Side Effect: Heart Failure
What is Heart Failure?
Heart failure (HF) is a complex clinical syndrome that is characterized by the inability of the ventricles of the heart to fill or pump blood appropriately, which decreases the amount of oxygenated blood that is delivered to the body. Heart failure is categorized by staging (A, B, C, or D) and limitations of activity based upon symptoms (New York Heart Association Classification I, II, III, or IV).
Abbreviated Overview of the 4 Stages of Heart Failure:
| Stage |
Definition & Criteria |
| Stage A: |
At risk of HF At risk but without symptoms, structural heart disease, or cardiac biomarkers indicating structural changes or injury |
| Stage B: Pre-HF |
• No symptoms or signs of HF
• At least 1 of the following:
o Structural heart disease
o Evidence for increased filling pressures
o Patients with risk factors and increased levels of B-type natriuretic peptide (BNP) or persistently elevated cardiac troponin in the absences of other causes |
| Stage C: Symptomatic HF |
Structural heart disease with current or previous symptoms of HF |
| Stage D: Advanced HF |
Marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize drug therapy |
Abbreviated Overview of the New York Heart Association (NYHA) Classification
| Symptoms |
Definition & Criteria |
| Class I |
No symptoms and no limitation in ordinary physical activity |
| Class II |
Mild symptoms and slight limitation during ordinary activity |
| Class III |
Marked limitation in activity due to symptoms, even during less-than-ordinary activity |
| Class IV |
Severe limitations, with symptoms even while at rest |
What does Heart Failure look like?
Symptoms of HF can vary, however common symptoms of HF include:
- shortness of breath when standing or lying flat
- chest pain
- fatigue with activity or at rest
- lack or loss of appetite
- cough
- lower leg swelling
Diagnosing HF is complex and is based on a comprehensive clinical history, physical examination and other tests to assess for specific cardiac dysfunction:
Electrocardiogram (ECG or EKG): looks at electrical activity of the heart.
Echocardiogram (ECHO): looks at the structure and function of the heart. This test is important for determining the percentage of blood the left heart ventricle pumps out with each heart beat (also called left ventricular ejection fraction or LVEF).
- HF with reduced ejection fraction (HFrEF): LVEF < 40%
- HF with mildly reduced ejection fraction (HFmrEF): LVEF 41-49%
- HF with preserved ejection fraction (HFpEF): LVEF > 50%
Blood tests such as B-type natriuretic peptide (BNP) or NT-proBNP may be done to check for increased blood volume.
Who gets Heart Failure?
There are many risk factors for developing heart failure, these include:
- Ischemic heart disease
- History of myocardial infarction (MI) or heart attack
- Hypertension
- Valvular heart disease
- Cardiomyopathy
- Familial or genetic
- Stress-induced
- Peripartum
- Cocaine or methamphetamine substance abuse
- Myocarditis
- Rheumatologic or autoimmune disorders
- Infiltrative cardiac disease (sarcoid, hemochromatosis)
- Endocrine or metabolic disorders (thyroid, acromegaly, pheochromocytoma, diabetes, obesity)
Certain chemotherapy agents such as anthracyclines (example: doxorubicin (Adriamycin®), epirubicin (Ellence®), liposomal doxorubicin (Doxil®)) and anti-HER2 therapy (examples: trastuzumab (Herceptin®), pertuzumab (Perjeta®)) can cause damage to the heart muscle increasing the risk of heart failure.
How to prevent Heart Failure
- Preventing heart failure in patients with cancer can be challenging. Patients should be carefully screened before certain types of treatment known to increase the risk of HF in order to identify any risk factors that could increase the risk of developing heart failure.
- During treatment, patients should be monitoring closely for any signs or symptoms of heart failure. In some cases, ECHOs may be done throughout treatment to ensure that the heart is pumping blood appropriately.
- In patients receiving anthracycline therapy, a medication may be given to prevent anthracycline induced heart damage, called dexrazoxane (Zinecard®).
- It is important to have a healthy lifestyle such as maintaining regular physical activity, keeping a normal weight, managing blood pressure and blood glucose if you have high blood pressure or diabetes, and avoiding tobacco products.
- Eating a well-balanced diet with whole grains and plant-based foods may also protect against developing heart failure.
How to treat Heart Failure
Treatment for heart failure is complex and may require stopping the therapy that may be causing the heart failure.
In addition to lifestyle modifications such as reducing sodium and fluid intake, one or more medications may be prescribed to treat heart failure, these medications may include:
Angiotensin-Converting Enzyme Inhibitors (ACE-I):
- Captopril (Capoten®)
- Enalapril (Vasotec®)
- Lisinopril (Prinivil®, Zestril®)
Angiotensin Receptor Blockers (ARBs):
- Candesartan (Atacand®)
- Losartan (Cozaar®)
- Valsartan (Diovan®)
Beta-Blockers:
- Bisoprolol (Zebeta®)
- Carvedilol / Carvedilol CR (Coreg®)
- Metoprolol succinate (Troprol®) / metoprolol tartrate (Lopressor®)
Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2s):
- Dapagliflozin (Farxiga®)
- Empagliflozin (Jardiance®)
Mineralocorticoid receptor antagonists (MRA):
- Spironolactone (Aldactone®)
- Eplerenone (Inspra®)
Diuretics:
- Loop diuretics
- Bumetanide (Bumex®)
- Furosemide (Lasix®)
- Torsemide (Demadex®)
- Thiazide diuretics
- Chlorothiazide (Diuril®)
- Chlothalidone (Thalitone®)
- Hydrochlorothiazide (HydroDiuril®, HCTZ)
- Indapamide (Lozol®)
- Metolazone (Zaroxolin®)
Other:
- Sacubitril + valsartan (Entresto®)
- Isosorbide dinitrate (Isordil®)
- Hydralazine (Apresoline®)
- Ivabradine (Corlanor®)
- Vericiguat (Verquvo®)
- Digoxin (Lanoxin®)
References
1. Malik A, Brito D, Vaqar S, et al. Congestive Heart Failure. [Updated 2023 Nov 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
2. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American college of cardiology/American heart association joint commission on clinical practice guidelines. Circulation 2022;145:e895-e1032.
3. Piper SE, McDonagh TA. Chemotherapy-related cardiomyopathy. Euro Cardiol Rev 2015;10(1):19-24
4. Zinecard (dexrazoxane) [product monograph]. Kirkland, Quebec, Canada: Pfizer Canada ULC; April 2023.
Created: June 24, 2024
Updated: June 24, 2024
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