Outpatient Heart Failure Management Common Problems

1. Outpatient Heart Failure Management Common Problems Elaine Winkel, M.D. University of Wisconsin Heart Failure and Transplant Program

2. Who takes care of heart failure patients? • 75% -primary care • 20%-cardiology • 5%-heart failure cardiologist

3. Heart Failure LV systolic dysfunction with an ejection fraction of < 40%

4. Heart Failure A syndrome characterized by left ventricular dysfunction, reduced exercise tolerance, impaired quality of life, and reduced life expectancy. Cohn

5. Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure

6. New Approach to the Classification of Heart Failure Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

7. Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class ACC/AHA HF Stage1 NYHA Functional Class2 A At high risk for heart failure but without structural heart disease or symptoms of heart failure (eg, patients with hypertension or coronary artery disease) None B Structural heart disease but without symptoms of heart failure I Asymptomatic II Symptomatic with moderate exertion C Structural heart disease with prior or current symptoms of heart failure III Symptomatic with minimal exertion IV Symptomatic at rest D Refractory heart failure requiring specialized interventions 1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113. 2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.

8. Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure

9. Common Diagnostic Errors LV systolic dysfunction commonly a missed diagnosis No symptoms Symptoms attributed to other diseases Symptoms ignored Signs ignored (CXR)

10. Why screen for LV dysfunction? May be asymptomatic Mortality related to degree of LV dysfunction, not symptoms High mortality once symptoms appear

11. Heart failure is worse than most cancers. -The Fat Man The House of God

12. Patients at risk for developing HF(Stage A) • Coronary disease or CAD equivalent (DM) • Hypertension • Hyperlipidemia • Congenital heart disease • Valvular heart disease • Stroke or other vascular disease –30% w/LVD • Arrhythmias

13. High risk patients • Drug abuse (cocaine, anabolic steroids) • Alcohol use • Family members with heart failure • Sickle cell disease • Sarcoidosis/amyloidosis • Muscular dystrophies • Collagen vascular diseases • Immigrant population-Chagas

14. High risk patients • End stage renal disease • Chronic lung disease-(long time beta-agonist use) • Certain malignancies (multiple myeloma) • History of cardiotoxic drugs (adriamycin)

15. High risk populations Good history, including family history Screen with echocardiography

16. Diagnostic errors LV systolic dysfunction not completely evaluated No cardiac cath Incomplete echo study Role of endomyocardial biopsy

17. Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure

18. Common presentations of HF • Fatigue • SOB • GI distress (anorexia, early satiety, abdominal bloating, nausea, vomiting) • Chest pain/pressure • Lightheadedness/dizziness/palpitations • No symptoms

19. Physical Exam • Often unhelpful especially in chronic or slowly progressive LV dysfunction • Physical signs frequently absent • History most important

20. Causes of SOB in patients with known LVD • New or worsening CAD • New or worsening valve disease • Unappreciated arrhythmia • Anemia • Lung disease • Deconditioning

21. Other causes of edema • Cirrhosis • Severe renal insufficiency • Nephrotic syndrome • Venous insufficiency • Lymphedema

22. Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure

23. Current medical therapy • ACE inhibitors/ARB’s/direct vasodilators • Digoxin • Diuretics • Beta-blockers • Aldosterone blockers

24. ACE Inhibitors-common errors • Short vs. long acting agent • Dose too low • ARB substituted- (cough, creatinine rise, etc.) • Asymptomatic patient w. LVD

25. Digoxin • Not given • Wrong dose • Dig level • Effect of amiodarone, spironolactone • Digoxin in women

26. Diuretics • Too much • Too little • Generic vs. brand name • Timing

27. Beta Blockers • Wrong time (concomitant w/ACE, decompensated, volume overloaded) • Wrong agent (atenolol, acebutelol, pindolol, carvedilol vs. metoprolol) • Wrong dose • Using BB alone • Asymptomatic patient w/LVD

28. Aldosterone Blockers • Spironolactone vs. eplerenone • Too much • Wrong patient (nl-hi K+, DM, Type IV RTA, renal insufficiency, non-compliant) • No follow-up

29. Drug management • Drugs/doses used in clinical trials • Generic vs. brand name drugs • Short vs. long acting agents • Pill bottles each visit • Timing to avoid lightheadedness

30. Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure

31. Non-pharmacologic therapy • Sodium restriction-2000 mg/day • Fluid restriction • Avoid alcohol • Small, frequent meals • Energy conservation

32. Deleterious drugs • Calcium blockers-nefedipine, diltiazem, verapamil • Antiarrhythmics • NSAID’s, COX-2 inhibitors (inc OTC) • Herbal agents (hawthorn, gingko, St. John’s wort) • Grapefruit juice • Inotropic agents-(milrinone, dobutamine)

33. Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure

34. Education and follow-up • Disease • Treatment • Diet/fluids • Exercise/rest • Avoid deleterious agents • Involve family • Close follow-up

35. Other therapies • Coronary intervention (PCI, CABG) • Ventricular reconstruction (aneurysm resection or Dor procedure) • Valve repair or replacement • Correction of arrhythmias-especially AF • Pacing (DDD, BiV) • ICD

36. “Genius is the infinite capacity for taking pains.” Sherlock Holmes