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Heart Failure

Heart Failure. At the end of this self study the participant will: Describe physical changes occurring from heart failure. Identify common medications given for heart failure. Heart Failure Statistics. 4.6 million people have CHF About 550,000 new cases/year

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Heart Failure

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  1. Heart Failure At the end of this self study the participant will: • Describe physical changes occurring from heart failure. • Identify common medications given for heart failure

  2. Heart Failure Statistics • 4.6 million people have CHF • About 550,000 new cases/year • Almost 1 million hospitalizations/year • About 22% male & 46% female MI victims will be disabled with heart failure w/in 6 yrs • 50% die within 5 years of CHF diagnosis • Current mortality rate > 45,000 / year Am. Heart Assoc. 2000 Heart & Stroke Statistical Update, 1999

  3. Evolution of Heart Failure Clinical Stages NORMAL Asymptomatic LV Dysfunction No Symptoms Normal Exercise Normal LV Function Compensated CHF No Symptoms Normal Exercise Abnormal LV Function Symptoms controlled by medical therapy Activity limitations Abnormal LV Function Decompensated CHF Symptoms persist despite usual therapy Activity limitations Abnormal LV Function Refractory CHF Symptoms not controlled with treatment Bolger, AF & Lopez Sendon, J. Chronic Congestive Heart Failure (slide presentation). 1999.

  4. Sympathetic Activation Increased HR Increased contractility Vasoconstriction Increased preload Increased MVO2 (myocardial volume oxygen consumption) Sustained sympathetic response Vasoconstriction Volume expansion Cellular proliferation Compensatory Responses Renin-Angiotensin-Aldosterone Activation

  5. Successful HF Management Essential Building Blocks: • HF Disease progression • Symptom (including depression) & medication management • Salt (sodium) & water restriction • Exercise & energy conservation • Support services Patient & Family Education

  6. Diuretics Diuretics: Eliminates sodium & water • Loop Diuretics (furosemide, bumetanide) • inhibits Na+/CL-/K+ exchange in ascending Loop of Henle • Thiazide Diuretics (hydrochlorothiazide) • inhibits active Na+/Cl- exchange in renal cortex • Potassium-sparing Diuretics (spironolactone) • inhibits Na+ reabsorption in distal/collecting tubules

  7. Diuretics Diuretics: Patient Management • Record daily weight with plan for intervention when elevated • Take early in day to limit nocturia • Take with food or milk • Rise slowly to minimize dizziness • Monitor hearing (loop diuretics) • Limit unprotected sun exposure • Monitor electrolytes PLAN: If weight increases

  8. Vasodilators Arterial Vasodilators • Arterial vasodilator (reduces afterload) • Not shown to be effective alone • Combination therapy with Nitrates for HF patients unable to take ACE-I Drug in this Class:hydralazine Gheorghiade, et al. Heart & Lung; 2000: 29:16-22 Cohn, JN et al. (V-HeFT II). NEJM. 1991: 325:303-310..

  9. Indications Essential hypertension Heart Failure (may increase activity tolerance) Stabilizes hemodynamics Decreases systemic vascular resistance Patient Management Give IV doses over one minute Following initiation of therapy and each dose or change in infusion rate: heart rate, blood pressure, and respiratory rate every 5 minutes x 3, then every 15 minutes x 3 Vasodilators Arterial Vasodilators Gheorghiade, et al. Heart & Lung; 2000: 29:16-22 Cohn, JN et al. (V-HeFT II). NEJM. 1991: 325:303-310..

  10. ACE Inhibitors Neurohormonal Antagonists Drugs in this Class: captopril enalapril ramipril lisinopril quinapril fosinopril benazepril moexipril First line therapy Outcomes: • Slow HF progression • Improve symptoms • Reduced morbidity & mortality

  11. ACE Inhibitors Neurohormonal Antagonists Indications: LV Dysfunction (EF <40%) with/without symptoms Undesirable Effects • hypotension • weakness/fatigue • hyperkalemia • dry cough • renal insufficiency • skin rash • angioedema Gheorghiade, et al. Heart & Lung; 2000: 29:16-22

  12. ACE Inhibitors Patient Management Neurohormonal Antagonists • Begin with adequate hydration using low doses (adjust diuretic - not ACE-I) • Educate patient about effects (hypotension) • Monitor electrolytes/renal function • Titrate to therapeutic doses • Avoid NSAIDS & K+ sparing diuretics Gheorghiade, M. et al. Heart & Lung, 2000.

  13. Angiotensin II Receptor Blockers (ARB) Neurohormonal Antagonists Drugs in this Class: losartan losartan with HCTZ valsartan irbesartan candersartan • Selective & competitive blocker of AT-1 receptors (vasodilation) • No effect on bradykinin or prostaglandin (no cough) Gheorghiade, et al. Heart & Lung; 2000: 29:16-22

  14. Patient Management Monitor kidney function May increase serum potassium Rare but serious side effect is angioedema (face, lips, throat Indications Hypertension CHF: persistently symptomatic patients with reduced ejection fraction May help control atrial fibrillation Angiotensin II Receptor Blockers (ARB) Neurohormonal Antagonists Gheorghiade, et al. Heart & Lung; 2000: 29:16-22

  15. ß-Adrenergic Blockers Neurohormonal Antagonists Drugs in this Class: metoprolol carvedilol bucindolol Potential Benefits: • Inhibits cardiotoxicity of catecholamines • Decrease HR, BP • Antianginal • Antioxidant • Antiproliferative

  16. ß-Blockers:Patient Management Neurohormonal Antagonists • Initiate after acute decompensation is managed (normal volume state) • Use low doses & titrate slowly • If needed, withdraw slowly to avoid rebound tachycardia & sudden death • Monitor drug effect on blood sugar Gress,TW, et al. NEJM: 2000: 342. Milfred-LaForest, SK. J Cardiovasc Nurs. 2000.

  17. Cardiac Glycosides Inotropes • Introduced in 1785 • ACC/AHA Indications: • systolic dysfunction not responsive to ACE-I & diuretics • atrial fibrillation & SVT • Reduced admissions but not HF mortality • Therapeutic range for HF 0.5-0.8 * Drug in this Class: digoxin * Rathmore et. al. (2003) Association of Serum Digoxin Concentration and Outcomes in Patients with Heart FailureJAMA 289(7), 871-878 ACC/AHA HF Guidelines. Circulation, 1995 Digitalis Investigators Group. NEJM, 1997

  18. Toxicity: Visual Disturbances Blurred vision Yellow tint Halos around lights Almost any dysrhythmia can occur with digtoxicity Patient Management: Monitor heart rhythm Monitor pulse rate Cardiac Glycosides Inotropes ACC/AHA HF Guidelines. Circulation, 1995 Digitalis Investigators Group. NEJM, 1997

  19. IV for acute/chronic HF Dopamine: enhanced renal perfusion (low doses) & BP effects Dobutamine: direct ß-1 to contractility & SV; Use lowest or intermittent dosing Use only when other therapies maximized/failed Positive Inotropes: ß-Adrenergic Stimulants Inotropes Drugs in this Class: dopamine dobutamine Gheorghiade, M. et al. Heart & Lung, 2000. Levine, BS. J Cardiovasc Nurs, 2000.

  20. Considerations: Dopamine is a vesicant – monitor for extavasation Dose dictates level of care needed If dose needs titration, patient needs to be in ICU If dose stable can go to level 2 nursing divisions See IV Medication guidelines for details Positive Inotropes: ß-Adrenergic Stimulants Inotropes Gheorghiade, M. et al. Heart & Lung, 2000. Levine, BS. J Cardiovasc Nurs, 2000.

  21. Natriuretic peptides • Nesiritide • IV only, ICU and level 2 nursing divisions • Requires heart monitoring/telemetry • Vasodilator • Stimulates renin angiotension aldosterone cascade • Monitor closely for hypotension, may need to decrease infusion rate or discontinue for hypotension

  22. Heart Failure Patient Specific Discharge Instructions • Activity Level • Diet • Medications • Follow-up appointments • Weight Monitoring • Symptoms Worsening • Smoking Cessation

  23. Heart Failure: Focus on Prevention • Primary Prevention • Prevent coronary artery disease • Manage lifestyle risk factors • Secondary Prevention • Limit infarct size; Prevent recurrent MI • Prevent CHF post-AMI • Tertiary Care • Prevent CHF progression Advisory Board Company. CHF Prevention, 1999

  24. Heart Failure in the 21st Century:Science is just beginning to unlock the door to all the processes that occur from the onset of LV dysfunction to end-stage deterioration. The etiologies and treatments are evolving - the important concepts to take home with you include • Assess & classify cardiac dysfunction • ACE-I, combined with diuretics & digoxin are primary treatments • Prepare patients & families to “partner” in their self-care • Consider ß-adrenergic blockers after basic therapy; Low / slow dosing • Monitor for research re: new therapies

  25. References • Gheorghiade, M., et al. Heart &Lung, 2000, 29 (1): 16-32 • Bourassa, MG, et al. JACC. 1993. 22 (Supp A) 14A-19A • Chakko, S. & Gheorghiade, M. Am Heart J. 1992, 124: 260-264. • Stevenson, WG, et al. Circulation, 1993, 88: 2953-2961

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