Control weight, pulse (beta-blockers) and blood pressure, monitor renal function and serum potassium, if ARM, the absence of urinary tract infections in diabetics, if iSGLT2, adjust the doses of loop diuretics by aiming for the minimum effective dosage.

– Explain the importance of dietary measures and a low-salt diet, which need to be adjusted according to the severity of the heart failure.

– Promote compliance in heart failure management by relying on family, specialty nurses, therapeutic education groups, and the establishment of telemonitoring.

What to remember

– Systematization of the early detection of cardiac insufficiency in patients at risk.

– In CI with an ejection fraction < 50%, four major drug classes have demonstrated efficacy in combination with loop diuretics. Their association must be early, in low doses, with a gradual but rapid increase in their dosage.

– iSGLT2 (empagliflozin and dapagliflozin) have a class effect in heart failure with a reduction in mortality, including heart failure with preserved ejection fraction.

According to an interview with Prof. Michel Galinier, Toulouse University Hospital

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