ACUTE DECOMPENSATED HEART FAILURE : 2010 HFSA GUIDELINES

1. ACUTE DECOMPENSATED HEART FAILURE : 2010 HFSA GUIDELINES BART COX, M.D., FACC ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE DIRECTOR, ADVANCED HEART FAILURE PROGRAM

2. DISCLOSURES NONE

3. OBJECTIVES • UNDERSTAND THE DEFINITION OF ADHF • UNDERSTAND THE 4 HEMODYNAMIC PROFILES AND HOW TO CORRELATE THERAPY TO EACH PROFILE • UNDERSTAND METHODS OF DECONGESTION • UNDERSTAND THE USE OF IV VASODILATORS

4. 2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES • JOURNAL OF CARDIAC FAILURE 2010; 16:475-539 (EXECUTIVE SUMMARY) • JOURNAL OF CARDIAC FAILURE 2010; 16: e1-e194 (COMPLETE GUIDELINE)

5. ACUTE DECOMPENSATED HEART FAILURE (ADHF): DEFINITION • JACOBELLIS V. OHIO (1964) AND SUPREME COURT JUSTICE POTTER STEWART • NEW ONSET OR GRADUAL OR RAPIDLY WORSENING HEART FAILURE SIGNS OR SYMPTOMS REQUIRING URGENT THERAPY.

6. HEART FAILURE STATISTICS • >5.5 MILLION HF PATIENTS IN USA • >650,000 NEW HF CASES ANNUALLY • ANNUAL US COST OF HF IN 2010 (DIRECT AND INDIRECT): $39.2 BILLION • 1 YEAR MORTALITY IS 20% • 5 YEAR MOTALITY IS HIGH AND WORSE FOR MALES • MALES: 59% • FEMALE: 45%

7. ADHF STATISTICS • 1 MILLION ADHF HOSPTIAL ADMISSIONS ANNUALLY • ANOTHER 2 MILLION ANNUAL ADMISSIONS IN WHICH HF COMPLICATED THE PRIMARY DIAGNOSIS • 30-50% OF PATIENTS DISCHARGED WITH ADHF WILL BE READMITTED WITHIN 3-6 MONTHS

8. ADHF STATISTICS • 50% OF ADHF ADMISSIONS HAVE LVEF > 40% • 50% OF ADHF ADMISSIONS HAVE LVEF < 40% • AVERAGE PATIENT ADMITTED WITH ADHF IS 75 YEARS OF AGE WITH SUBSTANTIAL COMORBIDITIES • MOST COMMON CAUSE OF ADHF HOSPITALIZATION IS EXACERBATION OF CHRONIC HEART FAILURE • IN HOSPITAL MORTALITY: 4%

9. 6 SLIDES OF BAD MEMORIES

10. INTRODUCTION TO FILLING PRESSURES • VENTRICULAR FILLING PRESSURE: THE PRESSURE IN THE VENTRICLE AT THE END OF DIASTOLE • LEFT VENTRICULAR FILLING PRESSURE = PCWP, MEAN LA PRESSURE, LVEDP • RIGHT VENTRICULAR FILLING PRESSURE= CVP, MEAN RA PRESSURE, RVEDP

11. INTRODUCTION TO FILLING PRESSURES • CONGESTION= SALT AND WATER RETENTION; FLUID OVERLOAD; • TO RELIEVE CONGESTION IN ADHF PATIENTS, DECREASE FILLING PRESSURES • TO DECREASE FILLING PRESSURES, DIURESE (OR ULTRAFILTRATE) AND VASODILATE

12. FILLING PRESSURE IS THE PRESSURE AT THE END OF DIASTOLE

13. INTRODUCTION TO PERFUSION IN ADHF • IN ADHF, PERFUSION IS A FUNCTION OF CARDIAC OUTPUT • CARDIAC OUTPUT= HR X STROKE VOLUME (SV) • STROKE VOLUME IS DEPENDENT UPON: • PRELOAD: THE AMOUNT OF BLOOD IN THE VENTRICLE AT THE END OF DIASTOLE • CONTRACTILITY OF THE VENTRICLE • AFTERLOAD: RESISTANCE TO VENTRICULAR EMPTYING

14. INTRODUCTION TO PERFUSION IN ADHF • TO IMPROVE CARDIAC OUTPUT: • OPTIMIZE RATE AND RHYTHM (ELIMINATE BRADYCARDIA, TACHYCARDIA, AV DISSOCIATION) • OPTIMIZE PRELOAD (VENTRICLE NEITHER TOO FULL NOR TOO EMPTY) • IMPROVE CONTRACTILITY • DECREASE AFTERLOAD (DILATE RESISTANCE VESSELS)

15. INTRODUCTION TO PERFUSION IIN ADHF • CARDIAC INDEX = CARDIAC OUPUT / BSA • TO IMPROVE PERFUSION, IMPROVE CARDIAC OUTPUT (OR INDEX)

16. THE FOUR HEMODYNAMIC PROFILES

17. RECOGNIZING THE FOUR HEMODYNAMIC PROFILES • NO CONGESTION = DRY • CONGESTION= WET • NORMAL PERFUSION=WARM • DIMINISHED PERFUSION=COLD

18. PROFILES AND HEMODYNAMICS • DRY= PCWP < 18 AND RA PRESSURE < 8 • WET = PCWP > 18 OR RA PRESSURE > 8 • WARM= CARDIAC INDEX> 2.2 • COLD= CARDIAC INDEX < 2.2

19. RECOGNIZING THE FOUR HEMODYNAMIC PROFILES • 2 COMPONENTS OF DECOMPENSATED HEART FAILURE • ELEVATED FILLING PRESSURES (MOST COMMON) • REDUCED CARDIAC INDEX (RARE)

20. 2 MINUTE ASSESSMENT AND THE 4 HEMODYNAMIC PROFILES

21. PRINCIPLES OF THERAPY IN A CONGESTED PATIENT: DECREASE THE FILLING PRESSURES • RELIEVE CONGESTION BY REDUCING FILLING PRESSURES • ABSENT CRITICAL ORGAN HYPOPERFUSION THAT LIMITS REDUCING THE FILLNG PRESURES, IMPROVING CARDIAC INDEX DOES NOT WORK!!!!

22. PRINCIPLES OF THERAPY: THE OPTIMAL FILLING PRESSURE • OPTIMAL PCWP IS < 15-16 mm Hg; RA <8 • LOWERING FILLNG PRESSURES -> IMPROVED SV • WHAT’S WRONG WITH ELEVATED FILLNGPRESSURES? • RESPONSIBLE FOR CONGESTIVE SYMPTOMS • ACTIVATE NEUROHORMONES (RAS, SNS) • INCREASE VALVULAR REGURGITATION • RESPONSIBLE FOR PULMONARY HTN • CAUSES RIGHT VENTRICULAR DYSFUNCTION • CAUSES ABNORMAL LV FILLNG PATTERNS

23. FILLING PRESSURES AND STROKE VOLUME (SV)

24. STROKE VOLUME IMPROVED BY DECREASING MITRAL REGURGITATION

25. Warm and dry

26. Warm and wet

27. PROFILE B: WET AND WARM • MOST PATIENTS PRESENTING WITH ADHF ARE PROFILE B • GOAL OF TX: SX IMPROVEMENT BY REDUCTION OF FILLING PRESSURES • FOR MAJORITY, IV DIURETIC TX IS THE MAIN INTERVENTION • MAY NEED TO ADD 2.5-10 mg METOLAZONE PO OR CHLORTHIAZIDE 500-1000 mg IV

28. PROFILE B: ROLE FOR ADJUNCTIVE AGENTS • USE OF ADJUNCTIVE THERAPIES BEYOND DIURETICS HAS NOT BEEN DEMONSTRATED TO IMPROVE OUTCOMES IN HOSPITALIZED ADHF PATIENTS WITH PROFILE B • INOTROPES: ISCHEMIA/ARRHYTHMIAS/ DEATH • NESIRITIDE: EXPENSIVE PLACEBO • ENDOTHELIN ANTAGONIST: NO IMPROVEMENT • VASOPRESSIN ANTAGONIST: NO SUSTAINED BENEFIT

29. PROFILE B: VERY HIGH OR VERY LOW SYSTEMIC VASCULAR RESISTANCE (SVR) • VERY HIGH SVR= > 1500 dyne/sec/cm-5 • HOW TO RECOGNIZE HIGH SVR: • HIGH BP • VERY NARROW PULSE PRESSURE • PA CATHETER MEASUREMENT • VERY LOW SVR (WITHOUT MEDS)= LOW BP + REASONABLE PULSE PRESSURE + WARM EXTREMITIES

30. PROFILE C: COLD AND WET

31. PROFILE C: COLD AND WET • < 3% OF PATIENTS PRESENT WITH CARDIOGENIC SHOCK • WET = CONGESTION (PCWP>18) • COLD = INADEQUATE PERFUSION (CI<2.2) • TX: YOU MAY NEED TO WARM THEM UP BEFORE DRYING THEM OUT • DIURESIS WILL IMPROVE CARDIAC OUTPUT • DIURESIS MAY NOT BE POSSIBLE IF RENAL PERFUSION IS SEVERELY IMPAIRED • WHAT TO USE: VASODILATOR OR INOTROPE? • CHECK THE SVR AND LOOK AT THE BLOOD PRESSURE

32. PROFILE C: IV VASODILATORS OR INOTROPES? • CHOICE OF THERAPY DEPENDS ON SYSTEMIC VASCULAR RESISTANCE AND BP • IF SVR IS HIGH, CHECK THE SBP • SBP>85mm Hg: VASODILATOR • SBP<85 mm Hg: INOTROPE + IABP (INTRAORTIC BALLOON PUMP)

33. PROFILE L: COLD AND DRY

34. PROFILE L: COLD AND DRY • EXTREMELY RARE PRESENTATION • REQUIRES PA CATHETER PLACEMENT TO EVALUATE FILLING PRESSURE • PCWP<12 AND RA<6: DC DIURETICS, PO FLUIDS • PCWP >16: PROFILE C • PCWP 12-16 + RA PRESSURE NORMAL: • VASODILATORS , IABP, AND INOTROPE ARE TEMPORARY FIX • NEEDS VAD/ TRANSPLANT EVALUATION

35. DIURETICS

36. HFSA GUIDELINE: HOW TO DIURESE • DIURESE WITH IV LOOP DIURETIC • ULTRAFILTRATION MY BE USED IN LIEU OF IV DIURETICS • DIURESE UNTIL DRY • DIURESE AT THE CORRECT RATE

37. THE DOSE TRIAL: BOLUS OR INFUSION, LOW DOSE OR HIGH DOSE?

38. Kaplan–Meier Curves for the Clinical Composite End Point of Death, Rehospitalization, or Emergency Department Visit . Felker GM et al. N Engl J Med 2011;364:797-805

39. HFSA GUIDELINES: WHAT TO MONITOR DAILY DURING IV DIURESIS • MONITORING OF INTAKE & OUTPUT AND DAILY WEIGHT IS RECOMMENDED TO ASSESS CLINICAL EFFICACY OF DIURETIC THERAPY • ROUTINE USE OF A FOLEY CATHETER IS NOT RECOMMENDED FOR MONITORING VOLUME STATUS • OBSERVE FOR DEVELOPMENT OF DIURETIC-INDUCED SIDE EFFECTS • DAILY Na, K, Mg, RENAL FUNCTION, AND ORTHOSTATIC VITALS

40. HEISENBERG’S UNCERTAINTY PRINCIPLE • REGARDING SUBATOMIC PARTICLES, YOU MAY KNOW THE EXACT POSITION OR THE EXACT VELOCITY BUT YOU CAN NEVER KNOW SIMULTANEOUSLY THE EXACT POSITION AND THE EXACT VELOCITY

41. COX’S UNCERTAINTY PRINCIPLE • YOU MAY HAVE AN ACCURATE DAILY WEIGHT, OR YOU CAN HAVE AN ACCURATE DAILY INTAKE AND OUTPUT, BUT YOU WILL NEVERSIMULTANEOUSLY HAVE AN ACCURATE INTAKE AND OUTPUT AND WEIGHT

42. DIURETIC SIDE EFFECTS • ELECTROLYTE ABNORMALITEIS • HYPOKALEMIA • HYPOMAGNESEMIA • HYPONATREMIA • HYPOTENSION • GOUT EXACERBATION • HEARING LOSS (RARE) • INCREASED INCIDENCE OF DIGOXIN TOXICITY • RENAL INSUFFICIENCY • MUSCLE CRAMPS ARE USUALLY DUE TO OVERLY RAPID DIURESIS

43. HFSA GUIDELINES: VOLUME OVERLOAD, RENAL DYSFUNCTION, AND DIURETIC USE • PATIENTS WITH MODERATE – SEVERE RENAL DYSFUNCTION AND EVIDENCE OF FLUID RETENTION SHOULD CONTINUE TO BE TREATED WITH DIURETICS

44. CARDIORENAL SYNDROME: OUTDATED AND INCOMPLETE EXPLANATION

45. CARDIORENAL SYNDROME: THE CURRENT EXPLANATION

46. HFSA GUIDELINES: DESTROYING DIURETIC RESISTANCE • DIAGNOSE IT: ARE THEY TRULY WET? • DECREASE THE Na AND FLUID INTAKE • DOSE IT: INCREASE DOSE OF DIURETIC • DRIP IT: FUROSEMIDE DRIP AT 5-20 mg/hr • DOUBLE THE SITE OF ACTION : ADD 5-10 mg po METOLAZONE OR IV CHLORTHIAZIDE 500-1000 mg • DEVICE IT: AQUAPHERESIS/ ULTRAFILTRATION

47. THE DIET AND FLUID RESTRICTION • 2 GRAM SODIUM DIET • 2 LITER/DAY FLUID RESTRICTON

48. WHAT ABOUT HYPONATREMIA • SODIUM < 137 mEq/L ASSOCIATED WITH PROLONGED HOSPITALIZATION AND INCREASED IN-HOSPITAL MORTALITY • IN GENERAL, HYPONATREMIA IS ASSOICIATED WITH DEATH, HIGH REHOSPITALIZATION, LONGER HOSPITAL STAYS, NEUROCOGNITIVE CHANGES, AND RENAL/HEPATIC DYSFUNCTION • MOST HYPONATREMIC PATEIENTS WITH ADHF ARE VOLUME OVERLOADED

49. WHAT ABOUT HYPONATREMIA? • ETIOLOGY: INABILITY TO EXCRETE FREE H20 PRIMARILY DUE TO NEUROHORMONAL ACTIVATION • NOREPI, ANGIOTENSIN II, AVP • HYPONATREMIA IS A MARKER FOR POOR CARDIAC OUTPUT AND NEUROHORMONAL ACTIVATION

50. TREATING HYPONATREMIA IN ADHF • WATER RESTRICTION< 2 L/DAY • MAXIMIZE ACEI OR ARB • VASOPRESSIN ANTAGONIST (TOLVAPTAN) RESERVED FOR ADHF WITH HYPONATREMIA CAUSING SIGNIFICANT COGNITIVE SYMPTOMS