Heart Failure Teri Diederich, APRN April 7, Objectives. Heart Failure Statistics 3/29/2016

Transcription

1 Heart Failure Teri Diederich, APRN April 7, 2016 Objectives Verbalize heart failure statistics Understand cardiac anatomy and physiology Define heart failure and it s effects on cardiac anatomy Identify the stages and symptoms of heart failure Verbalize medications used to treat heart failure and how they impact cardiac physiology Review non-pharmacological treatment of heart failure Review end-stage heart failure and treatment options Heart Failure Statistics About 5.1 million people in the US have heart failure 1 in 9 deaths in 2009 included heart failure as a contributing cause Almost half of people with heart failure die within the first 5 years of diagnosis Heart failure costs an estimated $32 billion each year for health care services, medications, and missed days of work 1

2 Cardiac Anatomy Systole cardiac contraction during which heart ejects blood into the arteries Diastole cardiac cycle during which heart relaxes and fills with blood Cardiac Performance Preload ventricular wall tension at the end of diastole. Stretch on ventricular fibers before contraction Afterload ventricular wall tension during contraction. Resistance that must be overcome to eject Contractility property of heart muscle that accounts for changes in the strength of contraction. Often reflects chemical or hormonal changes Stroke Volume Volume of blood ejected from the ventricle during systole Ejection fraction the percentage of blood that leaves the ventricle during systolic contraction Pathophysiology of Heart Disease 2

3 Heart Failure Definitions A syndrome caused by cardiac dysfunction, generally resulting from myocardial muscle dysfunction or loss and characterized by either LV dilation or hypertrophy or both HFSA The heart is unable to pump sufficiently to need the needs of the body Symptoms include dyspnea, fatigue, exercise intolerance Physical signs include edema, rales, JVD, gallops Heart Failure Definitions Systolic Heart Failure syndrome characterized by signs and symptoms of HF and reduced LVEF. Commonly associated with LV dilation Diastolic Heart Failure or Heart failure with preserved ejection fraction syndrome characterized by symptoms of HF and preserved LVEF. Commonly associated with nondilated LV Normal Echo 3

4 Echo Systolic Heart Failure 4

5 Causes of Heart Failure Heart failure with reduced ejection fraction Ischemia Viruses Familial/Genetic Tachycardia Thyroid disease Toxins Peripartum Adult congenital heart disease Heart failure with preserved ejection fraction Hypertension Valvular disease Constrictive disease Infiltrative diseases Stages/Class of Heart Failure AHA definitions relating to stage of heart failure A-D Structural and symptom driven classification system NYHA function class I-IV Symptom driven classification system 5

6 Evaulating Heart Failure Assess severity of heart failure Asses cardiac structure and function echo Determine cause of heart failure Evaluate for coronary disease and reversible ischemia Asses for arrhythmias Identify exacerbating factors Identify comorbidities Identify potential treatment barriers Physical Assessment Adequate Perfusion? Cool extremities Altered mentation ACE intolerance Worsening renal function Congestion? Dry Warm Dry Cold Wet Warm Wet Cold Orthopnea Rales JVP Hepatomegaly Ascites Edema Putting it all together Acute vs chronic Involvement of left or right ventricle or both Systolic or diastolic More than the patient has CHF 6

7 Case Study 65 y/o male with PMH significant for severe CAD, s/p CABG in 1984, HTN, HLP, DM-II, and ischemic cardiomyopathy with last reported EF 15%. He presents to HF clinic with progressively worsening SOB, BL edema, and worsening fatigue. I can only walk from the living room to the kitchen before I have to stop, but if I sit in my chair, I don t feel short of breath. PE: VS: BP 98/55, RR 18, HR 110-regular, SpO2-92% + JVD to angle of mandible, +rales, + holo-systolic murmer at apex, + HJR, + BL LE edema. Case Study Labs H/Hct 11/34, BUN/Cr 45/1.8, LFT s AST 160, ALT 122, Bili 2.9 CXR Cardiomegaly, small R pleural effusion, prominent pulmonary vasculature ECG Sinus tachycardia. No change from priors ECHO: EF 10%, dilated LV with severe decreased systolic function. Dilated RV with severe decreased systolic function. severe MR. BAE. Case Study NYHA functional class? AHA stage of HF? Can someone put it all together 7

8 Heart Failure Treatment Treatment Goals Improve symptoms and quality of life Slowing the progression or reversing cardiac and peripheral dysfunction Reducing mortality Pharmacological treatments Non-Pharmacological treatments Device Therapy End-of-life measures Pharmacological Treatments ACE inhibitors or ARBS lisinopril, captopril, fosinopril, enalapril, losartan, diovan Beta Blockers bisoprolol, carvedilol, metoprolol succinate Aldosterone antagonists aldactone or eplerenone Vasodilators hydralazine and imdur Diuretics loop diuretics Digoxin Anticoagulation Amiodarone 8

9 ACE inhibitors/arbs Inhibits the renin-angiotensinaldosterone system Lisinopril (ATLAS) Enalapril (SOLVD) Valsartan (VAL-HeFT) Candesartan (CHARM) Reduce mortality, hospital admissions, improves cardiac remodeling Side effects hypotension, angioedema, hyperkalemia Beta Blockers Supresses adrenergic nervous system effects of heart muscle by blocking beta 1, beta 2 and /or alpha 1 receptors Bisoprolol Beta 1 (CIBIS study) Metoprolol XL Beta 1 ( MERIT-HF) Carvedilol Beta 1, Beta 2, and Alpha 1 (COPERNICUS) Decreases mortality, hospitalizations, arrythmias, myocardial oxygen consumption, hypertrophy, and myocte necrosis Side effects fatigue, COPD exacerbation, orthostatic hypotension Beta blockers are not recommended for acutely decompensated patients Diuretics Loop diuretics Reversibly inhibits Na/P/Cl cotransporter is ascending loop of henle Lasix, demadex, bumex Ease of use, bioavailability, IV vs PO Side effects hypotension, electrolyte imbalance Distal convoluted tubule diuretics Reversibly inhibits NA/Cl transport Hydrochlorothiazide, metolazone Combination synergy with loop diuretics Side effects electrolyte imbalance 9

10 Vasodilators Hydralazine and Nitrates Combination results in direct arteriolar dilation and arteriolar and venodilation Reduces afterload/preload, decreases mortality and hospitalizations Side effects multiple pills, dizziness and headaches Recommended for all African Americans with reduced ef Recommended for any symptomatic patient despite optimal standard therapy Aldosterone antagonists Blocks the action of circulation aldosterone at the site of aldosterone receptor located in tissues Reduces mortalitity, rehospitalizations, myocardial fibrosis Side effects hyperkalemia, gynecomastia Recommended for NYHA Class III or IV while receiving standard therapy Digoxin Inhibits myocyte Na/K ion exchange activity which results in increased levels of intra-cellular calcium leading to increased myocyte force of contraction DOES NOT EFFECT MORTALITY Side effects decreased AV node conduction, narrow therapeutic range Recommend for symptom relief Recommended to achieve adequate heart rate control in atrial fibrillation 10

11 Anticoagulation Recommended for patients with atrial fibrillation Recommended post revascularization Amiodarone Not recommended for primary prevention for sudden cardiac death Used to treat arrhythmias causing ICD shocks Side effects involving lungs, liver, and thyroid Multiple drug-drug interactions New Medications Ivabridine (Beautiful study) Hyperpolarization-activated cyclic nucleotide gated channel blocker Reduce hospitalizations for symptomatic HF patients with EF < 35 and resting HR > 70 in sinus rhythm On maximally tolerated beta-blockers or have contraindications to beta-blockers Contraindicated in acute decompensation, bp > 90/50, sick sinus syndrome, or pacemaker dependance 11

12 New Medications Entresto (sacubitril/valsartan) Paradigm-HF trial Combines ARB with Neprilysin inhibitor (raises levels of several endogenous vasoactive peptides including natriuretic peptides, bradkinin and adrenomedullin and may improve hemodynamics) Used instead of ACE/ARB Study showed reduction of death compared to enalapril and reduction of hospitalizations Major side effect is hypotension Case Study Sodium restriction 2 gram Fluid restriction 2 Liters Regular exercise Evaluate and treat for sleep apnea Modify risk factors PE BP 190/102, HR 98, LS coarse, 1-2+ LE edema, 92% CR bilateral infiltrates, and enlarged cardiac silhouette Labs WBC 12.2, Hgb/Hct normal, NA 138, K 4.8, BUN 42, Creatinine 1.78 What do you think? Case Study Treated for pneumonia, treated elevated BP and transferred here. Vitals BP s, SOB with cough, 2-3+ lower extremity edema, JVD, hepatojugular reflex Meds lasix 40 mg IV, coreg 25 mg bid, lisinopril 20 mg daily Now what? Echo time EF 5 10% with biventricular failure, mild MR, PASP What changes would you make now? 12

13 Treatment and further evaluation Decrease beta blocker, IV diuresis, add hydralazine/imdur Question stress test versus heart cath MRI after diuresis showed dilated, hypertrophied LV with ef 40%, mildly dilated RV with normal function Follow up?? Non-Pharmacological Treatments Sodium restriction 2 gram Fluid restriction 2 Liters Regular weights diuretics for 2 pound weight gain in 1 day or 5 pounds in 1 week Cardiac Rehab/Regular exercise Increases musculoskeletal O2 extraction Evaluate and treat for sleep apnea 50% of patients with heart failure have sleep apnea Depression 20-70% of patients with HF have depression and should be followed for this Modify risk factors Device Therapy More than 80% of patients who experience ventricular arrhythmias do not survive to receive ICD therapy Prophylactic ICD placement should be considered for patient with LVEF < 35% and on medical therapy for more than 90 days ICD should be implanted in patients post cardiac arrest outside of acute MI NYHA class III or IV patients should be evaluated for biventricular pacing Patients with life expectancy < 1 year should not have ICD implanted 13

14 Advanced Heart Failure Therapies Heart Transplantation LVAD, TAH Inotrope therapy Dobutamine Beta 1 agonist, weak Beta 2 agonist Milrinone Phosphodiesterase inhibitor, PDE-3 Dopamine DA receptor agonist (low dose), Beta receptor agonist (medium dose), and alpha agonist (high dose) Palliative Care Requires honest discussion with patient Expectations and goals IV inotropes can be used as home palliative therapy Turning off the ICD Not ending life, only stopping shocking therapies Comfort kits at home Opioids, ativan, haldol, atropine drops, IV diuretics Most family members become fearful/worried with visible breathing problems, also most difficult for patients to cope with Collaboration 14

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