HEART FAILURE: Putting It All Together

1. HEART FAILURE:Putting It All Together South Carolina Association Clinical Documentation Specialists Spring Meeting March 23, 2012 Joan M. Lacey, ACNP, ANP, AACC Carolina Cardiology Greenville, SC

2. Heart failure is a common clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ventricles ability to fill and eject blood and the bodies neurohormonal adaptation to this process

3. What Exactly is Heart Failure? A syndrome with many causes and manifestations! Pump failure and altered hemodynamics Altered cell biochemistry (Ca++ cycling) A Perfusion disorder: revascularization and mechanical assistance A rhythm disorder An endocrinopathy, neuropathy, and vasoregulatory dysfunction Abnormal proliferative signaling and gene expression Irreversible premature cell death Less than 50% 5-year survival in symptomatic HF cannot be excluded from the definition of HF

4. EF <40-45%Primary-in the heartGenetic/mixed/acquiredSecondary-occurs from other organ dysfunction Cardiomyopathy “HEART MUSCLE DISEASE”

5. An estimated 5.8 million Americans have congestive heart failure (CHF). (Source: excerpt from NHLBI, Congestive Heart Failure Data Fact Sheet: NHLBI) Survival at 5 yrs. 50% Prevalence of Congestive Heart Failure

6. MortalityEstimates of mortality rate per year for patient subgroupsClass II = 5-15% Class III = 20-50% Class IV = 30-70% http://www.heartfailure.org/eng_site/faq.asp#longlife

7. Hospitalizations and Mortality • Number one reason for admission • High readmission rate • 27% within one month • 50% within six months • 17% two or more admissions • 1 in 5 people die within one year of diagnosis • Systolic dysfunction: poorer prognosis • 50% die within five years (median survival) • Over 1 million hospitalizations per year • Leading cause of Medicare admissions

8. Heart Failure: The Epidemic Prevalence 5.8 million (US) 25 million (worldwide) Incidence 670,000/ year.

10. CAD 65%IDIOPATHIC DILATED 50%TOXIN-INDUCED ALCOHOL,COCAINE,CHEMOTHERAPUTIC DRUGS,RADIATIONINFECTIOUS /INFLAMMATORY COXSACKIE B, LYME DISEASE, HIV,HCV,CHAES,LUPUS,RA,GIANT CELL MYOCARDITIS, INFLUENZA,MYCOPLASMA PNAFAMILIAL DILATED CARDIOMYOPATHY 20-30% OF “IDIOPATHIC “DCM, ARVD,MUSCULAR DYSTROPHIES,HYPERTROPHIC CM, HEREDITARY HEMOCHROMATOSIS ETIOLOGY

11. PERIPARTUM: IN THE LAST MONTH OR FIRST 5 MONTHS POSTPARTUM ( IMMUNE VS. OCCULT LV DYSFUNCTION)STRESS-INDUCED: “TAKO-TSUBO”ENDOCRINE/NUTRITIONAL:DM,OBESITY,THYROID,ACROMEGALY AND GH DEFICIENCY,PHEOIRON OVERLOAD: HEREDITARY HEMOCHROMATOSISTACHYCARDIA INDUCED HYPERTENSIVE INFILTRATIVE: (RESTRICTIVE) AMYLOID,SARCOID ETIOLOGY

12. New York Heart Association (NYHA) Class Patient Symptoms Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath). Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. Class IV (Severe) Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

14. Types of Heart Failure Acute Chronic Systolic Diastolic Mixed

15. Systolic: Decreased EF: ½ the cases HF*Mild 45-50%*Moderate 35-40%*Severe <35%Diastolic: HFnEF(heart failure normal EF)½ the cases HF TYPES OF HEART FAILURE FUNCTION

16. Older, female, HTN, less CADLVEDP >16, EF > 50%EchoImpaired relaxation=grade 1 Pseudo normalization=grade 2Reversible Restrictive=grade 3Irreversible Restrictive=grade 4 DIASTOLIC

17. Left side:ischemic/valvularRight side: CorPulmonale, usually caused by LHF as pressure backs up into lungs. PHTN/PEs/chronic lung disease TypesLocation

18. CAD/anginaHTNOSA/OHVAlcohol/drugs/chemoViral illnessTripsPregnancy problems History

19. 1) Prevent functional decline2) Prevent complications3) Prevent hospitalizations4) Prevent progression of HF Goals of Treatment

20. *BB-selective/nonselective 35-65%RRR*ACE 20% mortality reduction/ARB*Diuretic-thiazide/loop/aqua*Nitrates /AA Hydralazine+ Nitrates*Morphine/anxiolytic*Digoxin-0.5-0.8 ng/mL in low EF*Aldosterone inhibitors (class II/III)*CCB avoid non-dihydropyridines/CS Medications

22. CBC/BMP/Na/LFTBNP good neg. predictive valueAlbumin/Pre-AlbuminRenal failure may be reason for or cause by HF Labs

23. Survival over time in patients with severe chronic heart failure (HF) and a left ventricular ejection fraction less than 30 percent who, at study entry, had either a normal plasma sodium concentration (greater than 137 meq/L, solid line) or hyponatremia (plasma sodium less than or equal to 137 meq/L, dashed line). Survival was significantly reduced in the patients with hyponatremia. The survival rate was very low (approximately 15 percent at 12 months) in those with a baseline plasma sodium concentration less than or equal to 130 meq/L. Data from: Lee, WH, Packer, M, Circulation 1986; 73:257.

24. Echo- poor quality, thin/obeseEKGStress test-function, new HFCoronary angiographyMRI-CAD,MI,HCM,ARVC,AmyloidCTSPECT (single photon emission computed tomography) Tests

25. IMAGING IN HF • Echocardiography • Nuclear cardiology • Cardiac CT and Cardiac MRI • Very high resolution • Very good tissue characterization • Very good quantitative analysis • Viability assessment • Functional assessment, including valve function

26. Benefits*High quality measurement of LV volume. *Comprehensive evaluation of virtually every aspect of cardiac anatomy and function.*ViabilityDisadvantageICD/PPM-relative contraindicationClaustrophobiaMotionHR <60Society for Cardiac Magnetic Resonancehttp://www.scmr.org/ Cardiac MRI

27. Exercise and Functional Capacity in Heart Failure HF-ACTION trial

28. Patients with LV systolic dysfunction and NYHA class II-IV symptoms who undergo exercise training in addition to usual care will have a 20% lower rate of all-cause death or hospitalization(primary endpoint) over two years than patients who receive usual care aloneWhellan DJ, O’Commor CM, LeeKL et al. Am Heart J 2007; 153:201-2-11 HF-ACTION Primary Hypothesis

29. Exercise training Usual care 3M 54% 28%12M 53% 33% Percent of Patients with Clinical Improvement

30. Based on the main analysis adjusted for HF etiology, exercise training produced a modest, non-significant decrease in the primary endpoint (all-cause mortality or all-cause hospitalization) and key secondary clinical endpoints. In protocol-specified analyses adjusted for prognostic factors, the treatment effect was statistically significant for the primary endpoint and for the secondary endpoint of CV mortality or HF hospitalization. ConclusionHF-ACTION

31. Most objective assessment of functional capacity in HF pt. Only of value in pt. whose exercise capacity is limited by HF.Influenced by age, gender, BMI. The percent predicted value may be a more reliable indicator of prognosis. Peak VO2

32. "the highest rate of oxygen consumption attainable during maximal or exhaustive exercise" VO2 max has been defined as:

33. Cumulative survival in patients with heart failure according to maximal oxygen consumption (VO2) in mL/kg per min. Survival is markedly reduced in patients with a peak VO2 below 10 mL/kg per min. Data from: Mancini, DM, Eisen, H, Kussmaul, W, et al, Circulation 1991; 83:778.

34. Measures the distance ambulated on a level hallway surface during six minutes. In a retrospective analysis of 440 patients from a randomized controlled trial with NYHA class III-IV HF baseline distance significantly predicted mortality and hospitalization; for each 100 m (328 ft) increase in distance walked. Similarly, in a series of 476 patients form a single referral center, the distance walked at baseline was an independent predictor of two-year survival.See 2002 Thoracic Society statement. Six-min. walk test correlates with VO2 max.

35. Hemofilteration UNLOAD (UltrafiltratioN versus IV Diuretics for Patients Hospitalized for Acute Decompensated Congestive Heart Failure; J Am Coll Cardiol, 2007; 49:675) 200 patients, 28 medical sites, randomization to UF or diuretics At 48 hours into treatment, the UF group: 38 percent greater weight loss 28 percent greater net fluid loss At 90 days following hospital discharge, the UF group: 43 percent reduction in rehospitalizations for HF 52 percent reduction in ED or clinic visits 63 percent total reduction in days rehospitalized The benefits seen in all subgroups analyzed

36. Today's Devices • Impella • GHS – first to use in SC • 2.5 or 5.0L/min • Directly unload the left ventricle in the heart • Reduce myocardial workload and oxygen consumption • Increase cardiac output and coronary and end-organ perfusion

37. EF<35%  Nonischemic vs. Ischemic Asymptomatic NSVT  SCA,VF or unstable VT NYHA class I-III Optimum OPT ICD Indications

39. *EF < 35% *NYHA Class I ischemic or *NYHA Class II ischemic or nonischemic HF *Stable OPT *LBBB/QRS > 120ms BiV-ICD Indications

41. *Refractory cardiogenic shock*Dependence on inotropes*Peak VO2 <10ml/kg/min*Severe ischemia and poor function not amendable to CABG/PCI*Recurrent symptomatic vent. *Arrhythmias refractory to Rx. Indications for Transplant

42. Jarvik

45. HeartMate

48. HeartWare international HVAD pump

50. Today’s surgical options Revascularization RF Ablation for Arrhythmia Aneurysm Resection Dor Batista VAD Valve surgery Transplant