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Heart Failure Management An Overview

Heart Failure Management An Overview. September 29,2010 Karen Harkness RN CCNC PhD. Definition. Not a clinical diagnosis

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Heart Failure Management An Overview

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  1. Heart Failure ManagementAn Overview September 29,2010 Karen Harkness RN CCNC PhD

  2. Definition • Not a clinical diagnosis • Heart failure is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion. (CCC guidelines, 2006)

  3. Epidemiology Incidence: 10-23% Age > 80 years Ontario: 9943 patients hospitalized between 1999-2001 ( F/up 6 yrs) Mean age: 76 years (SD 11.5) (60% >75 yrs of age) Female: 50% 1 yr mortality: 33% 5 yrs mortality: 69% Median survival: 2.4 yrs Age 70-75 male: median life expectancy 3.5 yrs. ( US population 12 yrs) Age 70-75 female: median life expectancy 2.9 yrs (US population 14.6 yrs) Most common diagnosis for patients admitted to hospital (Age >65 yrs) Most of the costs due to hospitalization Ko et al., Am Heart J 2008

  4. Pathophysiology of HF Cardioregulatory centres Sympathetic nervous system Baroreceptors AVP Aldosterone Angiotensin II release Peripheral Vasconstriction Renal SNS activation Salt and water retention

  5. Heart Failure- Terminology • LV Ejection Fraction (< 35%, <40%) • Heart failure with reduced ejection fraction • Systolic dysfunction • Normal LV Ejection Fraction (> 40%) • Heart failure with preserved ejection fraction (HF/PEP) • Diastolic Dysfunction

  6. Heart Failure- Terminology Stages A- No cardiac structural abnormalities, presence of risk factors (Hypertension, diabetes, obesity, smoking, CAD, excessive ETOH intake) B- No symptoms, cardiac structural changes C- Symptoms, structural changes D- Refractory symptoms, despite optimal management

  7. …… more terminology New York Heart Association Classification I- No symptoms II- Symptoms with moderate activity III- Symptoms with regular activity IV- Symptoms at rest

  8. Terminology… last slide…… Grade LV Systolic Dysfunction Grade I- Ejection Fraction >50% Grade II- Ejection Fraction 35-50% Grade III- Ejection Fraction 20-34% Grade IV- Ejection Fraction <20%

  9. Predictors of Heart Failure Based on ADHERE registry * Based on Framingham Criteria Coronary Artery Disease – most common reason for HF

  10. Aging and Heart Failure Cardiovascular Changes Ability to respond to stress - physiological- exercise or pathological -hypertension, ischemia • responsiveness to Beta stimulation • vascular stiffness (isolated systolic hypertension) • Heart muscle stiffer- impaired relaxation – major filling occurs in late diastole (atrial kick really important for CO) • Altered myocardial energy metabolism in mitochondria

  11. Aging and Heart Failure Other system changes Kidneys- • GFR (8 cc/min/ decade) • Capacity to respond to intravascular volume changes - More likely to get electrolyte imbalances with diuretics - Less responsive to diuretics Lungs - Respiratory reserve (increased sense of SOB secondary to CO) - V/Q mismatch - Sleep disordered breathing Nervous System - Impaired thirst mechanisms (watch get ‘too dry’) - Impaired auto regulation (cerebral changes) - Impaired reflex responses (orthostatic hypotension)

  12. Common Clinical Presentations of Heart Failure • Dyspnea • Orthopnea • PND • Fatigue • Abdominal distension • Cough • Edema • Weight gain Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

  13. Uncommon Clinical Presentations of Heart Failure • Cognitive impairment* • Delirium* • Nausea* • Abdominal discomfort • Nocturia • Oliguria • Anorexia • Cyanosis * May be more common presentation in elderly patients. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

  14. Physical exam JVP elevated Enlarged apical impulse S3 Murmur of mitral regurgitation Peripheral edema Other: HJR Ascites

  15. Diagnosis of Heart Failure Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

  16. Management of ADHF AHF diagnosed, treatment based on symptoms and signs Volume overload Volume overload + low cardiac output Mild overload Mod. –severe overload Mild- Mod low output Very low output • consider PA line • Add vasodilator after BP stabilized • Inadequate response to IV diuretics • Increase oxygen req • CPAP and BIPAP req • fatigue IV diuretics IV lasix bolus IV diuretics + IV vasodilators SBP > 90 mmHg SBP < 90 mmHg • Milrinone • Dobutamine • Dobutamine • Vasopressors • Cr < 200 umol/L 40 mg • Cr > 200 umol/L 80 mg • consider lasix infusion • Add IV nitrates Howlett Can J Cardiology, July 2008

  17. Lab Tests- Decompensation • Electrolytes, Urea, Creatinine • Creatinine can be elevated due to AHF (improves with Rx) • Decreased renal perfusion, renal venous congestion • Hyponatremia - dilutional from increased ADH • Potassium • CBC- Anemia, WBC • Liver Function • Hepatic congestion: increased bilirubin, ALP, INR • Other : TSH, Glucose • BNP

  18. Brain Naturetic Peptide (BNP) • Hormone synthesized in the heart- response to wall distension • Oppose vasoconstriction, sodium retention and anti-diuretic effects of RAAS • “Natural” vasodilator and diuretic BNP and NT-pro BNP BNP < 100pg/ml NT-proBNP < 400 pg/ml BNP 100-400 pg/ml NT-proBNP 400-2000 pg/ml BNP > 400pg/ml NT-proBNP > 2000 pg/ml HF unlikely HF uncertain Need echo evaluation High HF probability Other causes of BNP- Acute PE, Pulmonary hypertension, Anemia, Cor pulmonale, Renal insufficiency, Septic Shock, Hyperthyroidism Palazzuoli et al., Intern Emerg Med Sept 2010

  19. Why Decompensation? Cardiac in Origin • Atrial fibrillation or flutter (new, uncontrolled) • Sinus Tachycardia • Ischemia/infarction (HF usually stubborn and/or acute onset) • Hypertension • Suboptimal pharmacological regimen for HF Non-cardiac • Infections(urinary, resipratory) • Anemia/ Blood loss • Medication interaction (pharmacological, non-pharmacological) Behavioral • Medication non-compliance (unintentional ?) • Excessive salt or fluid intake (unintentional ?)

  20. Goals of Therapy • Relieve symptoms / congestion (find and address ‘trigger’) • Stabilize condition and lower risk for (re) hospitalization • Initiate treatments that will slow disease progression and improve long-term survival • Limit significant adverse effects (arrhythmia, renal failure, over-diuresis )

  21. Management HF with Preserved LV Systolic Function • Control blood pressure • Control heart rate • Diuresis if congestion • Revascularize if reversible ischemia

  22. Management of HF (EF<40%) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

  23. Pharmacological management NYHA I ACE(Ramipril, Enalapril), Betablocker(Bisoprolol, Carvedilol) ARB (ACE intolerant. Candesartan) NYHA II Diuretics (furosemide) NYHA III ARB(hypertension) Spirolonlactone (right sided HF) DIGOXIN(atrial fib, K+ too high for other choices) Nitrates (orthopnea, CAD) NYHA IV Combination of diuretics (metolazone, Hcthz) IV diuretics

  24. Clinical tips ACE inhibitore.g. Ramipril • Start low 1.25 mg daily • Try BID dosing if concerned of low bp ARB- Candesartan • Start low ( 4 mg daily) Beta Blockers • Coreg- renal excreted, more effect on bp than other BB Lowest dose 3.125 mg BID • Bisoprolol- daily, start 2.5 mg OD (1.25 mg really tiny), Beta 1 selective

  25. Clinical tips Lasix • Try alternate days if a nuisance to patient • If BID, second dose before 4 pm • If IV, try infusion if concerned about low bp or not responding to bolus dosing Bumetanide • Better GI absorption in gut edema • 1 mg = 40 mg lasix Metolazone • Be very careful with over diuresis • Tiny dose- 1.25 mg OD prn • Maintenance- 1-2 times a week vs. daily

  26. Clinical tips Aldactone • Tiny dose– 12.5 mg alternate days • Do not add if already taking ACE and ARB • Helpful with right sided HF • Breast tenderness in men, especially if taking Digoxin Eplerenone • Like aldactone, haven’t tried yet (no breast tenderness) Nitrates • Apply when they are most symptomatic with SOB Digoxin- keep level 0.5-1.0 • Start tiny – 0.625 mg OD to alternate days

  27. Clinical tips Hydralazine and nitrates • Start low ( Hydralazine 5 mg q 8h) ( Isordil 10 mg q8h) Calcium Channel Blockers • Avoid Diltiazem unless you know normal LV systolic function • Prefer Amlodipine for ongoing hypertension

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