Heart Failure - Chronic Follow Up

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. Remote hemodynamic monitoring of pulmonary artery pressure should be considered in symptomatic patients with heart failure, NYHA Class III symptoms, and heart failure hospitalization within the previous 12 months to reduce the risk of subsequent heart failure hospitalization.
 
Referral to a heart failure specialist should be considered in patients at high risk of advanced heart failure: Those needing chronic intravenous inotropes, NYHA Class III-IV symptoms or persistently elevated natriuretic peptides, end-organ dysfunction, left ventricular ejection fraction of <20% or poor right ventricle function, 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. In patients with advanced heart failure, proactive discussions about disease trajectory, goals of care and advance care planning, together with access to an integrated multidisciplinary heart failure palliative care team, are recommended to support end-of-life communication and improve quality of life and symptom burden.

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. It must be noted that prognosis in patients with advanced heart failure treated medically remains poor with >40% 1-year mortality.

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