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Heart Failure in the Transplant Patient. Presented by: Bethany Westerfeldt RN, CCRN, MSN, NP-C, ANP, BC For WITNS October 13, 2012. Objectives. 1. Discuss types of Heart Failure LV systolic dysfunction HF with preserved LV systolic function ( HFpEF ) aka diastolic dysfunction
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Heart Failure in the Transplant Patient Presented by: Bethany Westerfeldt RN, CCRN, MSN, NP-C, ANP, BC For WITNS October 13, 2012
Objectives • 1. Discuss types of Heart Failure • LV systolic dysfunction • HF with preserved LV systolic function (HFpEF) aka diastolic dysfunction • 2. Discuss brief pathophysiology of Heart Failure • 3. Assessment of Heart Failure • 4. Treatments of Heart Failure
Types of Heart Failure:Systolic Dysfunction • Many etiologies: • Most common etiologies: CAD, HTN, DM, substance abuse(cocaine, alcohol), chemo, peripartum, uncontrolled tachycardia, viral, valvular heart disease, severe illness • Affects cardiac output or quantity of blood pumped to rest of body • Can be improved or controlled with medication and lifestyle changes • Frequency of diagnosis increases with age, more prevalent after age 65 though affects pts at any age point • Syndrome of neurohormonal activation affecting many body systems
Types of Heart Failure:Diastolic dysfunction • Defined as HF with preserved LV systolic function (normal LVEF) or EF more than 40% • LV often with hypertrophy, concentric remodeling with increased extracellular matrix, abnormal relaxation and filling, decreased diastolic dispensability • Shares activation of neurohormonal activation with systolic dysfunction • Prevalence: 40-50% of all pts diagnosed with HF, often seen in conjunction with systolic dysfunction • More commonly in elderly, females and pts with hypertension
Heart Failure Classifications: • New York Heart Association (NYHA) functional classification of HF: • No limitations of physical activity, no symptoms with ordinary activity • Slight limitation, symptoms with ordinary activities • Marked limitation, symptoms with less than ordinary activities • Severe limitation, symptoms of HF at rest
Therapeutic Goals: • Prolong life • Slow/reverse cardiac remodeling • Reduce visits and admissions to hospital • Improve overall functional capacity and quality of life • Reduce dyspnea and fatigue • Control/minimize edema and fluid retention
Transplant population: • At risk for conditions the increase HF risk (both types): • Hypertensive disease, DM, sleep apnea and CAD • Antirejection meds that increase BP, renal disease, risk DM • Solid weight gain: risk for DM, HTN, sleep apnea, atrial arrhythmias • Preexisting conditions: • Limiting activity: Gout, arthritis/DJD, other musculoskeletal disorders, obesity • Structural heart disease: valve disorders, storage diseases (amyloid, hemochromatosis, saroidosis)
CKD and CV disease: • Known high risk of development of CVD in pt. with HTN • Systolic BP more significant than DBP on CV all cause mortality • Pulse pressure (SBP minus DBP) • Independent predictor of MI, HF and CV death • Reflects stiffness larger arteries • Increases with advancing age from 50 yr. on up • Reliable prognostic factor for mortality CKD • Pts on HD or renal transplant patients
Neurohormonal effects of Heart Failure • SNS activity: “whipping a dying horse”-the catecholamine stimulation • Stimulation of Alpha 1 & Beta 1&2 receptors • Increases cardiac output by increasing heart rate& stroke volume • Prolonged stimulation leads to myocyte hypertrophy, dilation, ischemia, arrhythmias, deterioration and death of cardiac cells • Activates Renin-Angiotensin-Aldosterone System (RAAS)-> (further) vasoconstriction & sodium retention
Prevalence of specific signs & symptoms in systolic & diastolic HF
Signs & Symptoms • Dyspnea & fatigue • Limitation of exercise tolerance • Fluid retention-may lead to pulmonary edema • PND & orthopnea • Cough, can be primarily nocturnal • Poor appetite • Early satiety & bloating • Chest pain: not always in pts with CAD • Palpitations • Lightheadedness • Especially positional • Edema, ascites, anasarca • Poor sleep quality • Difficulty thinking clearly, or concentrating • These abnormalities can impair functional capacity & quality of life
Clinical signs: • Increased adrenergic activity • peripheral vasoconstriction (cool extremities) • pallor &/or cyanosis of digits • diaphoresis • tachycardia • loss of normal sinus rhythm • distention (obvious) of peripheral veins due to vasoconstriction (prominent JVD) • narrowed pulse pressure
Clinical signs • Pulmonary rales & /or wheezes: • usually an acute heart failure finding • Chronic HF pts mobilize pulm fluid into lymph nodes: • are enlarged on x-ray & CT • JVD: indication of right atrial pressure (preload) • Normal JVD is under 10 cm • HJR: compression over liver causes distention of JVD further • Indicates congested abdomen/liver and/or inability of right heart to accept or eject the transiently increased volume
LV systolic dysfunction • Ischemic: CAD is the cause of approximately 2/3 of pts LV dysfunction • Remodeling: change in tissue & geometry of LV • Neurohormonal changes: • affect endothelium of vessels as well as cardiac muscle with deposition of fibrinous material • alters contraction and electrical pathways of myocardium • Neurohormonal activation of Renin-Angiotensin-Aldosterone system & Norepinephrine • Down-regulation of alpha, beta 1 & beta 2 adrenergic receptors
Treatment of Systolic HF • Diuretics, ACE-Inhibitors, Beta blockers, Digoxin, Aldosterone blockers, Vasodilators & IV Inotropic agents • Value of these agents shown in multiple clinical trials • Shown to decrease symptoms & increase length/quality of life
Diastolic Dysfunction • Abstracted charts from 37,500 Medicare pts from National Heart Failure Project database • Only 57% of pts had LV fxn assessed • Of 19,710 pts with documented EF, 1/3 had EF> 50% • This group was 79% women with mean age of 79.7 yrs
Characteristics of Outpatient Diastolic HF • Overwhelmingly female (85%) & elderly(70 yo) • Marked increase in LV mass/volume ratio • Higher BMI • More likely to have HTN • Exercise limitation similar to systolic HF pts
Diastolic Dysfunction • Increased myocardial stiffness • Ventricular interaction or pericardial restraint • Abbreviated LV filling time • Multifactorial: thyrotoxicosis, AV fistula, beriberi • Volume overload stress • Obesity • Impaired LV relaxation • Myocardial ischemia • Hypertrophy • Systolic dysfunction • DM • Hypothyroidism
Diastolic Dysfunction Diagnostic Criteria • Required criteria: • Normal EF (> 50%) • Clinical Evidence of Heart Failure • Framingham of Boston Criteria • Plasma BNP &/or chest x-ray • Cardiopulmonary exercise testing • Confirmatory Criteria: • LVH or Concentric Remodeling • Left Atrial Enlargement (in absence of AF) • Echo Doppler or Cath Evidence of Diastolic Dysfunction • Exclusions: Non-Myocardial Disease
Treatment of Diastolic HF • Class I • Control systolic & diastolic BP • Control ventricular rate in AF • Use diuretics to control edema • Class IIA • Coronary revascularization • Class IIB • Restore & maintain NSR • Beta blocker, ACE-I, ARB, Calcium antagonists, digitalis
Treatment of DHF • General approach: • Symptom reduction • Control blood pressure • Decrease circulating volume • Salt & fluid restriction • Diuretics • Nitrates • Neurohormonal blockade (ACEI/ARB) • Treat tachycardia • Increase duration of diastole (slow HR) in select pts • Maintain synchronous atrial contraction
Treatment DHF • Lifestyle modification & education • Salt & fluid restriction • Exercise program • Other dietary concerns • Weight control • Target underlying mechanisms • Drugs: • that improve calcium homeostasis • blunt hormonal activation • prevent & regress fibrosis are in existence or development
Treatment of DHF • Look at underlying disease processes contributing to DHF & choose drug combinations to combat them • Eg: Diabetic elderly female • Angiotensin blocking drug • Diuretic • beta blocker • CCB if resting HR>70. • Most often requires antihypertensive • Lots of trial & error to finding right combination of meds that minimize symptoms & side effects
Patient self care at home: systolic & diastolic HF • Weigh daily • same time • same clothing amount • Report daily gain of >3 lbs. or overall >5 lbs. • Low salt diet (2 grams) • Take all meds as prescribed • Report any side-effects or problems with meds • Know symptoms of HF & report worsening: • SOB or decreased activity tolerance • Increased fatigue, unable to sleep lying down • Swelling of ankles or abdomen • Frequent colds • Decreased urination, increase in weight
Pt. care at home: • Participate in regular exercise & stress reduction • Plan daily activities in advance to conserve energy • Plan strategies to help reduce fatigue: • delegate jobs • take naps or rest periods • Withdrawal of meds known to affect clinical status: • NSAIDS • antiarrhythmic • most calcium channel blockers
Lifestyle & monitoring • OTC medications to stay away from: • NSAIDS: • ASA (high dose) • ibuprofen • naproxen • Decongestants: • Sudafed • anything with ephedrine • Most diet pills
Case Study • 44 yo male, previous hx DM and DD renal tx ‘05, no known CAD (negative stress prior to tx) • Presents with 4-6 wk hx progressive DOE, weight gain, decreased appetite, cough that worsens at night • States he’s having hard time at work, carries 60 lb. bags & other equipment road construction • Believes he has “bad cold”, treated by PCP for bronchitis/pneumonia without relief of symptoms
Case study • Sx not improved after steroidsabx • History reveals change in appetite, bloating, PND-wakes up after 2 hrs coughing, sits on side of bed or walks around • Reports chest “soreness”, mid sternal area, no radiation, no palpitations, no diaphoresis, n/v • What would you suspect? • What would you do next?
Case study • CXR shows cardiomegaly, pulmonary congestion • 12 lead ecg shows NSR • no evidence of acute MI • normal voltage • TTE shows • LV systolic dysfunction • LVEF 25% • moderately dilated RA & LA • normal RV function • LVEDD 65 mm (nl= 56) • no thrombus • Labs: lytes wnl, bun/cr:35/1.8, t bili 1.6, ast 66, alt 94, TSH 8.7 with normal fT4, TT3.
Treatment • If possible: • Start or increase ACE inhibitor or ARB • Diurese • Once near euvolemic • Start or increase beta blocker (preferably carvedilol or metoprolol succinate)
6 months later… • Calls with SOB without weight gain • Appetite poor • Decreased activity tolerance • Increased fatigue • PND and orthopnea
What to do next? • Assess over the phone: • What brings on SOB/activity limitations • Assess for edema • Other symptoms: • chest discomfort • palpitations • Early satiety, bloating, nausea… • Labs: • Creatinine rise from 1.4 to 1.8 • BUN rise from 28 to 36 • Serum potassium 3.6, sodium 130
What do you do next? • Most likely, increased renal indices from volume overload • Diurese, based on symptoms and labs • Leave ACE-I unchanged • F/u labs in 3-7 days • If equivocal, get pt to be assessed in clinic • TTE can be done in pts difficult to assess volume status • Can always schedule for RH cath (may need anticoag management in pts on warfarin)
Case study 2 • 78 yo female s/p OH Tx ‘02 presents with progressive SOB, weight gain • longstanding hx htn • obesity • swelling of her legs • bloating over past couple of months • Hx reveals: • poorly controlled BP for past 45 yrs • sedentary lifestyle • no DM • hypothyroid • States she’s been sleeping in her husband’s recliner for past 3 weeks • sleep quality poor r/t fatigue • poor quality of life “unable to do anything”
What do you suspect? What questions do you want to ask her? What do you want to do with her?
Case Study 2 • Physical exam: • JVP elevated to 15 cm above RA • No scleral icterus • Oropharynx pink, moist • Lungs with few basilar crackles & wheezes • Abdomen soft, obese; Liver WNL • Extremities +2 to knees bilaterally • Blood pressure: 178/92
Findings • CXR shows pulmonary congestion • TTE shows: • concentric LV hypertrophy • abnormal E/a ratio (diastolic filling) • LVEF 75% • BNP elevated to 528 • lytes normal • creatinine 2.4 • LFT’s normal • 12 lead ecg shows: • increased voltage in precordial leads ( LV hypertrophy) • NSR • Left heart cath with minor luminal irregs • RHC with elevated PCWP, RA,RV and PA pressures
What do you do next? • Diurese • Helps relieve symptoms • Labs to evaluate lytes and renal function • Can schedule for clinic visit • Trend home monitoring data