Monitoring
Patients with heart failure, even with
stable and well-controlled symptoms, require follow-up at intervals no longer
than 6 months to assess symptoms and treatment optimization. A follow-up visit
1-2 weeks after hospitalization (earlier [within 7 days] if admitted for
worsening heart failure) is recommended to check for signs of congestion and
drug tolerance and to initiate and/or uptitrate evidence-based therapy.
Patients with prior heart
failure with reduced ejection fraction who currently have a
left ventricular ejection fraction of >40% are considered to have an
improved left ventricular ejection fraction (heart failure with
improved ejection fraction) and should continue optimized guideline-directed
medical therapy, even in those who may become asymptomatic, in order to avoid left
ventricular dysfunction and relapse of heart failure.
Referral to a heart failure specialist
should be considered in patients needing chronic intravenous inotropes, NYHA
Class IIIB/IV symptoms or persistently elevated natriuretic peptides, end-organ
dysfunction, ejection fraction of ≤35%, repetitive defibrillator shocks,
multiple hospitalizations in the past 12 months, clinical deterioration, edema
despite dose escalation of diuretics, low systolic blood pressure or high heart
rate, and progressive intolerance or down-titration of guideline-directed
medical therapy. Other indications for referral include a new-onset heart
failure regardless of ejection fraction, chronic heart failure with high-risk
features, heart failure etiology requiring a second opinion, a yearly review of
patients with confirmed advanced heart failure, and for patient assessment for possible
clinical trial inclusion.
It is also essential to provide
palliative and end-of-life care services to patients with advanced heart
failure. Palliative care can be initiated during the early part of the disease
process as it may enhance patient care and result in improvement of symptoms.
Prognosis
The assessment of prognosis for
patients with heart failure provides better information for the patients and
their families to plan for their futures. Validated
multivariable risk scores for chronic heart failure (eg the Seattle Heart
Failure Model, the Heart Failure Survival score, and the Meta-analysis Global
Group in Chronic Heart Failure [MAGGIC] score) have commonly been used to
provide estimates of the patient’s survival.The assessment of prognosis
likewise helps in the identification of patients in whom cardiac
transplantation or mechanical device therapy should be considered.
Conditions associated with a poor prognosis
in heart failure include the following:
- Advanced age
- Ischemic etiology
- Worsening NYHA functional status (Class III-IV)
- Chronic hypotension
- Resting tachycardia
- Intolerance to guideline-directed medical therapy at optimal dose
- Increasing need for diuretics, refractory volume overload
- More than one heart failure hospitalization within the last year
- Resuscitated sudden death, CRT non-responder clinically
- Decreasing peak exercise O2 uptake
- Iron deficiency with or without anemia
- Anemia is independently associated with the severity of heart failure and iron deficiency seems to be uniquely associated with a reduction in exercise capacity and additionally, iron deficiency in heart failure patients is associated with a worse prognosis
- Progressive deterioration of hepatic or renal function
- Persistent hyponatremia
- Marked elevation of BNP/NT-proBNP
- Elevated biomarkers of myocardial fibrosis (soluble ST2 receptor, galectin-3, high sensitivity cardiac troponin) and neurohormonal activation
- Widened QRS duration of >120 msec on 12-lead ECG
- Tachycardia and Q waves
- Left ventricular hypertrophy and complex ventricular arrhythmias
- Decreasing left ventricular ejection fraction